Comparison Between Clinical Simulation and Traditional Teaching for Cardiopulmonary Knowledge and Skills

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1 International Journal of Educational Research and Information Science 2015; 2(4): Published online October 23, 2015 ( Comparison Between Clinical Simulation and Traditional Teaching for Cardiopulmonary Knowledge and Skills Muayyad M. Ahmad *, Ahmad A. Aqel Clinical Nursing Department, Faculty of Nursing, the University of Jordan, Amman, Jordan address (M. M. Ahmad), (A. A. Aqel) To cite this article Muayyad M. Ahmad, Ahmad A. Aqel. Comparison Between Clinical Simulation and Traditional Teaching for Cardiopulmonary Knowledge and Skills. International Journal of Educational Research and Information Science. Vol. 2, No. 4, 2015, pp Abstract Purpose: The purpose of this study was to examine the effect of using simulators on the level of cardiopulmonary resuscitation knowledge and skills acquisition and retention compared with traditional training for nursing students. Methods: Pretest posttest method was used. A test of multiple choice questions and checklist format was used in three phases: baseline, acquisition, and retention phases. Results: The results showed significant differences between the participants of the high fidelity simulators training group and the participants of the traditional static manikin training group on the acquisition of cardiopulmonary resuscitation knowledge and skills. The participants in both groups showed a decrease in their cardiopulmonary resuscitation knowledge and skills after three months of training. However, the retention scores of cardiopulmonary resuscitation knowledge and skills for the participants in the high fidelity simulators group was decreased after three months, still significantly higher than the static manikin training group. Conclusion: This study may assist nursing educators in incorporating the use of high fidelity simulators in cardiopulmonary resuscitation training. Keywords Simulation, Education, Students, CPR, Nursing 1. Introduction 1.1. Background and Significance Simulation is used to support teaching, promote critical thinking among students and enhance the quality of patients' care (McFetrich & Price, 2006). Moreover, using simulation in education has been found to be useful in practicing the necessary skills in a safe environment and increasing the knowledge and skills retention (Ziv, Wolpe, Small, & Glick, 2003). However, the effect of simulation teaching method on the retention of knowledge and skills is still questionable among nursing educators (Lasater, 2007). Moreover, acceptance of clinical simulators is not common as a possible solution to enhance the clinical competencies for nurses practicing at the bedside (Decker, Sportsman, Puetz, & Billings, 2008). International Liaison Committee on Resuscitation (2010) indicates a need for continuing research into teaching methods that may improve the retention of CPR knowledge and skills in an effort to increase the survival rate and the quality of care for patients with cardiac arrest. Thus, further research is needed to explore ways to increase the retention of CPR knowledge and skills with a variety of teaching approaches, such as high fidelity simulators. Cardiopulmonary resuscitation (CPR) has been a concern for years (AHA, 2010; Bullock, 2000). Unfortunately, we did not have exact number of cardiac arrest in Jordan, approximately 300,000 out-of hospital cardiac arrests were reported each year in the United States (AHA, 2010). There is only a 10% survival rate after CPR because of the poor quality of performance by the public and health care providers (Eman, et al. 2015; Alspach, 2005; Abella, et al. 2005). Studies have documented that the quality of CPR performance by nurses and nursing students is poor due to ineffective initial training which lead to poor retention of CPR knowledge and skills (Abella, et al. 2005; Ahmad, 2015). Other studies showed that Cardiopulmonary resuscitation knowledge and skills decline rapidly, often within weeks of completing a course (Jacobs & Nadkarni, 2004; Madden, 2006). Thus, either nurses need to attend

2 84 Muayyad M. Ahmad and Ahmad A. Aqel: Comparison Between Clinical Simulation and Traditional Teaching for Cardiopulmonary Knowledge and Skills multiple trainings each year or new methods of training that enhances retention of CPR knowledge and skills are needed. Many nursing colleges have used different teaching methods to improve the retention of student's CPR knowledge and skills (Hamilton, 2005). A combination of teaching methods and repetition of skills have been found to increase CPR skills retention (Wang, et al. 2008; Hamilton, 2005). Nursing students have positively valued simulation based learning in terms of increasing confidence in the ability to do CPR as effective as in real settings (Leighton & Scholl, 2009; Ahmad & Safadi, 2009). In Jordan, there is an increasing number of nursing colleges that are integrating the use of high fidelity simulation in the educational process in order to improve students' competencies (Shahnaz & Ahmad, 2015; Aqel & Ahmad, 2014; Dardas & Ahmad, 2015). A study by Akhu- Zaheya, Gharaibeh, and Alostaz (2012) was conducted to observe the effects of high-fidelity BLS simulation on knowledge acquisition, knowledge retention, and selfefficacy of nursing students in Jordan. The results of this study revealed that nonsignificant differences in knowledge acquisition and retention between traditional method group and HFS group. On the other hand, another study was conducted by Al Hadidi and Suleiman (2012) to measure the effects of boost training session supported by simulation on the retention of CPR knowledge and skills of nursing students. The result revealed that the boost session supported by simulation has improved the students CPR knowledge and the skills. The focus of this study on measuring the learning outcomes of using HFSs as a teaching and learning tool in order to increase nursing students CPR knowledge and skills to perform efficient CPR Theoretical Framework This study was guided by Kolb's (1984) experiential learning theory. Learning is the process of creating knowledge through the transformation of experience (Kolb, 1984). Kolb in his experiential learning theory considers the experience as the central part of learning. In this study, high fidelity simulation was used as a teaching method in order to gain and retain CPR knowledge and skills as it is based on realistic experience. The main propositions of the experiential learning theory are: (1) learning is a process rather than an outcome, (2) learning is continuous and grounded in experience, (3) experience involves actions and reflection, (4) learning is a holistic approach, (5) learning is a synergetic between the person and the environment, and (6) learning is a process that creates knowledge. According to Kolb, (1984) in order to learn, it is necessary to reflect on your experience and make generalization to formulate a new concept which then can be applied to the same situation. Experiential learning theory is composed of four phases: concrete experience, reflective observation, abstract conceptualization, and active experimentation (see Figure 1). These phases are continuous cycling learning process. Kolb, (1984) stated that students may enter the cycle at any phase. In the first phase of concrete experience, students learn by performing the action and feeling the effect of actions. The actual simulation experience represents the concrete experience phase. In the second phase of reflective observation, students learn through observing other students, active participation, and feedback during the debriefing session. In the third phase of abstract conceptualization, students learn through thinking and analyzing the situation. During the phase of abstract conceptualization, students start to generate new ideas through analyzing the events that occurred during the concrete phase and through the discussion and feedback during the debriefing session (Overstreet, 2008). In the last phase of active experimentation, students are able to apply the new knowledge learned during the abstract conceptualization. This phase recognize how knowledge acquisition have been maintained and retained. Figure 1. Kolb's Learning Cycle.

3 International Journal of Educational Research and Information Science 2015; 2(4): Methods 2.1. Study Design Pretest-posttest design was conducted to examine the effectiveness of HFS training versus traditional static manikin CPR training on the acquisition and retention of CPR knowledge and skills among second year nursing students. The intervention group as an independent variable was manipulated and true randomization was maintained. The sample is all nursing students enrolled in the first adult health nursing course. According to Polit and Beck (2004) "the controlled experiment is considered the ideal for yielding reliable evidence about causes and effect (P. 168)." Manipulation was accomplished through the use of different teaching interventions. Participants were randomly assigned into two equivalent groups; intervention and control group. The control group was participated in a 4 hour session of traditional training which is consisted of PowerPoint presentation of AHA Adult Basic life Support (BLS) including Automated External Defibrillator (EAD), and demonstrations on static CPR manikin. The intervention group received the same power point lecture in addition to training on high fidelity simulator called Emergency Care Simulator. The emergency care simulator is available in the nursing laboratory at The University of Jordan. For the purpose of this study, management of chocking, infant and child CPR was omitted. The independent variables are the teaching methods which are composed of traditional CPR training plus a cardiopulmonary arrest scenario program with high fidelity simulation for the experiment group. The dependent variables are the acquisition and retention of CPR knowledge and skills Ethical Considerations The study method and protocol were reviewed by the ethical committee in the Faculty of Nursing at The University of Jordan. Target students who are willing to participate in this study have received both oral and written information about the purpose, content and duration of the study. The confidentiality of the participants was protected by providing a code number for each participant. In addition, the collected questionnaire and tests were kept in a locked cabinet to keep the participants information private and confidential. The Participants were assured that withdrawal from the study at any time will have no penalty. The procedure and data collection procedure were explained to all participants. The participants were informed that the conduction of this study is a part of academic requirement to obtain the doctoral degree of nursing. The significant of this study was explained to all participated. Commitment was gained throughout the phases of the study. Students were informed that s filling the demographic data sheet is considered as an agreement to participate Sample and Sampling A simple sampling technique was used to recruit all nursing students enrolled in the first adult health nursing course at The Jordan University. Inclusion criteria include; nursing students enrolled in the first adult health nursing course, agree to participate in the study, and have no previous experience of CPR. The exclusion criteria include; students who have previous experience with CPR, who have Basic Life Support (BLS) certificate, who are bridging from associated degree to baccalaureate degree. This study was conducted in the nursing laboratory at the University of Jordan, which is the first governmental University in Jordan. It offers all academic degree levels in nursing (Baccalaureate, master, and doctorate). The nursing laboratory at the University of Jordan is well equipped with dolls, materials, static manikins and high fidelity simulators. METI Man high fidelity simulator version 6 will be used in this study Sample Size Power analysis allows us to determine the sample size required to detect an effect of a given size with a given degree of confidence. In this study, the comparison using t- tests (2-tailed) for independent samples, a medium effect size (d =.50), provided 80% power to detect difference at the 0.05 significance level, a sample of 128 participant is needed 64 for each group (Polit, 2010). The accessible population was all students enrolled in the first adult health course at The University of Jordan Instrumentation The instrument has two sections; the first section is the demographic data sheet to identify any potential group variances. The demographic data sheet consists of a checklist and gap filling questions type concerning all variables such as age, gender, living place, Grade Point Average (GPA), CPR experience, and if bridging to baccalaureate. The second part was the CPR pretest and posttest which consist of 14 multiple choice questions on CPR knowledge (AHA, 2010). Pretest and Posttest for CPR knowledge was performed with 14-item multiple-choice questions extrapolated from the American Heart Association exam for BLS (AHA, 2010). This test was used to evaluate the participants CPR knowledge on the three phases of the study: baseline, acquisition, and retention phase. The questions related to infant and children as well as the questions related to stroke and foreign body airway obstructions were removed because the focuses of this study on adult CPR only. The most important aspects of CPR knowledge questions include performing the correct sequence of CPR, correct rate and depth of compression and the correct rescue breathing, the correct ratio of compression to ventilation, the correct performance of compression and breath, the correct use of AED. Chronbach's alpha was determined to establish reliability of the altered AHA CPR knowledge test, and it was (.789).

4 86 Muayyad M. Ahmad and Ahmad A. Aqel: Comparison Between Clinical Simulation and Traditional Teaching for Cardiopulmonary Knowledge and Skills CPR skills checklist are consistent with the guidelines for adult CPR (AHA, 2010). The items in the checklist include; the correct assessment of the victim responsiveness, calling for help, checking the pulse with the correct location, chest compressions with appropriate rate and depth, opening the airway, perform rescue breathing causing the chest to raise using either bag-mask or face mask, and correct attachment of AED pads and delivering the shock. 3. Results This study aimed to evaluate the effectiveness of using the high fidelity simulation (HFS) versus traditional static manikin training method on the acquisition and retention of CPR knowledge and skills. Thus, an experimental study was conducted over one academic semester at The University of Jordan specifically among second year nursing students enrolled in the first adult health nursing course. The participants were randomly divided into two groups. The control group has received theoretical CPR lectures and CPR training on static manikin. The intervention group has received theoretical CPR lectures and CPR training on high fidelity simulator Sample Characteristics The 124 nursing students enrolled in the first adult health nursing course have completed the demographic data sheet. Only 90 students have completed the 3 phases of the study; the base line, acquisition and retention phase. Based on the inclusion and exclusion criteria of the study, 34 students were excluded because: eighteen students have an associated degree in nursing and they were doing bridging to bachelor degree in nursing, eight students have a previous CPR experience, and eight students did not complete all phases of the study. The final number of participants in each group was 45 students. The majority of the participants were females (N=71, 78.9%). The participants age ranged between 18 and 28 years (M=19.87, SD= 1.78). Around 60% of the participants reported their grade point average (GPA) as above good level. All participants indicated that they have neither previous CPR experience nor high fidelity simulation training. Although, the mean GPA of the participants in the control group was higher than the interventional group (M= 3.09, 2.82 respectively) both groups were almost equal in terms of gender and age Descriptive Analysis of Pre and Post CPR Knowledge Questions The results of this study showed that the most critical CPR knowledge aspects failed to achieve in more than 20% of the participants of the control group who received static manikin training were; the recommended procedure to minimize gastric inflation during bag-mask ventilation (64%), the characteristic of high-quality CPR (58%), order steps of Automated External Defibrillator (AED) operation (33%), defibrillation procedure by AED (27%), methods of airway opening (27%) and the immediate action after the AED delivers a shock (24%). The participants in the intervention group only failed in two questions; the recommended procedure to minimize gastric inflation during bag-mask ventilation (49%) and the characteristic of high-quality CPR (31%). Table 1. Frequency of Mistakes Questions in the Pre and Posttest CPR Knowledge. No. Questions Intervention Control Pretest N(%) Posttest N(%) Pretest N(%) Q12 Which of the following is recommended to minimize the stomach (gastric inflation) during bag-mask ventilation? Posttest N(%) 39 (87) 22 (48.4) 40 (89) 29 (64.4) Q9 Which of the following is a characteristic of high-quality CPR? 26 (58) 14 (31.1) 23 (51) 26 (57.7) Q7 The first step the rescuer should perform to operate the AED 18 (40) 1 (2.2) 21 (46) 15 (33.3) Q8 The rescuer should deliver a shock after 29 (64) 5 (11.1) 29 (64) 12 (26.6) Q11 The best way to open airway of an unresponsive victim with no suspected neck injury? 36 (80) 0 (0) 31 (69) 12 (26.6) Q1 After the AED delivers a shock, the rescuer should immediately 26 (58) 9 (20) 27 (60) 11 (24.4) Q4 The depth of chest compressions for an adult victim should be at least 31 (69) 1 (2.2) 28 (62) 5 (11.1) Q2 Where the hands should be placed to perform chest compressions on an adult? 24 (31) 1 (2.2) 24 (31) 4 (8.8) Q14 Each rescue breath should be given over 23 (51) 0 (0) 31 (69) 3 (6.6) Q3 The recommended rate for performing chest compressions for victims of all ages 20 (44) 0 (0) 11 (24) 2 (4.4) Q5 The compression-to-ventilation ratio for 1-rescuer adult CPR is 24 (31) 2 (4.8) 21 (46) 2 (4.4) Q6 Why is it important to compress to the appropriate depth during CPR? 35 (77) 3 (6.6) 32 (71) 2 (6.6) Q10 To reduce rescuer fatigue during team CPR, compressor roles should be switched every 12 (27) 1 (2.2) 17 (38) 1 (2.2) Q13 How does complete chest recoil contribute to effective CPR? 27 (60) 1 (2.2) 28 (62) 0 (0) *I = Intervention group, ** C = Control group ^Number of questions arranged in descending order based on the control group posttest mistakes ratio)

5 International Journal of Educational Research and Information Science 2015; 2(4): Although, the majority of participants in both groups (almost 90%) unable to answer the question which asks about the procedure of giving breathing via bag-mask ventilation in the pretest; the participants in the control group (64%) have failed to answer this question post training compared to 49% of the interventional group. Furthermore, the results of this study showed that 40% of both groups before training were failed to answer the question: the first step the rescuer should perform to operate the AED; post training 33% of the participants of the control group still failed to answer the question compared to 2% in the interventional group. Regarding the question which asks about when to deliver a shock by AED; pre training 64% of the participants in both groups failed to answer this question while post training 27% of the participants of the control group still failed and none failed of the intervention group. Another important finding regarding the question which asks about the best way to open the airway of an unresponsive victim with no suspected neck injury; high percentage (80%) of the interventional group failed to answer this question before training compared to 69% of the control group; post training none of the interventional group failed to answer this question compared to 27% of the control group. Similarly, the question which asks about the recommended rate of chest compression of all age group; pre training the failure percentage of the participants in the interventional group (44%) was more than the control group (34%); while post training none failed to answer this question from the interventional group compared to 4% of the control group. Furthermore, regarding the question which asks: to reduce rescuer fatigue during team CPR, when compressor roles should be switched? Although, the participants in the control group showed higher failure (38%) in answering this question than the participants of the intervention group (27%) in the pretest, only one participant (2%) failed to answer this question post training from the control group but 49% of the participants in the intervention group did. (Table 1) number of questions arranged in descending order based on the control group posttest mistakes ratio. Table 2. Frequency of Mistakes in Posttest of CPR Skills Aspects The Most Frequent Critical Aspects of CPR Skills Failed to Met The result of the study showed that the participants failed to perform some critical aspects of CPR skills in both groups: failed to activate emergency response system (control 29%, intervention 18%); failed to check the pulse (control 24%, intervention 22%); failed to perform adequate compression rate (control 40%, intervention 6%); failed to minimize interruption in chest compression (control 31%, intervention 7%); failed to provide effective breathing (control 33%, intervention 2%). The skill checklist composed of 14 points covering four CPR skill aspects; the initial assessment, chest compression, breathing, and defibrillation. Question one to three related to initial assessment, none failed to check responsiveness in both group. There were 29% of the participants in the control group failed to call for help, while only 18% failed in the interventional group. Regarding checking the pulse, around 20% from the control group failed to check the pulse in 10 seconds compared to 2% from the interventional group. Questions from four to nine covered the skills of chest compression. Around 40% of the control group failed to maintain adequate chest compression rate (at least 100/minute) and 15 % failed to administer appropriate depth (at least 5cm) compared to 2% and 7% respectively of the interventional group. Questions covered the skills of delivering shock. Results of this study showed that 53% of the participants in the intervention group have failed to attach the electrode pads compared to 4% of the control group. All participants in both group abled to deliver shock but some participants in the control group (29%) failed to resume CPR immediately after shock. Results of this study also revealed that 8.8% of the control group was unable to maintain clearance before delivering the shock compared to only 2.2% from the intervention group. (Table 2 questions arranged in descending order based on the control group posttest skills mistakes ratio). ^No. Skills Checklist Items Intervention Control Post skill test n (%) Post skill test n (%) 5 Adequate rate (at least 100/min) 3 (6.6) 18 (40.0) 10 Provide 2 breaths (must cause chest to rise) 1 (2.2) 15 (33.3) 8 Minimize interruptions in chest compressions 3 (6.6) 14 (31.1) 2 Activates emergency response 8 (17.7) 13(28.8) 14 Resume CPR beginning with compressions immediately after each shock. 0 (0) 13 (28.8) 3 Check for pulse in 10 seconds 1(2.2) 10 (22.2) 6 Adequate depth: at least 2 inches (5cm) 0 (0) 7 (15.5) 7 Allow complete chest recoil between compressions 2 (4.4) 7 (15.5) 12 Clear victim before ANALYZE and SHOCK 1 (2.2) 4 (8.8) 4 Proper hand placement & Begin 30 chest compression 1 (2.2) 2 (4.4) 11 Power ON the AED and Attach electrode pads 1 (2.2) 2 (4.4) 9 Open airway: head tilt-chin lift 1 (2.2) 0 (0) 13 Give Shock 0 (0) 0 (0) 1 Assess responsiveness 0 (0) 0 (0) ^Number of questions arranged in descending order based on the control group posttest mistakes ratio)

6 88 Muayyad M. Ahmad and Ahmad A. Aqel: Comparison Between Clinical Simulation and Traditional Teaching for Cardiopulmonary Knowledge and Skills 3.4. Descriptive Analyses for the Retention Skill Test Questions In order to identify the most frequent CPR skill aspects with high percentage deterioration over 3months; comparison between the post skill test and the retention skill test for each skill item was performed. Seven participants (15.5%) from the static manikin group were unable to apply adequate chest compression depth in the post skill test compared to 24 participants (53.3%) in the retention skill test. The above results mean that more than half of the static manikin group unable to retain adequate compression depth; while only 6% of the HFS group unable to retain adequate depth. All the participants in this study have good retention in two skill items; checking responsiveness and delivering shock regardless the teaching method used. The American Heart Association (2010) CPR recommended to resume CPR immediately after administering each shock instead of checking the pulse after Table 3. Frequency of mistake Questions of the Participants Retention Skills Test. shock. Both groups showed poor retention in the skill of resuming CPR immediately after shock regardless method of training: 31% of the static manikin group and 28.8% of the HFS group. The results of this study revealed that the static manikin group has greater skill loss than the HFS group in the following skill items: compression rate (58%), compression depth (53%), effective breathing (48%), and calling for help (44%) compared to 2%, 6%,6%, and 28% respectively in the HFS group. Although, 6.6% of the HFS group unable to provide adequate chest compression rate in the post skill test, the retention percentage was better (2.2%). This study also showed that the static manikin group has more poor retention than the HFS group on the skills of operating the AED and attaching the pads on the chest (26.6%); opening airway by head tilt-chin lift (24.4%) compared to 6.6%, 6.6% respectively of the HFS group. (Table 3 arranged in descending order based on the control group CPR skills retention test mistake questions ratio). ^No. Skills Checklist Items: Retention skills Intervention Control n (%) n (%) 5 Adequate rate (at least 100/min) 1 (2.2) 26 (57.7) 6 Adequate depth: at least 2 inches (5cm) 3 (6.6) 24 (53.3) 10 Provide 2 breaths (must cause chest to rise) 3 (6.6) 22 (48.8) 2 Activates emergency response system 13 (28.8) 20 (44.4) 8 Minimize interruptions in chest compressions 7 (15.5) 15 (33.3) 14 Resume CPR beginning with compressions immediately after each shock. 13 (28.8) 14 (31.1) 11 Power ON the AED and Attach electrode pads 3 (6.6) 12 (26.6) 9 Open airway: head tilt-chin lift 3 (6.6) 11 (24.4) 3 Check for pulse 4 (8.8) 11 (24.4) 7 Allow complete chest recoil between compressions 2 (4.4) 9 (20.0) 12 Clear victim before ANALYZE and SHOCK 2 (4.4) 6 (13.3) 4 Proper hand placement & Begin 30 chest compression 0 (0) 2 (4.4) 13 Give Shock 0 (0) 0 (0) 1 Assess responsiveness 0 (0) 0 (0) ^Number of questions arranged in descending order based on the control group retention skill test mistakes ratio) 3.5. Comparison Between Students Based on Their GPA The participants in this study classified into three groups based on their grade point average (GPA) level: (1) week and satisfactory, (2) good, and (3) very good and excellent groups. ANOVA test was performed to examine the effect of GPA on: 1) the baseline CPR knowledge, 2) CPR knowledge and skills acquisition and 3) CPR knowledge and skills retention of the participants in the control group. The test revealed significant differences between: 1) the GPA level groups and pretest CPR knowledge: (F=12.27, p <.001), 2) GPA and posttest knowledge, (F =13.66, p <.001), 3) GPA and posttest skills: (F =16.07, p <.001), 4) GPA and retention knowledge: (F =16.15, p <.001); 5) GPA and retention skills (F =19.11, p <.001). During the baseline phase (pretest), the findings of this study showed that the participants with very good and excellent GPA level had the highest mean (M = 6.93, SD = 1.14) of CPR knowledge test, followed by the participants with good GPA level (M = 5.65, SD =.87), and finally the participants with week and satisfactory GPA level (M = 5.18, SD =.75). During the acquisition phase: (1) posttest CPR knowledge and (2) posttest CPR skills: the participants with very good and excellent GPA level had the highest mean in posttest knowledge (M = 12.00, SD =.39) and in posttest skills (M = 13.14, SD =.66), followed by the participants with good GPA level, knowledge test (M = 11.05, SD =.75) and in posttest skills (M = 11.00, SD = 1.33) and finally the participants with week and satisfactory GPA level, posttest knowledge (M = 10.55, SD =.93) and posttest skill (M = 10.64, SD = 1.62). During the retention phase: (1) retention CPR knowledge test and (2) retention CPR skills test: the participants with very good and excellent GPA level had the highest mean in retention knowledge test (M = 11.36, SD =.92) and in the retention skills test (M = 12.21, SD =.80), followed by the participants with good GPA level, retention knowledge test (M = 9.80, SD = 1.15) and in the retention skills test (M = , SD = 1.50) and

7 International Journal of Educational Research and Information Science 2015; 2(4): finally the participants with week and satisfactory GPA level, retention knowledge test (M = 8.91, SD = 1.22) and posttest skill (M = 9.27, SD = 1.73). Follow-up post-hoc analyses, utilizing Tukey's HSD procedure indicated that nonsignificant differences between the participants with good GPA level and the participants with week and satisfactory GPA level at.05 level in the pretest CPR knowledge, acquisition tests of CPR knowledge and skills and retention tests of knowledge and skills (Table 4). Table 4. Cardiopulmonary Knowledge and Skills Baseline, Acquisition and Retention Based on GPA Level for the Control Group. ANOVA ^GPA=1 n= (11 ) ^GPA=2 n= (20 ) ^GPA=3 n= (14 ) Pretest knowledge 5.18 (0.75) 5.65 (0.87) 6.93 (1.14) Posttest knowledge (0.93) (0.75) Posttest skills (1.62) Retention knowledge Retention skills 8.91 (1.22) 9.27 (1.73) (1.33) 9.80 (1.15) 9.55 (1.50) (0.39) (0.66) (0.93) (0.80) * p.001 ^GPA = Grade Point Average. 1= week and satisfactory, 2 = good, 3= very good and excellent. F statistics Tukey HSD Significant comparison Mean difference * * * * * * * * * * Comparison between the participants GPA levels in the interventional group in relation to their mean scores on (1) posttest knowledge and skills and (2) the retention knowledge and skills test. ANOVA analyses showed significant differences in all participants level on (1) posttest CPR knowledge and (2) posttest CPR skills, (3) retention CPR knowledge test and (4) retention CPR skills (F = 22.13, P = <.001; F = 16.67, P = <.001; F = 14.99, P = <.001; F =16.17, P = <.001) respectively. Post-Hoc analyses showed nonsignificant differences between the participants with good GPA level and the participants with week and satisfactory GPA level in relation to their pretest CPR test at (P =.05). Furthermore, nonsignifacant differences were found between the participants with very good GPA level and good GPA level in posttest knowledge and skills at (P =.05). In addition, no significance differences were found in the retention mean scores of the good GPA participants and very good and excellent participants level at (P =.05) in relation to knowledge and skills retention at (P =.05) (Table 5). Table 5. Cardiopulmonary Knowledge and Skills Baseline, Acquisition and Retention Based on GPA Level for the Intervention Group. ANOVA ^GPA=1 + n= (18 ) ^GPA=2 + n= (14 ) ^GPA=3 + n= (13 ) Pretest knowledge 5.00 (0.90) 6.29 (0.73) 6.31 (1.38) 8.74 Posttest knowledge (0.88) (0.55) Posttest skills Retention knowledge Retention skills (0.91) (0.92) (1.53) (0.76) (0.73) (0.75) ** p.05 * p.01 *** p.001 ^GPA = Grade Point Average + 1= week and satisfactory, 2 = good, 3= very good and excellent (1.07) (1.01) (1.14) (0.60) F statistics Tukey HSD Significant comparison 1 v. 2 1 v. 2 1 v. 2 1 v. 2 Mean difference ** *** * * * * * * * * 4. Discussion and Conclusion 4.1. Knowledge Baseline Phase This phase aimed to evaluate the participants' baseline CPR knowledge before initiation of CPR training for both groups: control and intervention. The results showed that the differences between the control and the intervention groups were nonsignificant. There are no differences in their CPR knowledge between the groups which support the inclusion criteria of the study. Furthermore, this study showed that the participants in both group have low level of CPR knowledge at baseline phase. The American Heart Association (2010) emphasized the concept of a chain of survival to clarify the component of an effective response that would improve the chances of survival from cardiac arrest. The chain comprises five links: Immediate recognition of cardiac arrest and activation of the emergency response system, early CPR with

8 90 Muayyad M. Ahmad and Ahmad A. Aqel: Comparison Between Clinical Simulation and Traditional Teaching for Cardiopulmonary Knowledge and Skills an emphasis on chest compressions, rapid defibrillation, effective advanced life support and integrated post-cardiac arrest care. The first two links are dependent on the available individual at the scene; nursing students during their clinical rotation may be the first to discover and respond to cardiac arrest victims (Gombotz, Weh, Mitterndcrfar, & Rehak, 2006; Ahmad & Dardas, 2015; Alasad & Ahmad, 2014). Although the participants in this study are nursing students and showed a lack of basic knowledge in CPR, this study was needed to emphasize the importance of providing the participants with the needed knowledge of CPR Knowledge and Skills Acquisition Phase This phase aimed to examine the effect of different teaching methods on CPR knowledge and skills acquisition. The results in this study showed a significant difference in CPR knowledge and skills between the two groups. CPR knowledge and skills were significantly increased in both groups, however, the participants in the HFS group gained greater CPR knowledge and skills than the static manikin group.these results are consistent with the findings of the previous studies (Ackermann, 2009; Nehring & Lashley, 2010; Tawalbeh & Ahmad, 2013) who supported the learning outcome from the training on HFS by increasing nurses knowledge and skills. The significant results of this study could be explained based on Kolb s (1984) experimental learning theory, in which participants transfer the theoretical knowledge and apply it in a realistic setting that enhance their knowledge. According to the theory, learning is enhanced when individuals are actively practicing problem solving, decision making, and active reflection. One benefit of HFS is giving the opportunity to the trainee to have deliberate, repetitive practice with expert feedback (Kneebone, 2005; Tawalbeh & Ahmad, 2014). In this study, the differences in CPR knowledge and skills acquisition could be explained by the chances given to HFS group after gaining the theoretical CPR knowledge and then practiced on a reactive simulator. The participants' scores in the acquisition of CPR knowledge and skills test improved when learning was supported by team working, observing others' actions, and getting feedback during the debriefing session using HFS. Debriefing provides feedback and reflection that leads to effective learning (Fanning & Gaba, 2007; Ahmad & Al Nazly, 2014) and increases knowledge acquisition (Shinnick, Woo, Horwich, & Steadman, 2011). The significant result of this study is consistent with (Lasater, 2007) study who emphasized the added value of the HFS such as the ability of reproducing physiologic responses and respond to interventions provided. Furthermore, the HFS has additional features not present in the static manikins such as the ability to count heart beat as well as listen to breathing sounds. During training on the static manikin, participants required to ask the instructor if there is a pulse or not; while the participants in the HFS group have the opportunity to count the pulse and listen to breathing sound when required. Although many researchers support that HFS enhances critical thinking of the participants (Wotton, Davis, Button, & Kelton, 2010) knowledge acquisition through HFS has not been well integrated in teaching programs (Levett-Jones, Lapkin, Hoffman, Arthur, & Roche, 2011). The findings of this study support and valued the effectiveness of using HFS over the traditional static manikin for CPR knowledge acquisition. In this study, knowledge and skills acquisition were evaluated immediately after training. This could be argued for the suitability of assessing the knowledge and skills acquisition, further research is required to ascertain the appropriate evaluation time post training Knowledge and Skills Retention Phase This phase aimed to examine the effect of different teaching methods on the CPR knowledge and skills retention. The findings of this study showed significant differences in CPR knowledge and skills retention between the two groups. CPR knowledge and skills were significantly decreased in both groups after three months of training. However, the participants in the HFS group showed more retention of CPR knowledge and skills than participants in the static manikin group. These results are consistent with the findings of previous studies that examined CPR retention (Ackermann, 2009; Smith, Gilcreast, & Pierce, 2008; Ahmad, 2014). Smith, Gilcreast and Pierce found that nurses who received CPR training on a static manikin have nearly 37% deterioration of their skills and knowledge within 3 months of training and 42% at 12 months. This study supports reported findings from other studies of the benefits of HFS use on participants' retention of knowledge and skills. Thus, frequent refreshing CPR training using HFS to enhance students' knowledge and skills retention is needed. Furthermore, the American Heart Association (2010) guidelines rearranged the sequence of CPR from Airway- Breathing-Compressions (ABC) to Compressions-Airway- Breathing (CAB). Since 1960 health educators were teaching the ABCs of CPR, this approach was causing significant delays in starting chest compressions; refreshing CPR courses for educators and clinical instructors are needed. The findings of this study showed that the static manikin group has greater loss than the HFS group in some critical aspects of CPR skills such as: Activating the emergency response system, providing adequate compression rate and depth, and providing effective breathing. This result is consistent with the previous studies conducted in the United State of America indicated that some aspects of CPR skills decline rapidly post training: chest compression, ventilation and interruptions during compression (Alspach, 2005). In this study high percentage (85%) of the HFS group retained the above CPR skill aspects after three months of training; that support and valued HFS training over the traditional static manikin. This study cannot be generalized due to limitations that have been discussed later in this study Implications The findings of this study confirm that student nurses can benefit from participation in HFS training. A significant

9 International Journal of Educational Research and Information Science 2015; 2(4): increase in the post-test knowledge and skills after the HFS training was observed. Moreover, the findings of this study supported the effectiveness of HFS and reported that HFS provided an alternative approach to learning that allowed participants to integrate theory and practice. The participants in the high fidelity simulation group had the opportunity to repeat practicing CPR skills and reflect upon their mistakes. These benefits enhance the learning outcomes of nursing students. Furthermore, nursing educators should determine the best educational practice when HFS is integrated into nursing curriculum. Nursing educators should use simulation scenarios that are suitable to students' levels Conclusion The results of this study supported findings about effectiveness of HFS in relation to CPR knowledge acquisition and retention in clinical teaching. The results also indicate that the HFS group had greater knowledge and skills than the static manikin on the acquisition and retention phase. In the mean time, both groups have shown deterioration in knowledge and skills in the retention phase. In general, HFS in this study had proven to be encouraging teaching method that can be used as an alternative method in nursing education. As the results of this study have strong evidence base, clinical educators may incorporate this technology in the clinical curricula in order to maintain and refine nursing students' knowledge and skills. Acknowledgement This study was partially funded by the University of Jordan References [1] Abella, B. S., Alvarado, Myklebust, H., Edelson, D. P., Barry, A., O'Hearn, N., Vanden Hoek, T. L., & Becker, L. B. (2005). Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest. Journal of the American Medical Association, 293, [2] Ackermann, A.D. (2009). 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