Design
This study used a randomized controlled design. Written informed consent was obtained from all participants before inclusion in the study, which was previously approved by the Sangmyung University Institutional Review Board (SMUIRB AP-2017-003).
Research hypotheses
Hypothesis 1. The intervention group who receive blended learning CPR education will have a higher CPR knowledge score after education than that before education.
Hypothesis 2. The intervention group who receive blended learning CPR education will have a higher CPR attitude score after education than that before education.
Hypothesis 3. The intervention group who receive blended learning CPR education will have a higher CPR self-efficacy score after education than that before education.
Hypothesis 4. The intervention group who receive blended learning CPR education will have a higher CPR knowledge score after education than that of the control group.
Hypothesis 5. The intervention group who receive blended learning CPR education will have a higher CPR attitude score after education than that of the control group.
Hypothesis 6. The intervention group who receive blended learning CPR education will have a higher CPR self-efficacy score after education than that of the control group.
Participants
This study adheres to the CONSORT guidelines and was a prospective randomized controlled trial aiming to identify effects of blended learning CPR education on nursing students’ CPR-related knowledge, attitude, and self-efficacy. The minimum sample size for analyzing differences between two groups with a two-tailed test was calculated using G*Power 3.1. With a statistical significance level of 0.05, power of 0.85, and effect size of 0.60, the sample size was calculated to be 51 for each group, totaling 102. Considering potential dropouts, 120 nursing students were recruited from a single institution. Nursing students who provided their written informed consent to participate in this study, had not completed the emergency department training course, and had never received blended learning CPR education were eligible to participate in the study. We excluded fourth-year students, as they had completed the emergency department training course, while 40 first-year, 40 second-year, and 40 third-year students were recruited. Education was administered and data collected between September and November 2017. (Fig. 1).
Randomization
For each grade-level, students were assigned to the intervention and control groups based on the order of entering the lecture room, where odd numbers were assigned to the intervention and even numbers were assigned to the control group. To adjust for differences among years in school, twenty students from each grade-level were randomly assigned to the intervention and control groups each, resulting in a total of 60 students in the intervention group and 60 students in the control group.
Intervention of blended learning CPR education
The blended learning CPR education program was designed as a four-session program. In Session 1, program orientation was given. In Session 2, students watched a video titled “How to perform chest compression CPR and use automated defibrillator”. The video described the definition of CPR, the overall CPR process, basics of chest compression CPR, and how to use an automated defibrillator. In Session 3, students watched a video titled “Basic course for standard CPR education program”. The video contained information about cardiac arrest cases and need for CPR, successful CPR cases, chest compression process, chest compression training, cases in which no one is available to help, how to use the speaker feature of a cell phone, repeated CPR training, how to use an automated defibrillator, precautions for using a defibrillator, how to use an emergency medical information application, and how to deliver rescue breaths. In Session 4, students were given a lecture using a printout made by the investigator based on the key contents of the KACPR guideline and 2010 AHA guideline for CPR and emergency cardiovascular treatment (Table 1). The printout containing CPR guidelines was also distributed to and read by the control group. In other words, the control group had only the 90-min lecture.
The pre-intervention questionnaire was administered to both the intervention and control groups at the same time. Both groups completed a questionnaire containing items to measure knowledge, attitude, and self-efficacy for CPR. The investigator collected the completed questionnaires. The post-intervention questionnaire was administered to both the intervention and control groups at the same time, immediately after the end of the education program. The questionnaire was identical to the pre-intervention questionnaire, measuring participants’ knowledge, attitude, and self-efficacy for CPR. The investigator collected the completed questionnaires (see Additional file 1).
Instruments
Knowledge
Knowledge was measured with an instrument developed by Byun [20] based on CPR guidelines published by the AHA in 2010. This 20-item scale comprised two items for checking for consciousness, two items for checking for breathing, seven items for delivering chest compressions, four items for maintaining airway and delivering rescue breaths, and five items for using a defibrillator. The total score ranged from 0-20, with a higher score indicating a higher level of knowledge.
Attitude
Attitude was measured using an instrument developed by Cho [21] with reference to the AHA guidelines and KACPR guidelines. Three types of attitudes were measured. Emotional attitude, which refers to one’s feelings about “performing basic CPR to a cardiac arrest patient,” was measured with 10 items rated on a seven-point scale. Behavioral attitude was measured with three items, including “I will try my best to perform CPR when I witness a cardiac arrest patient,” rated on a four-point scale. Finally, cognitive attitude was measured with three items, including “I think performing CPR promptly is important for the outcome of a cardiac arrest patient,” rated on a four-point scale. Five items for emotional attitude were reversely scored. The total score ranges from 0-94, with a higher score indicating a more positive attitude. The Cronbach’s a for emotional, behavioral, and cognitive attitudes in Cho’s [34] study were 0.69, 0.77, and 0.63, respectively. The Cronbach’s a for emotional attitude, behavioral attitude, and cognitive attitude in this study were 0.63, 0.85, and 0.87, respectively.
Self-efficacy
Self-efficacy was measured using a self-efficacy scale developed by Park [22] and modified and adapted by Byun [20]. The scale comprises 12 items, including “I am confident that I can perform CPR during an emergency.” The total score ranges from 0-120, with a higher score indicating a higher level of self-efficacy. The reliability (Cronbach’s a) of the tool in Park’s [22] study was 0.93, and that in this study was 0.90.
Statistical Analysis
The collected data were analyzed with the Statistical Package for the Social Sciences (SPSS) 22 software (IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp., 2013). Participants’ general characteristics were presented as a real number and percentage and as mean and standard deviation, and pre-intervention homogeneity between the groups was tested via c²-test, t-test, and ANOVA. The changes after education in the intervention and control groups were analyzed with paired t-test, and differences for the intervention between the two groups were analyzed with ANCOVA with knowledge, which differed between the two groups, as the covariate.