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Basic life support (BLS) education is essential for improving bystander cardiopulmonary resuscitation (CPR) rates, but the imparting of such education faces obstacles during the outbreak of emerging infectious diseases, such as COVID-19. When face-to-face teaching is limited, distance learning—blended learning (BL) or an online-only model—is encouraged. However, evidence regarding the effect of online-only CPR training is scarce, and comparative studies on classroom-based BL (CBL) are lacking. While other strategies have recommended self-directed learning and deliberate practice to enhance CPR education, no previous studies have incorporated all of these instructional methods into a BLS course.
This study aimed to demonstrate a novel BLS training model—remote practice BL (RBL)—and compare its educational outcomes with those of the conventional CBL model.
A static-group comparison study was conducted. It included RBL and CBL courses that shared the same paradigm, comprising online lectures, a deliberate practice session with Little Anne quality CPR (QCPR) manikin feedback, and a final assessment session. In the main intervention, the RBL group was required to perform distant self-directed deliberate practice and complete the final assessment via an online video conference. Manikin-rated CPR scores were measured as the primary outcome; the number of retakes of the final examination was the secondary outcome.
A total of 52 and 104 participants from the RBL and CBL groups, respectively, were eligible for data analysis. A comparison of the 2 groups revealed that there were more women in the RBL group than the CBL group (36/52, 69.2% vs 51/104, 49%, respectively;
We developed a remote practice BL–based method for online-only distant BLS CPR training. In terms of CPR performance, using remote self-directed deliberate practice was not inferior to the conventional classroom-based instructor-led method, although it tended to take more time to achieve the same effect.
Not applicable.
Basic life support (BLS) education plays a critical role in improving a community’s awareness of sudden cardiac arrest (SCA) and bystander cardiopulmonary resuscitation (CPR) rates. The outbreak of emerging infectious diseases, such as COVID-19, has become an obstacle to promoting BLS education in most emergency medical service (EMS) systems worldwide [
Several evidence-based strategies have been proposed for promoting CPR education. For example, the American Heart Association (AHA) recommended self-directed learning and deliberate practice during the pandemic [
In fact, distance learning (synonymous with online learning or e-learning) was proposed for CPR training as early as 2006 [
In addition, deliberate practice is a training approach in which learners are given the following: (1) a discrete goal to achieve, (2) immediate feedback on their performance, and (3) ample time for repetition to improve their performance [
To overcome the challenges in CPR education brought about by COVID-19, a novel online-only BL-based BLS course that implements distance learning and self-directed deliberate practice was developed to train the following: bystander CPR rate, automated external defibrillator (AED) use, and timely EMS activation for out-of-hospital cardiac arrest. The aim of this study is to describe the development of a novel online-only BLS training model—remote practice BL (RBL)—and compare its effect on learners’ performance with that of a conventional CBL course in an educational setting. We hypothesized that the RBL method would be noninferior to the CBL method in terms of the BLS sequence and CPR performance.
A static-group comparison study was conducted to compare the effects of RBL-based BLS courses with CBL-based courses on learners’ performance in an educational setting.
This study was conducted during the COVID-19 nationwide level 3 epidemic alert in Taiwan by SaveANNE Education, a qualified BLS training institute that hosts over 250 BL-based BLS training courses annually.
The CBL-based BLS courses at SaveANNE Education have 3 main parts. Part A is an online lecture session with 7 knowledge-related instructional videos that focus on first aid, EMS, BLS, CPR, and AED, followed by a mandatory online test with 20 multiple-choice questions (MCQs;
The Little Anne QCPR manikin (Laerdal Co) and its QCPR training app were used to show learners real-time and summative feedback on CPR compression performance, paired with AED Practi-TRAINER Essentials (WNL Products). The manikin to learner and instructor to learner ratios were 1:1 and 1:4, respectively. All qualified BLS instructors were paramedics with more than 3 years of practical EMS experience. All teaching materials, including instructional videos, MCQs, skill-training scenarios, and assessment criteria, were developed by the SaveANNE Education core team, comprising 2 experienced paramedics, 1 emergency physician, 1 EMS medical director, and 1 professional filmmaker.
In May 2021, the Taiwan Central Epidemic Command Center raised the nationwide COVID-19 epidemic alert to level 3. As a result, most on-site educational facilities, including SaveANNE Education training classes, were suspended. Therefore, the CBL-based BLS course was modified into a new RBL-based BLS course, which also comprised 3 parts. Part A of the RBL-based BLS course was the same as the CBL-based course. Part B was modified to be a self-directed remote deliberate practice session that followed principles that were similar to the CBL-based course: (1) 3 identical discrete skill-related goals, including chest compressions, operating an AED, and adult BLS sequences; (2) immediate manikin-driven feedback on chest compression performance; and (3) ample time for repetition to improve performance [
In the final assessment session of both the CBL and RBL-based BLS courses, the instructor had the opportunity to give feedback on learners’ BLS-related knowledge, skills, and attitudes, and each of the learners had the opportunity to repeat the final assessment session until they passed.
The transition from classroom-based blended learning to remote practice blended learning for a basic life support course. MCQ: multiple-choice question.
During the study period, SaveANNE Education used the internet to invite learners from 38 and 68 RBL and CBL-based courses, respectively, to join as study participants. The exclusion criteria for the participants were as follows: (1) informed consent was not obtained and (2) course participation was insufficient.
The sample size was estimated based on previous preliminary data, with an expected mean chest compression score of 95 (SD 4.5) among CBL-based BLS course learners. A sample size of 27 in each group had a power of 0.8 to detect a difference of 5 in means, assuming that the common SD was 6.5, using a 2-tailed, 2-group
The participants in the experimental group were recruited during the nationwide COVID-19 level 3 epidemic alert, when only RBL-based BLS courses were available. As a first step, the participants were shown a web page where they watched the part-A instructional videos [
After receiving the training kit, the participants could start remote deliberate practice. As shown in the practice manual (
The online final assessment session was conducted one-on-one via a Google Meet video conference between the instructor and participant (
Finally, the study’s objectives and procedures were disclosed to the participants, who were invited to complete an online Google Form questionnaire consisting of 21 mandatory questions regarding the following: (1) age, gender, occupation, and motivation for attending the BLS course; (2) preexisting experience with CPR; (3) self-rated CPR performance before and after the self-directed deliberate practice session; (4) posttraining feedback regarding the difficulty of the BLS course, self-confidence and attitudes toward CPR and AED, and effectiveness of learning online, and (5) informed consent for participation in this study and provision of the studied information. For self-assessment questionnaires, we used a 5-point Likert scale ranging from 1 (totally disagree) to 5 (totally agree;
SaveANNE Education remote practice blended learning–based basic life support course training kit, which includes (A) a remote practice basic life support course manual, (B) a Little Anne quality cardiopulmonary resuscitation manikin, and (C) the set of Automated External Defibrillator Practi-TRAINER Essentials.
Screen capture of high-quality compression-only cardiopulmonary resuscitation instructional video.
Screen capture of online final assessment session for the remote practice blended learning group.
The primary outcome was the Little Anne QCPR manikin–rated chest compression score. The secondary outcome was the number of retakes of the final assessment.
Statistical analyses were performed using SPSS (version 24; IBM Corp). Participants’ demographics and other characteristics were expressed as numbers and percentages. The QCPR manikin–rated chest compression score, 5-point Likert scale score, and time spent on courses were expressed as the mean (SD). The Shapiro-Wilk test was used to examine the normality of the data. Differences between the 2 groups were compared with the chi-square test for categorical variables and the nonparametric Mann-Whitney
The study design was approved by the National Taiwan University Hospital Institutional Review Board (202206110RINC).
During the study period, 191 online questionnaires, along with informed consent forms, were sent to the RBL- and CBL-based BLS course learners, comprising 74 and 117 participants in the RBL and CBL groups, respectively. After excluding 35 participants (35/191, 18.3%) owing to criteria such as informed refusal, teaching-protocol violations, manikin errors, and invalid answers to the questionnaire, 52 and 104 participants were eligible for data analysis in the RBL and CBL groups, respectively (
The participants’ characteristics are shown in
In terms of learning performance, the RBL and CBL groups’ mean scores in the online lecture sessions were not significantly different (90.9 vs 91.8,
However, the RBL group tended to spend more time practicing ahead of the final assessment session (12.4 vs 8.9 days,
For posttraining self-evaluation, our results revealed most participants in the RBL and CBL groups agreed that their self-confidence for CPR and AEDs, and their willingness to perform CPR and AED on a stranger, improved after the training. The mean Likert-scale scores in the RBL and CBL groups for confidence for CPR and AEDs (4.75 vs 4.81, respectively,
Flowchart of data collection. BLS: basic life support; CBL: classroom-based blended learning; RBL: remote practice blended learning.
Univariate analysis of characteristics of participants in the remote practice blended learning and classroom-based blended learning groups.
Characteristics | Remote practice blended learning group (n=52) | Classroom-based blended learning group (n=104) | |||
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.64 | ||||
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10-19 | 3 (5.8) | 4 (3.8) |
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20-29 | 31 (59.6) | 69 (66.3) |
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30-39 | 11 (21.2) | 23 (22.1) |
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40-49 | 5 (9.6) | 6 (5.8) |
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50-59 | 1 (1.9) | 2 (1.9) |
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60-69 | 1 (1.9) | 0 (0) |
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.02 | ||||
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Male | 16 (30.8) | 53 (51) |
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Female | 36 (69.2) | 51 (49) |
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>.99 | ||||
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Health care provider | 2 (3.8) | 3 (2.9) |
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Non–health care provider | 50 (96.2) | 101 (97.1) |
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.30 | ||||
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Voluntary | 11 (21.2) | 30 (28.8) |
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Mandatory | 41 (78.8) | 74 (71.2) |
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.61 | ||||
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Within last 6 months | 3 (5.8) | 2 (1.9) |
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Within 6-12 months | 6 (11.5) | 14 (13.5) |
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Within 12-24 months | 5 (9.6) | 15 (14.4) |
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More than 24 months | 27 (51.9) | 56 (53.8) |
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Never attended | 11 (21.2) | 17 (16.3) |
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.34 | ||||
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Yes | 2 (3.8) | 9 (8.7) |
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No | 50 (96.2) | 95 (91.3) |
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Online lecture session scores, mean (SD) | 90.9 (6) | 91.8 (6.3) | .38 | ||
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|||||
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Chest compression release | 96.9 (4.5) | 96.4 (5.5) | .58 | |
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Chest compression depth | 99.2 (1.4) | 99.5 (1) | .02 | |
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Chest compression rate | 94.9 (5) | 95.5 (4.5) | .66 | |
Retakes of final assessment, mean (SD) | 1.4 (0.6) | 1.1 (0.3) | <.001 | ||
Time spent before the final assessment (days), mean (SD) | 12.4 (5.3) | 8.9 (5.5) | <.001 | ||
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|||||
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Less than 30 minutes | 9 (17.3) | N/Ab | N/A | |
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30-60 minutes | 21 (40.4) | N/A | N/A | |
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60-90 minutes | 9 (17.3) | N/A | N/A | |
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90-120 minutes | 5 (9.6) | N/A | N/A | |
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More than 120 minutes | 8 (15.4) | N/A | N/A | |
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|||||
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Far below average | 0 (0) | N/A | N/A | |
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Below average | 1 (1.9) | N/A | N/A | |
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Average (ie, meet passing criteria) | 24 (46.2) | N/A | N/A | |
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Above average | 15 (28.8) | N/A | N/A | |
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Far above average | 12 (23.1) | N/A | N/A | |
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|||||
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Increased knowledge of CPR and AEDc | 4.94 (0.24) | 4.86 (0.49) | .31 | |
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Increased confidence for CPR and AED | 4.75 (0.52) | 4.81 (0.42) | .62 | |
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Increased willingness to perform CPR on a stranger | 4.58 (0.60) | 4.57 (0.67) | .87 | |
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Increased willingness to use AED on a stranger | 4.83 (0.43) | 4.74 (0.65) | .68 | |
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Refusal to perform basic life support on a stranger | 1.73 (1.12) | 1.81 (1.41) | .41 |
aCPR: cardiopulmonary resuscitation.
bN/A: not applicable.
cAED: automated external defibrillator.
Multiple linear regression analysis of the association between blended learning modalities and their outcomes in all participants (n=156).
Outcome variables | β | |||
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||||
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Constant | 12.652 (6,149) | <.001 | |
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Blended learning modalitiesb | .044 | .516 (6,149) | .61 |
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Occupationc | .170 | 2.105 (6,149) | .04 |
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Genderd | –.080 | –.96 (6,149) | .34 |
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Age | –.064 | –.792 (6,149) | .43 |
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Time spent before the final assessment (days) | –.013 | –.155 (6,149) | .88 |
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Online lecture session scores | .095 | 1.183 (6,149) | .24 |
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||||
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Constant | 65.720 (6,149) | <.001 | |
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Blended learning modalities | –.095 | –1.104 (6,149) | .27 |
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Occupation | –.044 | –.544 (6,149) | .59 |
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Gender | .031 | .377 (6,149) | .71 |
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Age | .077 | .938 (6,149) | .35 |
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Time spent before the final assessment (days) | –.122 | –1.445 (6,149) | .15 |
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Online lecture session scores | .015 | .182 (6,149) | .86 |
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||||
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Constant | 14.222 (6,149) | <.001 | |
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Blended learning modalities | .019 | .222 (6,149) | .83 |
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Occupation | .063 | .791 (6,149) | .43 |
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Gender | .071 | .871 (6,149) | .39 |
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Age | –.109 | –1.365 (6,149) | .17 |
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Time spent before the final assessment (days) | –.175 | –2.121 (6,149) | .04 |
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Online lecture session scores | .153 | 1.931 (6,149) | .06 |
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Constant | 3.437 (6,149) | .001 | |
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Blended learning modalities | .347 | 4.375 (6,149) | <.001 |
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Occupation | .082 | 1.093 (6,149) | .28 |
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Gender | –.054 | –.702 (6,149) | .48 |
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Age | .123 | 1.627 (6,149) | .11 |
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Time spent before the final assessment (days) | –.077 | –.997 (6,149) | .32 |
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Online lecture session scores | –.152 | –2.041 (6,149) | .04 |
aQCPR: quality cardiopulmonary resuscitation.
bFor blended learning modalities, classroom-based blended learning was 0 and remote practice blended learning was 1 in all analyses.
cFor occupation, health care provider was 0 and non–health care provider was 1 in all analyses.
dFor gender, female was 0 and male was 1 in all analyses.
Multiple linear regression analysis was also conducted to assess the association between self-directed deliberate practice acquisition and study outcomes in the RBL group (
Multiple linear regression analysis of the association between deliberate practice measures and outcomes in the remote practice blended learning group (n=52).
Outcome variables | β | |||
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||||
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Constant | 17.900 (6,45) | <.001 | |
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Time spent on deliberate practice (hours) | .231 | 1.817 (6,45) | .08 |
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Self-rating after deliberate practice | –.125 | –.909 (6,45) | .37 |
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Occupationb | .391 | 2.878 (6,45) | .01 |
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Genderc | –.053 | –.384 (6,45) | .70 |
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Age | –.079 | –.620 (6,45) | .54 |
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Time spent ahead of the final assessment (days) | –.112 | –.865 (6,45) | .39 |
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Constant | 55.727 (6,45) | <.001 | |
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Time spent on deliberate practice (hours) | .048 | .328 (6,45) | .75 |
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Self-rating after deliberate practice | –.047 | –.297 (6,45) | .77 |
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Occupation | –.050 | –.318 (6,45) | .75 |
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Gender | .041 | .257 (6,45) | .80 |
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Age | .111 | .758 (6,45) | .45 |
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Time spent ahead of the final assessment (days) | –.224 | –1.501 (6,45) | .14 |
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||||
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Constant | 15.512 (6,45) | <.001 | |
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Time spent on deliberate practice (hours) | .267 | 2.042 (6,45) | .047 |
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Self-rating after deliberate practice | .174 | 1.240 (6,45) | .22 |
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Occupation | .068 | .488 (6,45) | .63 |
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Gender | .176 | 1.248 (6,45) | .22 |
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Age | –.108 | –.825 (6,45) | .41 |
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Time spent ahead of the final assessment (days) | –.280 | –2.111 (6,45) | .04 |
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||||
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Constant | 3.448 (6,45) | .001 | |
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Time spent on deliberate practice (hours) | .028 | .219 (6,45) | .83 |
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Self-rating after deliberate practice | –.432 | –3.079 (6,45) | .01 |
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Occupation | –.037 | –.269 (6,45) | .79 |
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Gender | .291 | 2.066 (6,45) | .045 |
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Age | .260 | 1.998 (6,45) | .052 |
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Time spent ahead of the final assessment (days) | –.155 | –1.174 (6,45) | .25 |
aQCPR: quality cardiopulmonary resuscitation.
bFor occupation, health care provider was 0 and non–health care provider was 1 in all analyses.
cFor gender, female was 0 and male was 1 in all analyses.
This study made 3 major findings. First, it demonstrated a novel but feasible online-only BL-based BLS course design for implementing distance learning and self-directed deliberate practice. Second, it confirmed that this remote self-directed deliberate practice method was not inferior to conventional classroom-based instructor-led methods in terms of the BLS sequence and CPR performance. Third, it revealed that the RBL group needed more retakes to achieve the same performance as the CBL group at the end of the courses. These findings could be helpful in exploring innovative resuscitation education, which may shape better strategies or guideline modifications for enhancing bystander CPR achievements.
Our RBL-based BLS course design was derived from a literature review. Although previous studies have shown that online-only learning [
Our study’s results have strengthened the evidence that the CPR performance of self-directed deliberate practice learners is similar to that of conventional instructor-led learners. A systematic review of 22 randomized trials comparing the effect of these 2 training methods in BLS courses also found that the most frequent conclusion of these trials was that self-directed courses had similar educational outcomes as instructor-led courses [
As regards cost-effectiveness, it has been postulated that as a BL approach allows for some parts of the course material to be viewed and learned online, the overall in-person course can be shortened, which in turn reduces costs and the time that participants and faculty members spend in the classroom environment [
Nevertheless, it has been pointed out that using these approaches is not necessarily cost-effective, and consideration should be given to the following: the type of BL, staff expertise, and the educational setting [
This study’s self-directed deliberate practice design in BL was a novel approach. In the RBL group, increased time spent on deliberate practice was significantly associated with a better QCPR chest compression rate score (
Finally, it is of interest that we noted relatively poor CPR performance among RBL group participants, who spent more time before the final assessment session. We speculate that these learners may have been less aggressive in learning or faced problems with deliberate practice. Hence, more attention should be paid to these learners in future BL-based CPR education.
Our study had some limitations. First, it was a nonrandomized experimental study. Second, the participants and evaluators were not blinded to the interventions, given that it would have been difficult to do so in an educational study. Third, the sample size was small, although the number of participants permitted adequate power for the analyses. Fourth, we did not assess several aspects of BLS skills in specific scenarios, such as scene-safety checks, calls for help, and open airways. Fifth, as we used a questionnaire, we were only able to measure participants’ estimated time spent on deliberate practice, and not the actual time spent, in the RBL group. Sixth, considering the influence of the precondition that the participants had expertise in online learning, we were unable to determine the participants’ prior experience and familiarity with online learning, which could have influenced the study results. Seventh, we did not evaluate skill retention after a specific time period after the course. Long-term skill decay in the 2 cohorts over various periods of time (eg, 3, 6, or 9 months or longer) is unknown. Finally, as this pioneering study was conducted in a single institution, there could have been external variations in socioeconomic status, internet culture, software, and infrastructure settings. More studies are needed to fill knowledge gaps on the issue of CPR education.
We developed a remote practice blended-learning method for online-only distant BLS course CPR training. Layperson CPR training using a remote self-directed deliberate practice method was not inferior to the conventional classroom-based instructor-led method in terms of BLS familiarity and CPR performance. Although this novel online-only BL method tended to take more time to achieve the same effect as conventional BL, we consider it to be a reasonable alternative CPR training method.
Multiple-choice questions after the online lecture.
CPR + AED blended learning: Remote practice BLS course material.
Questionnaire after the BLS course.
automated external defibrillator
American Heart Association
blended learning
basic life support
classroom-based blended learning
cardiopulmonary resuscitation
emergency medical service
multiple-choice question
quality cardiopulmonary resuscitation
remote practice blended learning
sudden cardiac arrest
This study was funded by the following project grants: Taiwan National Science and Technology Council (grant 101-2314-B-002-122-MY3), Taiwan Ministry of Science and Technology (grants 104-2314-B-002-034, 105-2314-B-002-171, and 108-2320-B-002-053-MY2), and National Taiwan University Hospital Top Down (T07-107-109).
The data that support the findings of this study are available from the corresponding author, PCIK, upon reasonable request.
None declared.