Nursing students’ knowledge, attitude, self-efficacy in blended e-learning of cardiopulmonary resuscitation: a randomized controlled trial


 Background: Although various forms of online education are on the rise worldwide, effects of such innovative approach are yet to be validated. This study analyzes whether blended e-learning cardiopulmonary resuscitation (CPR) education that integrates e-learning and face-to-face education is effective in improving nursing students’ knowledge, attitude, and self-efficacy.
Methods: The participants of this study were 120 nursing students randomly assigned to the intervention group (n = 60) or the control (n = 60). Differences before and after the education of each group were analyzed with a paired t-test, and the differences between the two groups were analyzed with ANCOVA with knowledge as the covariate.
Results: The findings indicated that the intervention group had significantly higher knowledge, F(1,117) =595.78, p <.001, and emotional attitude, F(1,117) = 9.61, p = .002, about CPR than the control group.
Conclusions: Blended e-learning CPR programs could be used as effective supplemental CPR education for nursing students.


Background
Heart disease, along with cancer, is one of the leading causes of death. Out of every three people in the Organisation for Economic Co-operation and Development (OECD) countries, one dies from a circulatory disease, such as ischemic heart disease [1]. In fact, an estimated 31% of the deaths worldwide each year are due to cardiovascular diseases (CVDs), and cardiac arrest and stroke account for 80% of total CVD deaths. In such a context, it is very important for health workers to be prepared to administer CPR to patients with CVD [2]. Korea is no exception, and heart disease is the second leading cause of death, following cancer [1]. The onset of cardiac arrest is unpredictable in many cases, and it is crucial to administer CPR immediately following onset, as it becomes fatal 4-6 minutes after onset [3,4]. Nurses are likely to be first responders, because they spend significant time alongside patients and are often the first to realize when a patient is experiencing an in-hospital cardiac arrest. Thus, it would be beneficial for nursing students to have proper knowledge and high self-efficacy about CPR to strengthen their skills for future use [5,6]. Nurses' personal belief, attitude, skills, experience, and knowledge affect their nursing practice [7]. Further, knowledge about CPR in relation to the standard treatment for cardiac arrest is the basis for administering CPR effectively [8], 3 and self-efficacy is a predictor of CPR performance [8,9]. A study that analyzed nursing students' self-efficacy as an outcome of a simulation-based Basic Life Support education program [5] and another study both reported that nursing students who performed chest compression properly have higher self-efficacy [4].
To be able to respond during cardiac arrest situations promptly and effectively, nurses must be skilled at, prepared for, and updated on life-saving procedures [10], which may require repeated CPR training [11]. In particular, the attitudes of nurses and nursing students toward attempting CPR are an important factor in the prompt and successful responses to cardiac emergencies [12,13]. Despite that nurses have knowledge, skills, training, and professional obligation to independently administer CPR and defibrillation, they may be hesitant to take timely action [12]. In other words, one of the key factors hindering nurses from initiating CPR prior to the arrival of a physician or medical emergency team is their attitude [14,15]. Thus, it would be appropriate to include the first responder's attitude toward CPR practice as a variable when exploring the factors that are related to CPR performance.
Despite the growing demands for competent nurses in clinical practice, nursing education has been focused on theoretical lectures and observation-focused curricula, with declining opportunities for hands-on clinical practice [16]. For this reason, the importance of preparing educational alternatives is rising with some studies have reported the benefits of blended e-learning in nursing education [16,17].
Nursing curriculum should be designed such that students can experience cognitive, affective, and psychomotor aspects [18]. Beyond learning nursing skills, nursing students must acquire confidence as nursing professionals, be able to think about patients' health problems analytically and critically, and be able to efficiently solve problems in emergencies [17]. As prospective nurses, nursing students must acquire skills and evaluate them in order to be able to solve problems independently and deliver the proper care in emergencies that require CPR [4,19]. Therefore, this study examined the effects of blended e-learning, a type of education that could improve CPR competency in nursing students.
As education environments are changing with rapid advances in information and communication technology worldwide, education paradigms have shifted from traditional lecture-focused education to 4 learner-centered education, and various education programs utilize e-learning with computers and internet [20][21][22]. In particular, clinical training opportunities are being reduced due to a lack of resources, a high rate of nurse turnover, and patients' safety and as a result, online and blended education have been proposed as important alternatives [16]. Blended e-learning enables selfdirected, iterative learning, which may render it more effective than traditional training education in improving nursing competence [17]. A study that assessed the persistence of the effects of a CPR education based on theoretical lectures and training [8] found that knowledge and self-efficacy significantly decreased after three months, suggesting that continuous education and training are essential. From this perspective, video-based education is potentially a good alternative in that it enables self-directed, iterative learning.
Benefits of e-learning in CPR education include cost-effectiveness, consistent training of techniques based on the guidelines standardized by the American Heart Association (AHA), and delivery of consistent educational contents to all types of education recipients regardless of their skill level [23,24]. CPR e-learning is effective for teaching knowledge, attitude, and technique [25,26], and it has been reported to be more effective than instructor-centered CPR education in improving knowledge, self-efficacy, and performance [27,28]. However, some studies have reported that e-learning does not produce significantly better outcomes compared to traditional face-to-face education [29].
Further, applying both video training and theoretical education together was more effective than using video training alone, and it has been suggested that additional randomized controlled trials (RCTs) are needed to accurately assess the effects of e-learning [11,16,30].
Although various forms of online education are on the rise worldwide [16,30], the effects of such innovative approaches have yet to be validated [16]. In South Korea, the Ministry of Health and Welfare and the Korea Centers for Disease Control and Prevention (KCDC) develop and distribute standard CPR e-learning materials with government funding (http://www.cdc.go.kr), but no study has measured their effects. Thus, this study aims to examine whether a standardized CPR e-learning program, devised by a Korean public health institution in collaboration with experts, is effective.
Considering previous lack of effort to examine the effects of online-based learning programs, such as 5 on learners' performance, despite their rapid popularization [31,32], this study may contribute to increasing the foundational data for effective blended e-learning, a new potential education alternative for nursing students.

Research hypotheses
Hypothesis 1. The intervention group who receive blended e-learning CPR education will have a higher CPR knowledge score after education than that before education.
Hypothesis 2. The intervention group who receive blended e-learning CPR education will have a higher CPR attitude score after education than that before education. Hypothesis 3. The intervention group who receive blended e-learning CPR education will have a higher CPR self-efficacy score after education than that before education. Hypothesis 4. The intervention group who receive blended e-learning CPR education will have a higher CPR knowledge score after education than that of the control group.
Hypothesis 5. The intervention group who receive blended e-learning CPR education will have a higher CPR attitude score after education than that of the control group. Hypothesis 6. The intervention group who receive blended e-learning CPR education will have a higher CPR self-efficacy score after education than that of the control group.

Design and participants
This study adheres to the CONSORT guidelines and was a prospective randomized controlled trial aiming to identify effects of blended e-learning CPR education on nursing students' CPR-related knowledge, attitude, and self-efficacy. The minimum sample size for analyzing differences between two groups with a two-tailed test was calculated using G*Power 3.1. With a statistical significance level of 0.05, power of 0.85, and effect size of 0.60, the sample size was calculated to be 51 for each group, totaling 102. Considering potential dropouts, 120 nursing students were recruited from a single institution. Nursing students who provided their written informed consent to participate in this study, had not completed the emergency department training course, and had never received blended e-6 learning CPR education were eligible to participate in the study. We excluded fourth-year students, as they had completed the emergency department training course, while 40 first-year, 40 second-year, and 40 third-year students were recruited. Education was administered and data collected between September and November 2017. (Fig. 1).

Randomization
For each grade-level, students were assigned to the intervention and control groups based on the order of entering the lecture room, where odd numbers were assigned to the intervention and even numbers were assigned to the control group. To adjust for differences among years in school, twenty students from each grade-level were randomly assigned to the intervention and control groups each, resulting in a total of 60 students in the intervention group and 60 students in the control group.

Intervention of blended e-learning CPR education
The blended e-learning CPR education program was designed as a four-session program. In Session 1, program orientation was given. In Session 2, students watched a video titled "How to perform chest compression CPR and use automated defibrillator" produced by the Korean Association of Cardiopulmonary Resuscitation (KACPR; http://www.kacpr.org/main.php) and managed by the Ministry of Health and Welfare (MOHW; http://www.mohw.go.kr/react/index.jsp) and KCDC (http://www.cdc.go.kr). The video described the definition of CPR, the overall CPR process, basics of chest compression CPR, and how to use an automated defibrillator. In Session 3, students watched a video titled "Basic course for standard CPR education program" produced by the KACPR and managed by the MOHW, KCDC, and Ministry of Education and Ministry of Public Safety and Security. The video contained information about cardiac arrest cases and need for CPR, successful CPR cases, chest compression process, chest compression training, cases in which no one is available to help, how to use the speaker feature of a cell phone, repeated CPR training, how to use an automated defibrillator, precautions for using a defibrillator, how to use an emergency medical information application, and 7 how to deliver rescue breaths. In Session 4, students were given a lecture using a printout made by the investigator based on the key contents of the KACPR guideline and 2010 AHA guideline for CPR and emergency cardiovascular treatment (Table 1). The printout containing CPR guidelines was also distributed to and read by the control group.
[ Table 1 near here] The pre-intervention questionnaire was administered to both the intervention and control groups at the same time. Both groups completed a questionnaire containing items to measure knowledge, attitude, and self-efficacy for CPR. The investigator collected the completed questionnaires. The postintervention questionnaire was administered to both the intervention and control groups at the same time, immediately after the end of the education program. The questionnaire was identical to the preintervention questionnaire, measuring participants' knowledge, attitude, and self-efficacy for CPR. The investigator collected the completed questionnaires (see Additional file 1).

Knowledge
Knowledge was measured with an instrument developed by Byun [33] based on CPR guidelines published by the AHA in 2010. This 20-item scale comprised two items for checking for consciousness, two items for checking for breathing, seven items for delivering chest compressions, four items for maintaining airway and delivering rescue breaths, and five items for using a defibrillator. The total score ranged from 0-20, with a higher score indicating a higher level of knowledge.

Attitude
Attitude was measured using an instrument developed by Cho [34] with reference to the AHA guidelines and KACPR guidelines. Three types of attitudes were measured. Emotional attitude, which refers to one's feelings about "performing basic CPR to a cardiac arrest patient," was measured with 10 items rated on a seven-point scale. Behavioral attitude was measured with three items, including "I will try my best to perform CPR when I witness a cardiac arrest patient," rated on a four-point scale.
Finally, cognitive attitude was measured with three items, including "I think performing CPR promptly is important for the outcome of a cardiac arrest patient," rated on a four-point scale. Five items for emotional attitude were reversely scored. The total score ranges from 0-94, with a higher score indicating a more positive attitude. The Cronbach's a for emotional, behavioral, and cognitive attitudes in Cho's [34] study were 0.69, 0.77, and 0.63, respectively. The Cronbach's a for emotional attitude, behavioral attitude, and cognitive attitude in this study were 0.63, 0.85, and 0.87, respectively.

Self-efficacy
Self-efficacy was measured using a self-efficacy scale developed by Park [35] and modified and adapted by Byun [33]. The scale comprises 12 items, including "I am confident that I can perform CPR during an emergency." The total score ranges from 0-120, with a higher score indicating a higher level of self-efficacy. The reliability (Cronbach's a) of the tool in Park's [35] study was 0.93, and that in this study was 0.90.

Statistical Analysis
The collected data were analyzed with the Statistical Package for the Social Sciences (SPSS) 22 software (IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp., 2013). Participants' general characteristics were presented as a real number and percentage and as mean and standard deviation, and pre-intervention homogeneity between the groups was tested via c²-test, t-test, and ANOVA. The changes after education in the intervention and control groups were analyzed with paired t-test, and differences for the intervention between the two groups were analyzed with ANCOVA with knowledge, which differed between the two groups, as the covariate.

Pre-intervention homogeneity among participants
The mean age was 21.18 years in the intervention group and 21.27 years in the control group. The percentages of male and female participants were 16.6% and 83.4%, respectively for both groups.
Further, the percentages of all of the students in the sample with and without clinical training experience were 33.3% and 66.7%, respectively. Regarding having witnessed CPR, 21.6% had witnessed CPR while 78.4% had not in the intervention group, with the percentages being 30% and 70%, respectively, in the control group. A total of 78.3% of the intervention group had previously received CPR education, while 21.7% had not, with the percentages being 71.7% and 28.3%, respectively, in the control group. The percentages of students who had and had not performed CPR were 18.3% and 81.7%, respectively, in the intervention group, and the percentages were 15% and 85%, respectively, in the control group. The mean pre-intervention CPR knowledge score was 7.98 in the intervention group and 6.63 in the control group (p = .017). Among ratings on CPR attitudes, the mean emotion scores were 37.70 and 35.90 (p = .225), in the intervention group and control group, respectively. The mean behavior scores were 7.03 and 7.56 (p = .077), respectively, and the mean cognition scores were 7.25 and 7.51 (p = .373), respectively. The mean CPR self-efficacy scores were 71.51 and 69.31 (p = .567), respectively. Thus, prior to the start of the intervention, the two groups did not significantly differ in any of the outcome variables except for CPR knowledge (Table 2).

Hypothesis 2
After receiving blended e-learning CPR education, the intervention group's CPR attitude scores  (Table 3).

Hypothesis 4
The intervention group that received blended e-learning CPR education had a significantly higher CPR knowledge score 16.40 (SD = 1.56) than that of the control group 6.46 (SD = 2.62). Thus, Hypothesis 4 was supported (Table 4).

Hypothesis 5
The intervention group that received blended e-learning CPR education had a significantly higher CPR emotional attitude score 40.85 (SD = 8.01) than that of the control group 36.05 (SD = 6.87), with no significant differences in other two components of attitude. Thus, Hypothesis 5 was partially supported (Table 4).

Hypothesis 6
The intervention group that received blended e-learning CPR education had a higher CPR self-efficacy score 82.02 (SD = 18.39) than that of the control group 75.25 (SD = 16.38), but the difference was not statistically significant. Thus, Hypothesis 6 was not supported (Table 4).

Discussion
By analyzing the effects of a blended e-learning program based on e-learning materials developed by major Korean public health institutions with government funding on CPR knowledge, attitude, and self-efficacy, this study has added new evidence supporting the effectiveness of blended CPR e-11 learning. The most notable accomplishment was that the intervention group that underwent this blended e-learning program showed significant improvements in their pre-interventions scores in knowledge, emotional attitude, behavioral attitude, cognitive attitude, and self-efficacy following the completion of the e-learning program. In this study, the intervention group underwent CPR education via blended e-learning. They had a higher CPR knowledge score after education than the control group. This aligns with the findings of a previous study that analyzed the effects of a web course called "Help-brain-heart," before CPR training on knowledge, CPR skills, and willingness to act in teenagers [36], where web-based learning improved students' theoretical knowledge of acute myocardial infarction (AMI) and stroke and lifestyle factors. Furthermore, our findings align with those of a Korean study on nurses who received basic CPR education using videos [31], where video-based education was effective in increasing knowledge in the single intervention group. This suggests that blended e-learning programs can improve learners' knowledge scores. In other words, administering blended e-learning CPR education to nursing students seems desirable for increasing their knowledge of CPR.
Furthermore, the intervention group, which underwent blended CPR e-learning, had a significantly more positive emotional attitude toward CPR after education compared to that of the control group. This is identical to the finding of a Korean study that administered basic CPR education on Korean nurses using a video program [31], where the intervention group had significantly better belief and emotion scores of CPR attitudes after education. In other words, as with knowledge, the emotional aspect of attitude mostly improves after education. However, behavioral attitude was slightly lower, though insignificant, and cognitive attitude score was higher in the intervention group, but not to a significant extent. These findings support a previous report that because CPR is a psychomotor skill, hands-on clinical training is more effective than lecture-based or video-based education in improving CPR performance [37][38][39][40]. Some previous studies have confirmed the effectiveness of hands-on education in improving CPR performance [37,38,40]. However, a supplemental learning method that increases temporal and spatial flexibility of learning administered before and after hands-on training, to prepare participants for the training and reinforce their learning, would be a cost-effective method [41]. Moreover, such methods could appeal to younger generations and be used for rehearsals [40].
Following the e-Learning, the intervention group showed a non-significant trend toward higher scores on the behavioral and cognitive aspects of attitude than did the control group. This aligns with the findings of a previous study that administered basic video-based CPR education to Korean nurses [31], where the intervention group did not show a significant difference in behavioral attitudes toward CPR after education. Furthermore, these results support a previous report that web lecture prior to CPR training does not affect practical CPR skills or willingness to act in nursing students [36].
Nevertheless, it was beneficial for increasing nursing students' knowledge [36].
With clinical learning at its core, nursing education aims to help students learn and practice nursing skills and develop self-efficacy [42], and thus, confirming the importance of self-efficacy for the development of psychomotor skills. In this study, the intervention group showed significantly higher self-efficacy after education, and the intervention group's self-efficacy score was higher than that of the control group, but not to a significant extent. This suggests that CPR education using a blended elearning method is effective in improving students' self-efficacy regarding the ability to perform CPR.
Students' self-efficacy refers to the scope or power of one's beliefs about one's ability to complete a task and accomplish the goal. Self-efficacy in nursing students prevents stress and burnout and increases learning performance by promoting participation in nursing education [42]. Particularly, improving self-efficacy as a psychomotor skill can lower stress in nursing students, the latter of which can have negative effects on clinical placement, such as in memory, attention, problem-solving skills, and coping skills. At the same time, self-efficacy is a predictor of academic success and personal development, as an increase of self-efficacy promotes one's participation in learning, and thereby improves learning outcomes [42].
The blended e-learning program used in this study integrated traditional lectures with video-based education using "How to perform chest compression CPR and use automated defibrillator" produced by the KACPR and managed by the MOHW and KCDC and "Basic course for standard CPR education program" produced by KACPR and managed by the MOHW, KCDC, Ministry of Education, and Ministry of Public Safety and Security. After the intervention, CPR knowledge, emotional attitude, and self-13 efficacy significantly increased. Thus, nursing students should regularly receive CPR education to enhance their ability to respond in medical emergencies.
Overall, CPR education using a video titled "How to perform chest compression CPR and use automated defibrillator" produced by the KACPR was effective in increasing knowledge, attitude (i.e., emotions, behavior, cognition), and self-efficacy for CPR. Therefore, it would be beneficial to use blended CPR e-learning programs that integrate lectures and videos to educate nursing students in CPR.
One limitation of this study is that the participants were nursing students studying in the same school, so the possibility of diffusion could not be completely eliminated. Furthermore, generalization of the findings is limited, as only nursing students from one school were examined. Finally, this study could not directly assess CPR psychomotor skill performance. Nor could this study provide training or assessment in CPR performance, due to the nature of the study procedure.
Based on these findings, we suggest the following. First, CPR education is effective for promoting CPR knowledge, attitude (emotion, behavior, cognition), and self-efficacy, so CPR education using blended e-learning should be incorporated into nursing curricula. Next, subsequent studies should administer simulation-based training to improve the outcomes of education and measure CPR performance. Also, subsequent studies should include more schools, as this study included only one school. Finally, studies should also verify an appropriate cycle of CPR refresher courses by investigating the persistence of educational outcomes.

Conclusions
This study added evidence supporting the integration of video-based education into traditional nursing education. This study, which investigated the effects of a blended CPR e-learning program, confirmed that integrating existing CPR instruction videos was effective in increasing CPR knowledge, attitude (i.e., emotions, behavior, cognition), and self-efficacy in nursing students. In today's clinical practice, there is a high demand for well-trained nursing graduates who are capable of effectively responding to various service needs in complicated environments. Shifting nursing education to one that integrates traditional education with skill training would minimize the gap between service 14 deliveries, enhance the quality of education, and ensure the safety of patients.