Effectiveness of a blended (distance and in-person) simulation education program on advanced cardiac life support for nursing students using the PARTNER model

Due to recent increases in population aging, meat-centric diets, and high stress, the incidence of acute cardiac arrest is rising. Approximately 80% of patients with acute cardiac arrest die within one hour, making it a life-threatening emergency situation [1, 2]. Nursing students often do not encounter cardiac arrest patients during clinical training, and it is challenging for them to participate in such critical situations when they do occur [3, 4]. Additionally, cardiac arrests in hospitals often arise from complex issues in patients, necessitating specialized education in advanced cardiopulmonary resuscitation including drug administration according to ECG findings, airway management, and correction of issues causing the arrest [5, 6]. However, specialized CPR training is only provided in some nursing schools, and is generally characterized by instructor-led theoretical education followed immediately by practical training, which is often inadequate [7].

Due to the unpredictability of clinical situations, theoretical knowledge acquired in classroom settings often fails to translate into immediate practical application without integration with practical skills [7]. Therefore, scenario-based simulation training reflecting various clinical situations is essential, though understanding complex scenarios can be challenging without adequate prebriefing [8]. A systematic blended learning approach that combines self-directed prebriefing with hands-on practice is crucial for integrating knowledge and enhancing clinical performance in managing emergencies like cardiac arrest [9]. Blended learning is an instructional approach that combines two or more learning methods, integrating both online (asynchronous) and face-to-face (synchronous) sessions. It is emphasized as an important and systematic practice for learner-centered education [10].

Despite efforts to promote self-directed learning through resources and instructional videos, merely providing learning materials does not necessarily enhance students’ motivation or ensure diligent study [11]. Web-based simulations after theoretical learning can provide a pseudo-experience similar to real clinical scenarios, enabling autonomous learning outside the classroom and better preparation for face-to-face practical sessions [12].

In face-to-face practical training, especially for advanced professional nursing skills like those required for cardiac arrest, scenario-based simulation training is necessary to link previously learned knowledge through systematic learning processes [13]. However, previous studies often comprised only brief simulations following group discussions or simple practice, which were insufficient for enhancing clinical performance [14].

Flipped learning, where students engage in theoretical study outside the classroom before engaging in case-based collaborative learning inside the classroom facilitated by instructor coaching, enhances problem-solving skills [15, 16]. The PARTNER model exemplifies a learner-centered approach to flipped learning, systematically structured in seven stages, starting with autonomous pre-class study to integrate knowledge, followed by collaborative learning centered around clinical scenarios in the classroom [14, 17]. Through team collaboration and case-based discussions, this model facilitates reflective contemplation for addressing complex cardiac arrest scenarios, thereby enhancing knowledge, confidence, and problem-solving abilities [18]. However, prior studies utilizing the PARTNER model have focused only on simple nursing techniques and theoretical education, with limited research on the effects of blended simulation training for advanced cardiopulmonary resuscitation. Thus, this study aims to apply a PARTNER model-based blended simulation training program in advanced cardiopulmonary resuscitation to nursing students to evaluate its effectiveness.

The purpose of this study is to compare the effectiveness of a blended simulation-based Advanced Cardiovascular Life Support (ACLS) education program utilizing the PARTNER model with traditional simulation education. This study aims to assess the effects of the program on nursing students’ ACLS knowledge, ACLS confidence, ACLS performance, clinical competence, and learning satisfaction.

This study was approved by the Institutional Review Board of K University (approval number 40525-202204-HR-018-13) following a review. After obtaining approval from the head of the nursing department to which the research subjects belonged, third-year nursing students at the College of Nursing, K University in Daegu, who voluntarily wished to participate, were recruited via notices on the college bulletin boards. Participants were not informed in advance of the group they were assigned to, and an orientation regarding the educational program was provided to each group. At the time of applying for the program and during the orientation session, participants were notified that they must attend all surveys and evaluations, both before and after the education. The researcher obtained written consent from the participants after explaining the purpose, necessity, methods, and duration of the study. To ethically protect the participants, it was specified that the collected data would not be used or disclosed for purposes other than the research, and personal information of the participants would not be used for any other purposes. Participants’ rights were protected by ensuring anonymity and informing them that they could refuse or discontinue participation at any time if they wished. During data collection for the program, questionnaires with participant information identification codes were used to protect personal information. It was explained that the collected survey data would be stored for three years and then destroyed using a shredder.

Data analysis was performed using SPSS 27.0 (IBM Corp., Armonk, NY, USA). General characteristics such as age, gender, preferred educational methods, and previous semester grades were analyzed using frequency, percentage, mean, and standard deviation. Normality was tested with the Shapiro-Wilk test. Homogeneity testing for variables was conducted using Fisher’s exact test and Independent t-test, and hypothesis testing was carried out using Repeated Measures ANOVA, Independent t-test, and Mann-Whitney U test.

This study attempted to identify the effects on knowledge, confidence, professional cardiopulmonary resuscitation performance, clinical performance, and learning satisfaction by applying a blended simulation education program for professional cardiopulmonary resuscitation using the PARTNER model for nursing college students. As a result, the intervention-applied experimental group showed significant improvements in knowledge, confidence, advanced cardiac life support performance, and clinical skills compared to the comparison group.

After applying the intervention program, knowledge scores increased by 29% in the experimental group and 20% in the control group, indicating that the educational method used in the experimental group was more effective in enhancing knowledge compared to traditional learning methods. In previous studies, professional cardiopulmonary resuscitation education using flipped learning was effective for nursing students [37]. According to the study by Nugraheni et al., in flipped learning, combining learning methods that involve applying knowledge to real clinical situations to solve problems is reported to be more effective in enhancing knowledge than simply providing materials or video lectures [38]. Therefore, this study suggests that providing web-based simulation training, rather than simple video learning, during the preliminary stage as pre-learning, was effective in enhancing knowledge. Therefore, video lectures and web-based simulation education should be provided together when designing professional cardiopulmonary resuscitation education programs in the future, so that learners can induce critical thinking and cultivate knowledge.

After implementing this intervention program, the confidence score increased by 34% in the experimental group and 26% in the control group. In a study that conducted core nursing education using the PARTNER model, discussions on various clinical situations and repetitive learning opportunities were provided to help increase core nursing-related confidence [14]. In this program, the PARTNER design provided opportunities for repetitive learning in various case-oriented clinical situations. In particular, it is believed to increase confidence in professional cardiac resuscitation by realistically providing various clinical cases through web-based and high-fidelity simulations. Therefore, to improve confidence when planning professional cardiopulmonary resuscitation education program, it is necessary providing opportunities for repetitive learning in the process of pre-learning linkage, cooperative learning, and debriefing in the PARTNER model.

The performance of professional cardiac resuscitation was 13 points higher when the experimental group trained in this intervention program converted to 100 points compared to the control group. In studies that applied flipped learning to professional cardiopulmonary resuscitation simulation education, professional cardiopulmonary resuscitation performance was lower than that of the control group when only various skill-related videos were provided [39]. This is believed to be the result of providing various opportunities to experience virtual clinical situations using blended learning methods that apply various learning methods to pre-learning and main learning, unlike Xin. et al.’s [39], which provided both technical videos and face-to-face simulations. In addition, by experiencing clinical situations through prior learning linkages, professional cardiopulmonary resuscitation performance would increase by participating in face-to-face simulation practice with confidence. However, in studies related to simulation, while self-confidence in performance showed improvement, performance ability did not show significant enhancement [40]. These results are believed to be due to the fact that previous studies primarily conducted simple performance training without incorporating elements such as teamwork and pre-learning activities. As previous studies indicated, evaluation and feedback can be effectively derived when instructors and learners interact in both directions [41]. Therefore, to increase professional cardiopulmonary resuscitation performance, it is necessary to apply a case-based pre-learning simulation and this class simulation by applying a PARTNER model when constructing education and to apply a blended learning method considering cooperative learning that communicates in both directions in this class.

In this study, clinical performance improved to 16.3% in the control group, compared to 22% in the experimental group, which showed a higher rate of increase than in the control group. In a study by Gerasimiak [42], the results were similar to those of learner-centered classes, which were more effective in developing practical application skills using knowledge, compared to lecture-style classes, and improved clinical practice skills by providing opportunities for repeated practice. This program is designed to provide web-based simulation at the pre-stage so that learners can analyze clinical situations and solve nursing problems on their own. In addition, the pre-learning content was strengthened in the pre-learning linkage stage, and sufficient time and self-study opportunities were provided for discussions with team members based on cases. This method of learning has a positive effect on clinical performance by systematically exploring the subjects themselves and inferring complex clinical situations based on logical consistency [43]. In medicine and nursing, where practical training is important, the effectiveness of blended education can be enhanced when repeated learning is combined with prior and face-to-face learning [44]. Therefore, the blended learning method, which provides web-based simulation in the pre-learning stage and applies high-fidelity simulation after pre-linked learning, has proven effective in improving clinical performance by analyzing clinical situations and developing nursing problem-solving skills. Therefore, it is considered that it is necessary to use web-based and high-fidelity simulation blended learning to improve clinical performance in the future professional cardiac resuscitation training plan.

After the intervention of this program, the learning satisfaction score was higher in both groups; however, the difference was not statistically significant. This can be seen because of the small group learning activities in both groups in this study as well, compared with the results of a previous study, which showed that learning satisfaction is higher in small education than in medium and large education [45]. In addition, the study participants were nursing students who voluntarily participated in a complex specialized cardiac resuscitation program, and their learning attitude was positive, which may have affected learning satisfaction [46]. Therefore, as a strategy to increase learning satisfaction, it is necessary to plan small-group activities in educational design and to improve learners’ assertiveness.

In summary, this study applied the PARTNER model to the design of specialized cardiac resuscitation education for nursing students and developed an educational program that blended non-face-to-face web-based simulation pre-learning, face-to-face linked learning, and high-fidelity simulation. Through this, pre-learned knowledge was connected to learning, and an environment with high interaction between instructors and students was created through clinical situation-based cooperative learning. This learning environment improves learners’ engagement and self-directed participation in class, which, in turn, improves their self-confidence, clinical performance, and learning satisfaction [47]. This plays an important role in supplementing the limitations of traditional simulation practical training, which is a one-time and one-way training [48]. Based on these results, it is believed that blended simulation education using the PARTNER model when implementing professional and complex clinical practice education in nursing education will contribute to the development of practical nursing skills by improving nursing students’ confidence in clinical nursing and clinical performance.

The limitations of this study are as follows. First, this study was conducted with nursing students from specific regions, which limits the generalizability of the findings. Second, there were limitations in objectively evaluating the study results due to the insufficient sample size and the challenges in verifying effects through random assignment. Third, this study has limitations in verifying the effects based on the duration and frequency of the intervention, as the education was provided over a short period.

The results of this study demonstrate that nursing students who participated in the blended simulation education program using the PARTNER model efficiently acquired complex ACLS knowledge in scenarios simulating cardiac arrest, thereby enhancing their confidence and immediate and effective performance in ACLS, leading to improved clinical competence. Therefore, this program provides guidelines for applying blended simulation using the PARTNER model in advanced cardiac life support nursing education and can ultimately contribute to training nurses equipped with advanced cardiac life support competencies.