Nurse Education in Practice 27 (2017) 134e143

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Nurse Education in Practice journal homepage: www.elsevier.com/nepr

Review

A review of simulation-enhanced, team-based cardiopulmonary resuscitation training for undergraduate students Arif Onan a, *, Nurettin Simsek b, Melih Elcin a, Sevgi Turan a, Bülent Erbil c, Kaan Zülfikar Deniz d a

Department of Medical Education and Informatics, Hacettepe University, Faculty of Medicine, Sihhiye Campus, 06100 Altindag, Ankara, Turkey Department of Computer Education & Instructional Technology, Ankara University, Institute of Educational Sciences, 06590 Cebeci, Ankara, Turkey Department of Emergency Medicine, Hacettepe University Faculty of Medicine, Sihhiye Campus 06100 Altindag, Ankara, Turkey d Graduate School of Educational Sciences, Ankara University, Institute of Educational Sciences 06590 Cebeci, Ankara, Turkey b c

a r t i c l e i n f o

a b s t r a c t

Article history: Received 7 December 2015 Received in revised form 16 August 2017 Accepted 31 August 2017

Cardiopulmonary resuscitation training is an essential element of clinical skill development for healthcare providers. The International Liaison Committee on Resuscitation has described issues related to cardiopulmonary resuscitation and emergency cardiovascular care education. Educational interventions have been initiated to try to address these issues using a team-based approach and simulation technologies that offer a controlled, safe learning environment. The aim of the study is to review and synthesize published studies that address the primary question “What are the features and effectiveness of educational interventions related to simulation-enhanced, team-based cardiopulmonary resuscitation training?” We conducted a systematic review focused on educational interventions pertaining to cardiac arrest and emergencies that addressed this main question. The findings are presented together with a discussion of the effectiveness of various educational interventions. In conclusion, student attitudes toward interprofessional learning and simulation experiences were more positive. Research reports emphasized the importance of adherence to established guidelines, adopting a holistic approach to training, and that preliminary training, briefing, deliberate practices, and debriefing should help to overcome deficiencies in cardiopulmonary resuscitation training. © 2017 Elsevier Ltd. All rights reserved.

Keywords: CPR Medical education Resuscitation training Teamwork Undergraduate education

1. Introduction 1.1. Background and context Cardiovascular diseases are the main cause of death worldwide (3 out of every 10 deaths) and, 42% of these deaths are due to heart attacks (Mendis et al., 2011). Heart attacks increase the risk for sudden cardiac arrest. Sudden cardiac arrest is responsible for 10% of all deaths and up to 50% of heart diseaseerelated deaths in the United States and other developed countries (Rea and Page, 2010). Emergent and skillful response during cardiopulmonary resuscitation (CPR) considerably raises patient survival rates, especially when it is administered outside of a hospital setting. The most

* Corresponding author. E-mail addresses: [email protected] (A. Onan), nurettin.simsek@ankara. edu.tr (N. Simsek), [email protected] (M. Elcin), [email protected] (S. Turan), [email protected] (B. Erbil), [email protected] (K.Z. Deniz). http://dx.doi.org/10.1016/j.nepr.2017.08.023 1471-5953/© 2017 Elsevier Ltd. All rights reserved.

important determinant of surviving a cardiac arrest is the presence of rescuers who are trained, willing, able, and equipped to act in an emergency situation. Resuscitation training is an essential element in clinical skill training for healthcare professionals (Soar et al., 2010). All healthcare professionals are expected to demonstrate competency in administering CPR. Therefore, educational practices should prove their effectiveness and ensure that the participants achieve the desired educational outcomes. The International Liaison Committee on Resuscitation (ILCOR) has strongly emphasized that healthcare professionals must receive their initial training in basic life support (BLS) before their graduation. Nevertheless, many students cannot demonstrate mastery level CPR performance when they graduate. American Heart Association (AHA) states that training programs deteriorate rapidly if not offered frequently short-duration “refreshing” activities that prevent decay and improves acquisition and retention of CPR skills (Meaney et al., 2013). In the case of cardiac arrest in hospital setting, nurses are

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generally the first responders and have very critical role while waiting for the advanced cardiac life support team (Heng et al., 2011). While CPR guidelines are altered, the roles of the multidisciplinary team members also changed and nurses’ responsibilities increased and that made them a more active member of the multidisciplinary resuscitation team (Terzi, 2008). Studies confirmed that emergency cases requiring CPR can be most effectively resolved using a team-based approach (Hunziker et al., 2009, 2010a,b). Individual and team-related factors, including leadership, communication, interaction, and team structure have an impact on CPR quality (Yeung et al., 2012) and should be included in nurse and all other health professionals training. The ILCOR describes the issues related to CPR and emergency cardiovascular care (ECC) education and divides these issues into 4 major categories: willingness to perform CPR, educational design, improving resuscitation quality, and issues related to implementation and outcomes (Mancini et al., 2010). Research on educational efforts revealed that the utilization of simulation techniques results in the mastery of CPR-associated skills and high quality of CPR execution (AHA, 2000). Several recommendations have been made regarding minimum training standards and training packages critical for implementing comprehensive CPR education (Perkins et al., 1999). Another point of emphasis was that these training events should be based on validated educational principles (Durak et al., 2006). Even though CPR programs incorporate common primary features, they differ in their professional requirements and content (examples include AHA, European Resuscitation Council - ERC, and ILCOR training). This variation has a decisive impact on each course's time, design, delivery, simulation modality, and types of evaluation. Simulation-based educational interventions pertaining to resuscitation provide a controlled, safe learning environment (Cooper and Taqueti, 2008). Coping with high-risk medical situations (Grzeskowiak et al., 2011), simulations allow for training on and assessment of sophisticated skills in an authentic ambiance without endangering patients (Akhu-Zaheya et al., 2012). Simulation training also provides practitioners with experience in addressing rare events, significant situations, and events or situations that require rapid response and vigilance (Gaba, 2004). Simulation technologies also offer tools and techniques for multiple data recordings that provide the opportunity for the detailed analysis of teamwork behaviors (Patel et al., 2009) and for the multidimensional evaluation of the effectiveness of these interventions (Cook et al., 2013). The main issue for healthcare systems is to maintain teams demonstrating interprofessional competencies in the workplace (Barr, 1998; Thistlethwaite, 2012). An interprofessional team can composed of two or more professionals or disciplines included, physicians, nurses and paramedics etc. A curriculum focused on this issue needs to be improved to include facilities where the students from different health professions meet each other, and learn how to work together (Patel et al., 2009). 1.2. Rationale The ILCOR strongly emphasizes the importance of CPR training and providers responsible for healthcare delivery take ILCOR's evidence-based CPR recommendations into account. CPR training at the postgraduate level mostly addresses certification and international initiatives that have strong jurisdiction. However, the methodological and theoretical bases of CPR educational interventions at the undergraduate level are currently unclear and controversial, especially on the integration of team-based learning. Therefore, there is a need for a review on simulation-enhanced, team-based CPR training at the undergraduate level.

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1.3. Objective The main goal was to review and synthesize published evidence relevant to educational science that addresses the question “What are the features and effectiveness of educational interventions related to simulation-enhanced, team-based cardiopulmonary resuscitation training?” 2. Method We conducted a systematic review of the medical literature to identify publications on the use of simulation-enhanced techniques for team-based resuscitation training, with a focus on their current and potential applications in cardiac arrest and emergency situations. The review protocol was developed in accordance with PRISMA statements and was registered in PROSPERO (Onan et al., 2013). Best Evidence Medical and Health Professional Education review procedures (Hammick et al., 2010) were followed by the reviewers as the main issue addressed medical practice and medical education. A modified Kirkpatrick model and its adaptation (Hammick et al., 2010) were used for collecting, interpreting, and reporting intervention outcomes. 2.1. Search strategy The literature search that was performed covered 5 databases (PUBMED, EBSCOHOST, COCHRANE, WILEY, AND SCIENCEDIRECT). Google Scholar searches were also performed. The databases were searched using the following terms and variations: “simulation” AND (student OR undergraduate) AND (resuscitation OR CPR OR “life support”) AND (team OR crew OR group) with no restriction in period of publication. The searches were conducted in September 2013. The search results consisted of a pool of articles derived from COCHRANE (33), EBSCOHOST (50), SCIENCEDIRECT (41), PUBMED (90), WILEY (21), and Gray (internet search, 9). A total of 219 articles remained after eliminating duplicates (see Fig. 1). 2.2. Article selection 2.2.1. Inclusion and exclusion criteria Protocol-based screening criteria were obtained from the initial pool of journal articles and were used by 2 independent review coders. The required criteria for the study are as follows: the involvement of undergraduate healthcare students (people), the implementation of simulation technology, an educational activity relevant to team-based CPR (exposure or issue), and information about educational intervention and outcomes (outcome). Initial requirements were performed through article abstract reviews. There were 89 articles that did not the meet the inclusion criteria and were eliminated (animal studies, fire fighter studies, review articles, etc.). During the full text review of the remaining 130 articles, 46 articles were eliminated as they were not meeting the inclusion criteria (postgraduate, absence of team building). The remaining 84 articles were evaluated by the coders using the quality assessment checklist, and 54 articles did not meet the full quality improvement criteria. 2.2.2. Final article pool When the Kirkpatrick classification was applied to these articles, we recognized that some articles had been reported as the part of a larger simulation study. There were 2 groups of studies at risk for bias: the studies by Kardong-Edgren et al. (2009; Kardong-Edgren and Adamson, 2009) and those by Husebø et al. (2011; 2012a; 2012b; 2013). Kardong-Edgren et al. (2009) mentioned in their article that their data were collected as an aspect of a larger

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Fig. 1. Representative flow diagram of the procedures for literature identification, analysis, and review.

simulation study reported in the other article by Kardong-Edgren and Adamson (2009). The study reported in this broader article was conducted as a part of a medical and surgical training course and, compared students’ satisfaction, test scores and, knowledge retention. Kardong-Edgren et al. (2009) specifically reported CPR skill retention based on the main study and using the same subjects and subgroups. The data and the results of these 2 articles were regarded as a single study in our analysis. The second group included the studies by Husebø et al. (2011; 2012a; 2012b; 2013). The first article was about team coordination, the second one was about briefing, the third one was about performance and, the fourth one was about debriefing. These 4 articles were evaluated and regarded as a single, comprehensive study for analysis with Husebø’s written confirmation. We sought to evaluate the effects of training interventions and defined effective simulation training as a sequenced learning process based on briefing, simulation practice, and debriefing stages. As a result, the review pool was reduced to 26 studies. 2.3. Data extraction To start with, a pilot study was performed by 2 independent coders on a small sample of articles (2 databases x 5 articles) to assess the applicability of the pre-defined data extraction sheet. The coders reached a consensus on a standardized data extraction protocol which was mainly based on ILCOR CPR key educational issues and educational recommendation topics. Pilot study revealed that coders gained experience and aligned their evaluation performances and interpreted definitions and review processes in the same way. After approving of the protocol, data showed in results were systematically extracted from the articles by the coders.

3. Results The included studies utilized heterogeneous study designs, interventions and outcome measures. The results were summarized under the descriptive characteristic headings used in the original articles. The theoretical basis of interventions and outcome measures are presented in a narrative format. 3.1. Descriptive characteristics of the articles (Table 1) Professions of the students involved in the studies were medicine (16), nursing (11) paramedic (2) and pharmacy (2). Most of the participants were from the professions of medicine and nursing. Designs of the studies were widely distributed: experimental (8), quasi-experimental (7), mixed methods (6) and descriptive (5). Studies have mainly referred international guidelines reflecting the period of studies. Considering team size, the number of rescuers for BLS is 2e4; for advanced cardiovascular life support (ACLS), 3e6; and for neonatal CPR, 3. Most of the courses were based on BLS (15) and ACLS (11). Automated external defibrillator (AED) was included in six of the BLS studies. Only four of the studies were designed as an interprofessional activity while others were uniprofessional. Crisis resource management (CRM) studies have the minority (3) and only one of them related with interprofessional context. 3.2. Theoretical basis of interventions There are comprehensive and guiding articles that describe the learning theories providing basis for CPR training (Bradley and Postlethwaite, 2003; Hunt et al., 2008) but very few did so in our study. Kardong-Edgren et al. (2009) focused on each student's skills for

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Table 1 Descriptive characteristics of the articles. No

Article

CPR Type

Design

Team/object size

Guide

1

Akhu-Zaheya et al. (2012)

BLS þ AED

Quasi-experimental

AHA 2010

2

Baker et al. (2008)

ACLS

3

Cavaleiro et al. (2009)

Neonatal CPR

Mixed methods IPE Experimental

4

Creutzfeldt et al. (2012)

BLS-CRM

Quasi-experimental

5

Dagnone et al. (2008)

ACLS

6

Davis et al. (2013)

ACLS

Descriptive IP Experimental

7

Delasobera et al. (2010)

ACLS

Mixed Methods

8

Fernandez Castelao et al. (2011)

ACLS þ CRM

Experimental

9

Fernandez et al. (2013)

ACLS

10

Grzeskowiak et al. (2011)

ACLS

11

Hunziker et al. (2010a,b)

a

ACLS

Quasi-experimental UPE Descriptive UPE Experimental

12

Hunziker et al. (2011),b

BLS þ AED

Descriptive

13

Husebø et al. (2011,2012a,2012b,2013)

BLS þ AED

Mixed Methods

14

Jankouskas et al. (2011)

BLS þ CRM

15

J€ antti et al. (2007)

BLS þ AED

Experimental IPE Descriptive

16

Kardong-Edgren et al. (2009 and Kardong-Edgren and Adamson 2009)

BLS þ AED

Mixed Methods

17

King and Reising (2011)

ACLS

Quasi-experimental

18

Leighton and Scholl (2009)

BLS

Mixed Methods

19

Li et al. (2013)

BLS

Experimental

20

Luctkar-Flude et al. (2010)

ACLS

21

Lukas et al. (2013)

BLS þ AED

Mixed Methods IPE Quasi-experimental

22

Mieure et al. (2010)

ACLS

Descriptive

23

Rezmer et al. (2011)

ACLS

Quasi-experimental

24

Rodgers et al. (2009)

ACLS

Experimental

25

Ruesseler et al. (2010)

BLS, ACLS, ATLS

Quasi-experimental

26

Van Heukelom et al. (2010)

ACLS

Experimental

3 - 4 rescuers 110 NS 5 rescuers 101 NS, 42 MS, 70 JMR 3 rescuers 45 MS 2-3 rescuers 30 MS 5 rescuers 101 NS, 36 MS, 25 JMR 5-6 rescuers 135 PHS 5-6 rescuers 117 PS 4 rescuers 112 MS 4-6 rescuers 165 MS, 64 MR 4 rescuers 136 MS 32P PS 3 rescuers 189 MS 3 rescuers 120 MS 2-4 rescuers 81NS 4 rescuers (2 NS 2MS) 50NS, 46 MS 2 rescuers 12 PS, 22 P 4 rescuers 32 NS1 5 rescuers/65 NS2 4-5 rescuers 49 NS 3 rescuers 30 NS 2 rescuers 330 MS 5 rescuers 44 NS, 60 MS 3 rescuers 141 MS 5 rescuers 24 PHS 3-4 rescuers 191 MS 5-6 rescuers 34 NS 5-6 rescuers 44 MS 3 rescuers 161 MS

Curriculum development Undefined ILCOR 2005 Curriculum development AHA 2005 AHA 2005 ERC 2005 AHA 2005 ERC 2005 AHA 2005 AHA 2005 ERC 2005 AHA 2005 ERC 2000e2005 AHA 2005 AHA 2005 AHA 2005 AHA 2005 Curriculum development ERC 2010 AHA 2005 Undefined AHA 2005 National Guide 2006 Curriculum development

NS:Nursing Student, MS: Medical Student, PHS Pharmacy student, PS: Paramedic Student, P: Paramedic, MR: Medical Resident, JMR: Junior Medical Resident. a Kardong-Edgren et al. (2009). b Kardong-Edgren and Adamson (2009).

effectively performing CPR. This study's conceptual framework was based on the “law of practice”. The students should pass from the cognitive phase to the associative phase through deliberate practice to acquire CPR capabilities. Fernandez et al. (2013) grounded their approach on the team training theory. They used the social learning theory to help students achieve the knowledge, skills, and attitudes expected by the resuscitation team. Ten Eyck et al. (2010) focused on students' clinical decision-making performance and CPR skills, including technical and nontechnical skills and particularly team leadership. They emphasized the deliberate practices safely within a controlled simulation environment. Ruesseler et al. (2010) studied students' skills on managing emergency cases. They studied the effects of simulation-based interventions on the ability of emergency medicine students to manage emergency situations.

Performance-based evaluation methods were used to objectively construct clinical exams. Baker et al. (2008) included collaboration-based experiential activities incorporating realistic, simulated clinical cases to address the need for complicated competences within the scope of interprofessional CPR training. They claimed that interprofessional learning (IPL) could be improved through the experiential, reflective, and contextual learning approaches integrated with adult learning principles. Husebø et al. (2013), Van Heukelom et al. (2010), King and Reising (2011), Rodgers et al. (2009) and Leighton and Scholl (2009) supported experiential learning in their studies. Creutzfeldt et al. (2012) compared the CPR knowledge and performances of the students who were instructed using various teaching methods. Mieure et al. (2010) stated that ACLS training

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required a team-based approach, and complex strategies for the improvement based on experiential learning. Akhu-Zaheya et al. (2012) examined the effects of high-fidelity BLS simulation on dependent variables associated with the acquisition and retention of knowledge and self-efficacy. They developed a theoretical framework merging self-efficacy with novice to mastery theory. Among other studies, Dagnone et al. (2008) argued that CPR training should be regarded as a result of IPL principles and the teamwork with critical care experiences including realistic interactions, and perceptions. Luctkar-Flude et al. (2010) studied whether scenarios used in interprofessional CPR training were sufficiently complex and realistic. Husebø et al. (2013) used Gibb's reflective cycle model as the conceptual framework in their simulated resuscitation teamwork study. That model attempted to explain the relationship between reflection and learning. They focused on the debriefing portion of CPR training, and examined how to construct debriefing activities to improve students' reflection skills within a team leadership context. Husebø et al. (2011; 2012a), revealed that the trainers had applied situational learning to develop students' comprehension to be able to overcome CPRrelated difficulties. High-fidelity simulation was defined as the technique used by many authors. Delasobera et al. (2010) and Rodgers et al. (2009) defined high-fidelity simulation as an educational technology. Briefly, the theories explicitly addressed in these studies were behaviorism, social cognitive theory, constructivism, social constructivism and reflective practice, and rarely, situational learning and novice-to-expert theory. 3.3. Outcome measures A Modified Kirkpatrick's 4 levels of evaluation model (Mosley et al., 2012) and its adaptation (Hammick et al., 2010) were used for collecting, interpreting, and reporting intervention outcomes. 3.3.1. Satisfaction (KL-1) Ten of the studies evaluated student satisfaction and reported a high degree of satisfaction with simulation-enhanced learning. Students who experienced IPL through simulations expressed higher satisfaction with cardiac resuscitation rounds. Baker et al. (2008) concluded that CPR simulation with IPL had positive impact on student satisfaction. Davis et al. (2013) and Mieure et al. (2010) also showed that general satisfaction levels of the students increased when a high-fidelity simulation technique was preferred. Similarly, Ruesseler et al. (2010) revealed positive satisfaction when the learning was based on simulation-based education. KardongEdgren and Adamson (2009) studied whether the utilization of medium-fidelity simulators made any difference in student satisfaction compared to more expensive simulators. The results showed no difference when access was granted to both simulators. Delasobera et al. (2010) also found out that the students were pleased with simulated based learning. The evaluation of simulation experiences by Van Heukelom et al. (2010) showed positive satisfaction in a debriefing-based study. Luctkar-Flude et al. (2010) reported that the groups, participated in an interprofessional simulation-based training module were pleased with the sessions focused on CPR education. Similarly, Dagnone et al. (2008) stated that medical and nursing students both accepted and welcomed interprofessional CPR rotations, and they prioritized these learning experiences. Finally, Rezmer et al. (2011) revealed that the students generally evaluated their simulation experiences with positive satisfaction ratings. In sum, studies evaluated student satisfaction reported a high degree of satisfaction on simulation-enhanced learning.

3.3.2. Modification of attitudes/perceptions (Table 2 - KL-2A) Thirteen of the studies evaluated students' attitudes and perceptions. Six of these studies investigated the effect of simulation on individual student's self-confidence. In a study by Jankouskas et al. (2011) evaluating CRM training, a statistical difference was observed between an individual group's attitudes toward an interprofessional resuscitation rotation. Rezmer et al. (2011) revealed a significant increase in confidence through the resuscitation simulation, but no change was observed in the perception of reality or efficiency. Akhu-Zaheya et al. (2012) observed some important differences (based on the fidelity of simulation) in the self-efficacy scores of the experimental group compared with those of the control group. The study by Ruesseler et al. (2010) addressing different forms of CPR included some expressions of high-level satisfaction related to individual student motivations during simulation-based education. In the study by Baker et al. (2008) students showed a consistently positive attitude in written assessments at their resuscitation rotation. Similarly, the study by Dagnone et al. (2008) showed a positive student attitude through written statements in simulation-based IPL. Mieure et al. (2010) reported that pharmacy students improved their understanding of ACLS through an interaction with patient simulators, and the functions in treating cases requiring ACLS. According to Davis et al. (2013) students felt much more selfconfident in demonstrating ACLS knowledge and skills in the simulation method than in the conventional class. The findings of Hunziker et al. (2011) revealed an important relationship between a team's stress/high overload levels during the resuscitation period and CPR performance. While negative sensations, motivation, and stress/severe burden were significantly high, positive sensations were quite low. However, positive sensations were high prior to and after resuscitation. Leighton and Scholl (2009) reported that when participants did not have any former CPR experience, as compared to a code scenario, increased confidence and decreased fear were expressed. Simulated clinical experiences helped students get a perception of reality and sense of self-efficacy related to their CPR performance. According to the study by Rodgers et al. (2009) during an AHA ACLS course, the team leaders of the high-fidelity simulation groups got higher confidence scores. In a debriefing-focused study, Van Heukelom et al. (2010) disclosed that student confidence regarding the realization of critical care skills was significantly increased. In their IPE-based simulation study, Luctkar-Flude et al. (2010) reported that students were more confident in their technical CPR skills such as airway management and, comfortable in their non-technical CPR skills. Briefly, studies reported that the effect of simulation-enhanced learning on students' self-confidence and their attitudes and perceptions on it were positive. 3.3.3. Acquisition of knowledge/skills (Table 2 - KL-2B) In four of the studies, the acquisition of knowledge and skills was studied together (Table 2: 4,7,14 and 21). In six of the remaining 12 studies, only the acquisition of knowledge was studied (Table 2: 1,3,6,13b,18,20) while the acquisition of skills was examined in the rest of the studies (Table 2: 8, 9,11,12,16,18) While evaluating the level of knowledge, MCQ, oral and written exams, and T/F questions were used. While addressing the level of skill, video analysis, observational checklists, simulated data analysis, and scoring skill sheets were used. In 6 of the 10 studies evaluating the acquisition of knowledge, simulation implemented in various ways made a difference in student knowledge levels (Table 2: 4,6,7,14,18,21) Also, 8 of the 10 studies incorporating skill assessment showed an increase in acquisition (Table 2: 4,7,8,9,12,14,16,18). The studies of Akhu-Zaheya et al. (2012) and, Cavaleiro et al.

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Table 2 Modification of attitudes/perceptions (Kirkpatrick level 2A) and acquisition of knowledge/skills (Kirkpatrick level 2B). No Article

1 2 3 4

Akhu-Zaheya et al. (2012) Baker et al. (2008) Cavaleiro et al. (2009) Creutzfeldt et al. (2012)

5 6

Dagnone et al. (2008) Davis et al. (2013)

7

Delasobera et al. (2010)

8

Fernandez Castelao et al. (2011)

9

Fernandez et al. (2013)

Nature of the training

Lecture Simulation Simulation Lecture Simulation Lecture V. Simulation Simulation Lecture Simulation

Lecture Simulation

11 Husebø et al. (2011,2012a,2012b,2013)

Lecture Simulation

12 Jankouskas et al. (2011)

Lecture Simulation

13 Kardong-Edgren et al. (2009 and Kardong-Edgren and Adamson 2009) 14 King and Reising (2011)

Lecture Simulation

What and how assessed

How was knowledge tested

Pre and post self-efficacy Post IDE perception

Pre and post MCQ Pre and post MCQ Pre and post T/F Q

Post attitude Post confidence

17 Luctkar-Flude et al. (2010) 18 Lukas et al. (2013)

Lecture/Simulation

19 Mieure et al. (2010) 20 Rezmer et al. (2011)

Lecture/Simulation Lecture/Simulation

21 Rodgers et al. (2009)

Simulation

22 Ruesseler et al. (2010)

Lecture/CP Simulation Simulation

How was skills tested

Pre and post video analysis

Sequenced written and MCQ Pre and post MCQ Pre and post scoring skill sheet Pre and post scoring skill sheet Teamwork observational checklist

Stress/Emotion wheel through the process Pre and post video analyses Pre and post video analyses

Post Interprofessional attitude Pre and post knowledge Test Post MCWQ test

Lecture Simulation Lecture Simulation Lecture Simulation Multimedia Lecture Simulation

23 Van Heukelom et al. (2010)

Acquisition of knowledge/skills (KL-2B)

Lecture Reading Simulation Multimedia Lecture Simulation Multimedia Computer Based Training

10 Hunziker et al. (2011)

15 Leighton and Scholl (2009) 16 Li et al. (2013)

Modification of attitudes/ Perceptions (KL-2A)

Post mega code checklist

Pre and post confidence and fear Pre and post skill testing sheet Post confidence Post simulator data Post perception Pre and post confidence Post confidence

Post MCQ test Post oral exam Pre and post written exam

Performance score sheet

Post self-motivation Pre and post confidence

KL-2A: Kirkpatrick level 2A, KL-2B: Kirkpatrick level 2B, MCQ: Multiple-choice questions, T/F: True/False CP: Clinical Practice.

(2009) and, Kardong-Edgren and Adamson (2009) revealed no differences in knowledge acquisition. In another study conducted by Davis et al. (2013) written exam results before and after training showed a notable difference in the acquisition of CPR knowledge during the simulation training. Rezmer et al. (2011) analyzed student results on oral mock code exams, and concluded that parameters such as the number of members in a team and roles of individual team members did not create any notable change. In another study by King and Reising (2011) a significant difference in MCWQ test results was observed in CPR knowledge between the low- or high-fidelity simulation groups. It was found that highfidelity simulation users achieved higher CPR skill levels. Creutzfeldt et al. (2012) studied game technology and concluded that group members who received pre-training with an MVW video game achieved greater CPR knowledge. In video analysis, the CPR skills of the same group were also found to be higher. As reported by Delasobera et al. (2010) the multimedia group showed greater CPR knowledge than the reading group. In the assessment of CPR skills obtained from a cardiac arrest scenario, the simulation group showed more notable improvement than the other 2 groups. According to Rodgers et al. (2009) their exam results showed that

the CPR knowledge of the group that used a high-fidelity model was notably higher than the group that used a low-fidelity model. In the study conducted by Mieure et al. (2010) higher knowledge scores were received on knowledge assessment just after HPS activities, but the post-workshop retention of CPR knowledge was low. Husebø et al. (2012b) observed the simulated cardiac scenario performances of the experimental and control groups. The experimental group observed the control group and then performed the skill. This observation did not have any impact on their performance. Fernandez Castelao et al. (2011) found that the skills of the group that received additional CRM training decreased in no-flow time and increased in team member verbalizations. Jankouskas et al. (2011) reported that CRM training led to an improvement in non-technical skills but not in technical skills. Li et al. (2013) reported that the training group that received a pre-training assessment and feedback on BLS training achieved greater skill development than the control group. Lukas et al. (2013) reported that adherence to CPR guidelines and CPR skills were improved when a CPR practitioner was assisted by the simultaneous guiding devices. Rodgers et al. (2009) found that their high-fidelity group

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scored higher on manual tasks than the low-fidelity group. Fernandez et al. (2013) also revealed that students who learned teamwork process during their emergency medicine rotation showed higher levels of teamwork. In summary, studies reported that the effect of simulation on skill acquisition is much more than knowledge. While approximately half of the studies reported an increase on the knowledge levels, eight of the 10 studies reported an increase on the skill acquisition. 3.3.4. Retention of knowledge/skills (Table 3 - KL-2C) The retention of knowledge was evaluated in 6 of the 11 studies, while skill permanence was examined in 9 of the studies. At least one positive impact was reported in 9 of the studies (Table 3: 1,2,5,6,7,8,9,10). In the study by Akhu-Zaheya et al. (2012) independent test results showed that there was no significant difference in the retention of BLS knowledge between the experimental and control groups. Delasobera et al. (2010) compared a multimedia training group with a reading group and observed a notable improvement in the multimedia group in their knowledge retention. Kardong-Edgren and Adamson (2009) compared simulator fidelity and observed that student performance was not related to fidelity in acquiring short- or long-term knowledge retention. In the second article (Kardong-Edgren et al. (2009) from this group, they evaluated students who performed according to the AHA layperson CPR guidelines and used public defibrillators. None of the groups successfully performed the CPR steps, but all successfully used defibrillators. In their study, King and Reising (2011) examined fidelity variations and concluded that there were no knowledge differences between groups, but the high fidelity group's mega code performance was higher. Hunziker et al. (2010a,b) showed that leadership training resulted in better team and CPR skills in groups received CPR training with or without leadership training. Leighton and Scholl (2009) gathered data on students' knowledge retention from video images shown during the debriefing. Each team's performance was observed as insufficient, and that only 4 of the 10 groups successfully practiced BLS. Using simulator data analysis, Grzeskowiak et al. (2011) reported problems in constant ECG monitoring, inappropriate defibrillator use, and not performing 2-

min CPR cycles. Jankouskas et al. (2011) reported that the teams received BLS þ CRM training showed a notable improvement in performing team processes. In their study, Li et al. (2013) evaluated 2 groups of students: a group with a pre-training evaluation and feedback (EF), and a control group. It was observed that the EF teams showed better skill retention in all retention tests. Ruesseler et al. (2010) evaluated the performances of the groups participated in simulation-based training and reported that participants showed better skills. The majority of the studies showed positive effect on retention of knowledge and skill on behalf of simulation-based learning activities. The follow-up test intervals were varied from 2 weeks to 12 mounts. It was showed that the effect of simulation-enhanced learning on students’ retention of knowledge/skills becomes more distinctive on long interval follow up test. The simulationbased activities, which serve repetitive and deliberate practice and diversity of fidelity, seemed to have positive influence on skill decay and retention that consistent with the current literature. 3.3.5. Evidence of transfer of learning to clinical practice (KL-3) There were no studies that reported results in this category. 3.3.6. Change in organizational practice (Table 4 -KL-4A) and patient benefits (Table 4 -KL- 4B) The results were positive in all seven studies that examined the effects of simulation on organizational practices and patient benefits. J€ antti et al. (2007) performed CPR training efficacy comparisons using ERC 2000 and ERC 2005 guidelines. Using simulator data parameters, they found that more effective results were achieved with the 2005 guidelines. In their study, Fernandez et al. (2013) evaluated the performances of the students in performing teamwork behaviors and patient care in high-fidelity simulator resuscitation. Students who attended teamwork process training during their emergency medicine rotation showed higher teamwork levels and patient care performance. Fernandez Castelao et al. (2011) observed that CPR quality increased with CRM training, the time interval of “no circulation” decreased (an indicator of performance quality), and the frequency of oral expressions by the team leader increased. It was also

Table 3 Retention of Knowledge/Skills (Kirkpatrick level 2C). No Article

Nature of the training

When tested at follow-up

Components of ability (How was tested) (KL-2C)

1 2

Akhu-Zaheya et al. (2012) Delasobera et al. (2010)

1 month 3 weeks

Second Post MSQ Short-term retention MCQ Test

3 4

Grzeskowiak et al. (2011) Hunziker et al. (2011)

5

Jankouskas et al. (2011)

6 7

Kardong-Edgren et al. (2009 and Kardong-Edgren and Adamson 2009) King and Reising (2011)

8

Leighton and Scholl (2009)

Lecture Simulation Lecture/Reading Simulation/ Multimedia Simulation Lecture Simulation Lecture Simulation Lecture Simulation Lecture Simulation Lecture Simulation

9

Li et al. (2013)

Knowledge

10 Ruesseler et al. (2010)

Lecture Simulation Multimedia Lecture/CP Simulation

KL-2C: Kirkpatrick level 2C MCQ: Multiple choice questions CP: Clinical Practice mos: mounts.

Skill

Not reported 4 mos

Simulator data Video and simulator data

Inadequate explanation 22 weeks/6 mos

Regression model

2 weeks/2 mos ¼>6 mos CPR certification/ 3 mos 1-3-6-12 mos 4 mos

Written retention test Two Post MCQ Debriefing Analyze

Video analyses Two Post Mega code Checklist Video analyses

Skill testing sheet OSCE

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Table 4 Change in organizational practice (Kirkpatrick level 4A) and benefits to patient (Kirkpatrick level 4B). No Article

Nature of the training

Period studied

Change in organizational practice, delivery of Benefits to patients/clients, families and care (KL-4A) communities (KL-4B) Changes

1

Fernandez Castelao et al. (2011)

8 mos

Team training cost

Grzeskowiak et al. (2011)

Lecture Simulation Multimedia Computer Based Training Simulation Lecture Simulation

2

Fernandez et al. (2013)

3

10 days

I/E

Training structure

4

Hunziker et al. (2010a,b)

Lecture Simulation

4 mos

5

Lecture Simulation

2 mos

6

Husebø et al. (2011, 2012a,2012b,2013) Jankouskas et al. (2011)

Lecture Simulation

I/E

7

J€ antti et al. (2007)

Lecture Simulation

I/E

Team training structure

Team training cost

How was tested

Benefits

Patient outcome Teamwork effect size Patient outcome Guideline Patient outcome Patient outcome Briefing and debriefing Patient outcome Training time Patient outcome

How was tested Video analyses Patient care checklist Simulator data Video and simulator data

Rubric Simulator data

I/E:Inadequate explanation mos:months KL-4A: Kirkpatrick level 4A KL-4B: Kirkpatrick level 4B.

observed that the expressions of management statements and provision of information to team members by each team leader increased after CRM training. Husebø et al. (2012a; 2013) stated that simulation-enhanced CPR training phases could bridge the gap between simulation and clinical practice. Trainers could systematically examine each student's understanding and could address each individual performance issue. This change would result in a change in organizational practices for team training. Hunziker et al. (2010a,b) conducted a study that compared the effects of additional leadership training on CPR training. Group members that received leadership training showed better team performance and got better average scores on output measurements. These results were evaluated as indicators of the improvement in patient outcomes. In the study by Jankouskas et al. (2011) experimental teams showed a more significant improvement in the measurement of team processes within the contextual framework of team validity. Lukas et al. (2013) disclosed that simultaneous resuscitation-guiding devices enhanced algorithm compliance and prevented inappropriate shock cycles. Researches that implemented CRM into CPR education were associated with an increase on team efficiency and indicated that effective teamwork improved patient safety and healthcare quality. 4. Discussion All articles included in this review were in compliance with the treatment recommendations of ILCOR CPR and ECC science. Undergraduate CPR training programs generally implemented accredited programs or developed their own programs with reference to published guidelines. Studies comparing alternative educational methods with conventional training courses generally evaluated the effectiveness in improving the acquisition and retention of specific skills. The main questions addressed by these studies were how to improve CPR training, how to enhance individual and team competencies, and how to implement guidelines to the practices. The nature of undergraduate CPR training, which has been reported in review articles, involved a mixture of lectures, reading, computer-based learning, simulation, and virtual simulation. The ILCOR has emphasized the application of reanimation science and the use of effective strategies in training and practice to improve patient care and its results within the context of CPR and ECC. We discussed the features and effectiveness of undergraduate CPR training within the thematic classification related to the

sequenced learning process of simulation training, teamwork, and came to the conclusions about the main categories of CPR education issues. We offered eight evidence-based principles for effective planning, implementation, and evaluation of team training programs specific to health care. 4.1. Briefing Because CPR was practiced in a simulated environment, the students needed to adapt themselves to the specific interactive method, and conceptualize the fidelity of simulation features. Half of the studies targeted the acquisition of CPR knowledge showed that simulation made the participants to achieve the similar levels of success compared to traditional methods, while the other half of the studies revealed higher knowledge achievement with simulation. It was suggested that interventions with orientation and briefing activities would improve knowledge acquisition (Mieure et al., 2010). 4.2. Resuscitation practice with feedback and reflection Simulation provides the students with the opportunity of deliberate CPR practices accompanied by feedback from an expert trainer. The restricted time allocated to the simulation sessions results in knowledge acquisition with simulation that is similar to conventional methods. Accredited programs can provide nearly 20 h of close contact training for students. Undergraduate study periods are less, and inadequate repetition does not result in longlasting learning. Husebø et al. (2012b) drew attention to the repetitive practice and reflection opportunities provided by simulation and highlighted the importance of early defibrillation and the length of time without intervention. Luctkar-Flude et al. (2010) also suggested additional learning sessions for the students expressing a lack of confidence so that they can have additional practice. 4.3. Debriefing with feedback and reflection Researchers regarded the debriefing sessions as the vital activities that enable students to reflect on their completed performance and improve their future performance (Davis et al., 2013). There were variations in the duration of debriefing sessions among the studies. Debriefing period should not be less than the scenario period; they should promote reflective learning, and guarantee the achievement of targeted learning (Husebø et al., 2013).

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4.4. Scenario and complexity It is highly critical for students to attend advanced life support activities to acquire a consistent skill set. Basic cardiac resuscitation skills training sessions should be organized so that the students could have an opportunity to review their basic skills prior to resuscitation sessions (Van Heukelom et al., 2010). They should be faced with the contextual diversity of potential CPR activities to become competent. Simulation experiences providing a diversity of scenarios could make a contribution through the addition of new information and improve the scope of student CPR knowledge (Akhu-Zaheya et al., 2012). Similar results were obtained for groups using high- and low-fidelity simulators in a study where expert evaluators gave scores for basic psychomotor skills when treating a case of cardiac arrest. As the scenario evolved and became more complicated, the group using the high-fidelity simulator showed better team performance (Rodgers et al., 2009). As a conclusion, it is possible to teach basic CPR skills using even inexpensive solutions. 4.5. Teamwork Healthcare providers must be able to work collaboratively to improve the quality of CPR in actual cardiac arrests and resuscitations (ILCOR, 2010). The effects of supportive approaches such as CPR team training, leadership skills, and CRM training were investigated. Improvements in teamwork led to improved patient safety-oriented outcomes and a notable decrease in costs associated with mortality and malpractice. It was possible to teach basic knowledge and skills using training methods requiring few resources during teamwork training. The students in all studies regarded IPL and simulation-enhanced interactive practices as positive. The studies that examines the effects of simulation-based CPR training have reported that simulation learning could be transferred to practice and it resulted in positive outcomes for patient safety (Edelson et al., 2008; Domuracki et al., 2009). Currently, accredited programs develop CPR activities in a virtual environment. This approach was examined in several studies. There were some conclusions that CPR knowledge and teamwork skills were effectively improved after practicing in a virtual environment (Creutzfeldt et al., 2012). It was reported that CPR team training designed as the avatar in a “multiplayer virtual world” environment could be used as a method for use with both pretraining and refreshment training, and could benefit and enhance CPR skills. 4.6. Refreshment and re-certification The valid general approach is to establish BLS provider certification followed by skill refreshment and re-certification every 1 or 2 years. The ILCOR suggests that this period of time should be shorter. The quality of rescuer education and frequency of retraining are critical factors in improving the effectiveness of resuscitation. Studies were careful to be in this period. 4.7. Guidance and feedback tools Kardong-Edgren et al. (2009) evaluated BLS skill retention and successfully improved the AED performance in all study groups. In this study, nursing students’ AED usage and expertise level were associated with written instructions and oral guidance provided with defibrillators. There were 2 studies referred to the ILCOR's suggestions about guideline compliance, and promoted the use of a defibrillator in CPR applications. It was emphasized that the rhythm should be urgently defined in VF situations, with the initial application of

defibrillation (Grzeskowiak et al., 2011). In another study, students in the simulation game group that received pre-training were more adherent to the guidelines, and they practiced chest compressions in more accurate cycles (Creutzfeldt et al., 2012). 5. Conclusion We concluded eight evidence-based principles that were summarized under the main categories of CPR educational issues for effective planning, implementation, and evaluation of team training programs specific to health care. Learning outcomes of the reviewed studies were associated with satisfaction towards education; increase both acquisition and retention of knowledge/skills, and positive changes in organizational practice. Although it was not the main focus of these studies, the willingness of students to participate in activities was queried in a few investigations. There were no studies on the ethical decisions made prior to or after cardiac arrest. There were also very few studies that included consecutive performance measurements (Creutzfeldt et al., 2012). The other important finding of the study is that only a few studies investigated effect of simulated team based learning on transfer of learning to clinical practice. Although there was some evidence about the effectiveness of the simulated teamwork on organizational practice and benefits of patient, there is still need to investigate strong evidence. Further studies need to focus this issue to show how the simulation learning transfer to practice and its effect of on patient safety. 5.1. Limitations of this systematic review This review only evaluated the interventional studies involving undergraduate students in team-based CPR training, with referenced guidelines taken into account. References American Heart Association, 2000. Part 6: advanced cardiovascular life support section 7: algorithm approach to ACLS 7C. A guide to international ACLS algorithms. Resuscitation 46, 169e184. Akhu-Zaheya, L.M., Gharaibeh, M.K., Alostaz, Z.M., 2012. Effectiveness of simulation on knowledge acquisition, knowledge retention, and self-efficacy of nursing students in Jordan. Clin. Simul. Nurs. 9, e335e342. Baker, C., Pulling, C., McGraw, R., Dagnone, J.D., Hopkins-Rosseel, D., Medves, J., 2008. Simulation in interprofessional education for patient-centred collaborative care. J. Adv. Nurs. 64, 372e379. Barr, H., 1998. Competent to collaborate: towards a competency-based model for interprofessional education. J. Interprof. Care 12, 181e187. Bradley, P., Postlethwaite, K., 2003. Simulation in clinical learning. Med. Educ. 37, 1e5. Cavaleiro, A.P., Guimaraes, H., Calheiros, F.L., 2009. Training neonatal skills with simulators? Acta Paediatr. 98, 636e639. Cook, D.A., Hamstra, S.J., Brydges, R., Zendejas, B., Szostek, J.H., Wang, A.T., et al., 2013. Comparative effectiveness of instructional design features in simulationbased education: systematic review and meta-analysis. Med. Teach. 35, e867e898. Cooper, J.B., Taqueti, V.R., 2008. A brief history of the development of mannequin simulators for clinical education and training. Postgrad. Med. J. 84, 563e570. Creutzfeldt, J., Hedman, L., Fell€ ander-Tsai, L., 2012. Effects of pre-training using serious game technology on CPR performanceean exploratory quasiexperimental transfer study. Scand. J. Trauma Resusc. Emerg. Med. 20, 1e9. Dagnone, J.D., Mcgraw, R.C., Pulling, C.A., Patteson, A.K., 2008. Interprofessional resuscitation rounds: a teamwork approach to ACLS education. Med. Teach. 30, e49e54. Davis, L.E., Storjohann, T.D., Spiegel, J.J., Beiber, K.M., Barletta, J.F., 2013. High-fidelity simulation for advanced cardiac life support training. Am. J. Pharm. Educ. 77, 59. http://dx.doi.org/10.5688/ajpe77359. Delasobera, B.E., Goodwin, T.L., Strehlow, M., Gilbert, G., D'Souza, P., Alok, A., et al., 2010. Evaluating the efficacy of simulators and multimedia for refreshing ACLS skills in India. Resuscitation 81, 217e223. Domuracki, K.J., Moule, C.J., Owen, H., Kostandoff, G., Plummer, J.L., 2009. Learning on a simulator does transfer to clinical practice. Resuscitation 80, 346e349. Durak, H.I., Çertug, A., Caliskan, A., Dalen, J.V., 2006. Basic life support skills training in a first year medical curriculum: six years' experience with two cognitiveconstructivist designs. Med. Teach. 28, e49e58.

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