Comparing two different schedules of online learning for updated cardiopulmonary resuscitation guidelines in Covid-19 patients: A randomized study

INTRODUCTION

Evidence regarding clinical management of patients with Covid-19 with cardiac arrest is evolving.¹ The vulnerable population includes individuals with underlying comorbid conditions who present with pneumonia, severe acute respiratory syndrome and multi-organ failure. These patients may have a cardiac arrest and require immediate cardiopulmonary resuscitation (CPR).^2,3 Giving CPR to such patients is challenging for healthcare workers due to the risk of viral contamination.^4–6 Newer CPR guidelines specific to Covid-19 are related to the use of personal protective equipment, prevention from aerosol-generating procedures, oxygen therapy and transport of patients.⁶

The nurses’ role as a member of the healthcare team is crucial during CPR. Considering the impact of Covid-19 on the delivery of CPR, we felt a need to update the comprehensive CPR (comprehensive cardiopulmonary life support [CCLS])-trained nurses to ensure an optimal outcome for these patients. CPR is a skill training programme but in view of the restriction to physical gatherings due to the pandemic, regular conventional classroom learning was not feasible.⁷ We decided to train nurses through an online mode. A literature review identified two different techniques of online learning, namely synchronous and asynchronous. Both are well-tested techniques of online learning, but no comparative study has been done to identify which is better for adult learners for CPR training. Therefore, our study compared the two online learning techniques for disseminating new CPR guidelines in terms of knowledge gain and acceptability by the nurses.

METHODS

This prospective randomized controlled study was approved by the ethics committee (IEC/NP- 542/2020) and registered with CTRI (2020/08/026977). We identified from the records, 160 nurses trained in CCLS and invited them via email to participate in the study. Informed consent was obtained through email. Confidentiality and anonymity of the participants were ensured. A total of 108 nurses responded and were screened for eligibility through an online eligibility proforma having 20 multiple-choice questions (MCQs) related to pre-Covid-19 CPR guidelines. Nurses who scored 80% or above (n=80) were allowed for registration. A total of 61 nurses completed the registration formalities and were randomized to synchronous (n=31) and asynchronous learning groups (n=30) using a computer-generated random sequence (Fig. 1).

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FIG 1.

Consort diagram showing the study flow

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RESULTS

Of the 61 nursing officers, the final sample size in the synchronous and asynchronous group was 26 and 28, respectively (Fig. 1). At baseline, both groups were comparable in terms of age, sex, professional qualification, total and current experience in the present area of work, the number of witnessed and managed cardiac arrest in Covid-19 patients and pre-assessment knowledge scores (p>0.05; Table I). Both schedules of online learning were effective in improving the knowledge scores of the nurses (11.93 [3.26] v. 21.15 [1.90], p=0.01, and 11.71 [3.12] v. 20.32 [1.71], p=0.01). Post-assessment knowledge scores of the nurses were comparable in both the groups (21.15 [1.90] v. 20.32 [1.71], p=0.1; Table II). The mean acceptability scores in the asynchronous group were statistically lower than in the synchronous group (38.93 [2.50] v. 42.5 [3.08], p=0.007). All nurses in the synchronous group and a few from the asynchronous group (n=5) recommended a synchronous schedule of online learning. They found the training programme highly informative, interactive, innovative and relevant, and suggested providing intimation about such workshops in advance to the participants and administration.

DISCUSSION

Our study revealed that both synchronous and asynchronous schedules of online learning were effective in disseminating CPR guidelines for Covid-19 in terms of improvement in the knowledge scores. The acceptability by nurses in the synchronous group was higher than by those in the asynchronous group.

Online learning is a valuable tool in medical education and, if used appropriately, can facilitate the learning of many psychomotor skills, which are otherwise best learned through performance.^8–13 All the participants in our study were habituated to the traditional facilitator and classroom models of learning. This online learning was a novel experience for them. In the synchronous group, there was provision for a small group live interactive discussion with ‘camera-on’ meetings, which provided a classroom-like environment to the participants. It promoted active engagement of the participants by adding human elements in a virtual classroom with the provision of immediate feedback. However, the degree of social interaction and peer group learning was not measured. In contrast, online learning in an asynchronous group can be equated with computer-based, self-motivated and self-paced distance learning.

Our study has some limitations. It was a single-centre, open-label study, where nurses were recruited from a single tertiary care facility. The possibility of the Hawthorne effect among the participants of the synchronous group cannot be ignored. The immediate gain in the knowledge scores can be attributed to the spill-over effect. Therefore, the long-term effect of the intervention remains to be explored. Because CPR is a skill training programme, all the nurses at the end of the training were requested to go to the nearest training centre for practising the newer guidelines. The hybrid method of online learning with classroom hands-on practice is an acceptable mode of imparting training to nurses.⁹ Therefore, the present online learning cannot be recommended for nurses who have no prior exposure to CCLS training.