Basic life support: evaluation of learning using simulation and immediate feedback devices

ABSTRACT Objective: to evaluate students’ learning in an online course on basic life support with immediate feedback devices, during a simulation of care during cardiorespiratory arrest. Method: a quasi-experimental study, using a before-and-after design. An online course on basic life support was developed and administered to participants, as an educational intervention. Theoretical learning was evaluated by means of a pre- and post-test and, to verify the practice, simulation with immediate feedback devices was used. Results: there were 62 participants, 87% female, 90% in the first and second year of college, with a mean age of 21.47 (standard deviation 2.39). With a 95% confidence level, the mean scores in the pre-test were 6.4 (standard deviation 1.61), and 9.3 in the post-test (standard deviation 0.82, p <0.001); in practice, 9.1 (standard deviation 0.95) with performance equivalent to basic cardiopulmonary resuscitation, according to the feedback device; 43.7 (standard deviation 26.86) mean duration of the compression cycle by second of 20.5 (standard deviation 9.47); number of compressions 167.2 (standard deviation 57.06); depth of compressions of 48.1 millimeter (standard deviation 10.49); volume of ventilation 742.7 (standard deviation 301.12); flow fraction percentage of 40.3 (standard deviation 10.03). Conclusion: the online course contributed to learning of basic life support. In view of the need for technological innovations in teaching and systematization of cardiopulmonary resuscitation, simulation and feedback devices are resources that favor learning and performance awareness in performing the maneuvers.

As a representation of the real-life event applied in a controlled environment, the use of simulation aims to provide safe care, enabling students and health professionals to practice and reflect on the skills (6) .
Teaching with simulation, and debriefing, is not limited to specific clinical laboratory encounters. It is possible to use case studies in the classroom, with discussion supported in virtual simulations; to propose in situ simulations (7) with actors, standardized patients or simulators, with or without recording of the activity for debriefing during discussion of the didactic content; assess the learning needs and fill performance gaps in different scenarios; to provide the monitoring and (re) planning of activities, enabling the educator and/or employer to evaluate the competencies of the student and/or recently hired professional in the organization (8) .
For the coherent orientation of the strategy, organizations such as the International Nursing

Association for Clinical Simulation and Learning
(INACSL) provide guidelines on terminology, integrity of participants, outline of objectives, role of facilitator, debriefing, evaluation of participants and activity (9) .
According to the guidelines of the American Heart Association (AHA/2015), in addition to the simulation, the use of technology in the management of CPR is emphasized, aiming at rapid action, valuation of adequate training, and coordinated efforts to increase the chances of post-arrest survival (10) .
In professional education and training, shortterm online courses are recommended for teaching and maintaining proper resuscitation maneuvers.
Technological resources, such as immediate feedback electronic devices, can be used to monitor CPR (6) , online or during real-time training.
The feedback devices are resources that allow the monitoring of performance in performing CPR, in relation to several parameters, such as compression ratio and depth, flow fraction, frequency and volume of ventilation, among others. According to the equipment used, different parameters are provided to be used as indicators of quality in the analysis of CPR administration.
The devices range from the most common, such as metronomes, to the more complex ones, such as defibrillators and simulators, equipped with software and pressure detection sensors for evaluation of compressions and ventilations (11) .
Considering that BLS skills seem to be learned with the same ease by self-learning (video or computer) and by practice, compared to traditional classes provided by instructors (11) , and seeking to combine educational technological resources on resuscitation maneuvers, the objective of this study was to evaluate the learning of the students participating in an online BLS course with the use of immediate feedback devices. The hypothesis of the study was that the online course contributes to incremental BLS learning.

Method
This was a quasi-experimental study, of a before- In the development of the online course on BLS, with a workload of 20 hours, we used the analysis, design, development, implementation, evaluation (ADDIE) model of instructional design, based on Andragogy (13) and the Significant Learning Theory (14) . The educational objectives were structured based on the Bloom  Table 1.
The ANOVA analysis showed significant differences in the means of pre-test scores among the 56 students in the first two years of the nursing course, and the group of six students in the last two years. The analysis showed that, after the online course, the increase in mean scores was the checklist records used to follow the student's actions were also used to analyze the results ( Table 2).
In the practical activity, according to the success of the 20 actions provided on the checklist, considering the score equivalent to 0.5 per item, the mean score was 9.1 (SD 0.95).
The plausibility of the hypothesis was confirmed in this study, and a contribution to learning about BLS with the online course was verified. Tobase L, Peres HHC, Tomazini EAS, Teodoro SV, Ramos MB, Polastri TF. Let the chest rise completely 55 90 Open the airway 59 97 Give two rescue breaths 60 97 Turn on the AED* 58 97 Apply AED* electrode pads to chest 62 100 Attach cables to AED* 60 97 Verify that no one is touching the person for rhythm analysis 56 90 Verify that no one is touching the person before shocking 54 87 Push the "shock" button 61 98 Perform compressions again after shock. 55 89

Discussion
The results of investigations and resuscitation guidelines converge upon the use of videos and online courses as resources in life support education (15) . Thus, the development of the online BLS course aimed at stimulating the participant's autonomy, favoring the selfmanaged learning process in a self-instructional way,

combining the assumptions of Andragogy and Significant
Learning Theory with educational technologies, due to the profile of students who seek distance-learning courses. Most are adults whose previous experiences can be widely used, since learning is understood as a process of gaining knowledge and/or experience (13) .
Among the results found in the evaluation of learning, the significant difference between the post-test and pre-

Conclusion
The results showed an increase in the mean score of the post-test, which indicated a more significant learning gain for students in the first years, or for those who did not attend emergency classes previously. In conducting similar studies, practical activity is suggest, both at the beginning and at the end of the online course.