Comparison the impact of face-to-face training package for resuscitation with presentation by messaging software on emergency medicine rotation interns

under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Comparison the impact of face-to-face training package for resuscitation with presentation by messaging software on emergency medicine rotation interns J Prev Epidemiol. 2021;6(1):e06 Original Article


Introduction
All physicians need to be very familiar with advanced cardiac life support (ACLS), which is a fundamental skill. ACLS is a collection of skills and interventions which can be applied by medical staff as they encounter patients suffering from heart stroke. America health association has provided this collection. There are reports showing that this skill is not educated or in case of training, sufficient confidence is not available for students to apply these skills through their education career. Accordingly, the necessity of true training of ACLS is more evident than ever (1).
There are many methods for training ACLS. Various studies have currently been devoted to investigate highly effective ways in ACLS. Conventional approaches in ACLS are used, including; Lectures, video presentations, practical educations on moulage. Several studies have been performed on this method, where its effectiveness is approved. Many medical centers have developed simulation centers as well as obligatory and formal courses for students, where student shall attend periodically to learn ACLS skills (2,3). Some recent studies have introduced other methods, showing more effectiveness compared to the traditional old method, like multimedia programs, online training programs to simulate ACLS (2).
Each proposed method follows its own advantages and disadvantages, and researchers have attempted to practice methods with high capability of providing better grounds of learning with higher level of durability.
Providing multimedia sharing, messaging services provide simple and economical methods for groups to be organized in order to have possibility of sharing and proposing contexts and questions or educational posters. Since physical presence is not required in 10.34172/jpe.2021.06 doi this approach and can be conveniently accessed any time and everywhere, capabilities of this messenger can come into interest by trainees.

Objectives
According to the studied literature, there was not any case of study in this area for cardiac resuscitation so far. Thus this research decides to investigate and study cardiac resuscitation training by means of these kinds of services and then compare them with traditional method of faceto-face training.

Study design
In this cross-sectional study, two training methods were applied and compared, regarding their role in improving emergency medicine department interns' knowledge of advanced cardiac support during one year.
All interns were randomly (according to random number table) divided into two groups. A group of direct training comprised of 6 to 10 individuals (at two sessions from 1 to 2 hours) corresponding with 4 scenarios. Distance training group were educated through forming virtual groups where WhatsApp messenger was used for ACLS skills at two sessions from 8 am to 4 pm. Context of session was available for members for 8 hours in virtual groups.
Statistical population of current project included all emergency medicine interns who were working in emergency department at the time of study. Convenience sampling was applied as sampling method. This research studied 73 rotation interns of emergency medicine.
For each group, a pretest was performed before rotation to evaluate knowledge level of interns about how they would act in cardiac arrest situation. Then, at the end of rotation, they were reevaluated about their knowledge on cardiac arrest. Emergency medicine assistant designed pretest and posttest items. Toward this goal, 80 questions (4 items) which were similar in number, taxonomy

Key point
The current study aims to compare two methods of face to face and distance training by WhatsApp messenger, regarding the impact of training on interns' knowledge and satisfaction for advanced cardio resuscitation rotational interns in emergency medicine. Seventy-three rotation interns of emergency medicine divided into two groups. Post-test mean score was 14.08 ± 2.84 for face to face group and 12.03 ± 3.22 for WhatsApp (P = 0.003). Interns' satisfaction score were 7.68 ± 1.08 and 7.36 ± 1.19 for face to face and WhatsApp group respectively (P = 0.25). By comparing mean scores of within group pretest and post-test, there was not any significant difference between face to face and WhatsApp groups (P = 0.89), however Cohen's effect size was 0.34 for face to face group which was greater than WhatsApp trained group value. That's advisable to employ face to face training method for interns. In case of need to smart phones applications, other applications with different training approaches can be examined in future studies. and complexity aspect and could cover all stages from diagnosis to curing, designed and verified by emergency medicine experts who were university members. For each period of tests, 20 items were randomly selected as posttest questions. All pre-test and post-test questions each had one score. Finally, the test scores of the two tests, before and after the training were calculated by the assistant.

Ethical issues
All legal permissions were acquired from Tehran University of Medical Sciences. The ethical committee of Tehran University of Medical Sciences (Ethical code# IR.TUMS.MEDICINE.REC.1396.4196) approved the study. This study followed ethical principles of Declaration of Helsinki. Moreover, This paper was extracted from the specialty medical thesis in emergency medicine of Farnaz Takavar (Thesis #43294) in Tehran University of Medical Sciences Faculty of Medical (Emergency Department).

Statistical analysis
Gathered data were analyzed using SPSS 23 software. Descriptive analysis was conducted through mean values of qualitative data and accordingly, frequency and frequency percent amounts were reported. 0.05 was regarded as the significance level. In order to analyze data, central indexes and distributive indexes were used. In analytic study, the normality of data was examined by Kolmogorov-Smirnov test and accordingly student t test or Mann-Whitney U test were selected. For each step of training of two groups, the level of interns' satisfaction was compared according to obtained scores. Moreover, analysis of covariance (ANCOVA) was aplied to compare posttest results based on the effect of pretest scores in two groups. Then, paired t test was established to separately compare pretest and posttest scores. In addition, Cohen's suggested method evaluated effect size to compare pretest and post-test scores. Interns' satisfaction level of courses was examined according to 10-point Likert scale.

Results
In this study, 34 men (46.6%) and 39 women (53.4) participated in this study. In face-to-face group 30 interns in their 4 th month of internship and 7 interns in their 9 th month of internship were studied. In WhatsApp group 31 interns of 17-month of internship and 5 interns of 11-month of internship were present.
Mean score of pretest (range 0 to 10) for face-to-face training was 6.64 ± 1.93 and 5.97 ± 2.0 for WhatsApp group. According to t test results, there was no significant difference between two groups in terms of pretest scores (P = 0.29; 95% CI= -14 to 0.43).
Post-test mean score (range 0 to 20) was 14.08 ± 2.84 for face-to-face group and 12.03 ± 3.22 for WhatsApp group. The median score of post-test were 14 and 12 for face-toface and WhatsApp groups respectively. Mann-Whitney U test revealed that posttest score is significantly higher Volume 6, Issue 1, 2021 than for face-to-face group compared to WhatsApp group (P = 0.03).
Establishing ANCOVA test as well as pretest scores monitoring, revealed that there is a significant difference between posttest scores of two groups of face-to-face and WhatsApp training (P = 0.01).
Percentage of scores was regarded to evaluate questions, since the number of pretest and posttest varied. Paired t test was established to compare the percent of correctly answered items in both pretest and posttest (Table 1). Although, a significant difference between pretest and posttest results was not observed for face-to-face training group, effect size measurement of 0.34 revealed that average knowledge level of interns is increasing for ACLS components.
In order to compare correctly answered items percentage in pretest and posttest, paired t test was employed ( Table  2). There was no statistically significant difference between pretest and posttest for both groups. In addition, calculated effect size was very small (effect size = 0.02).
Mean value of interns' satisfaction in face-to-face training groups and WhatsApp groups were 7.68 ± 1.08 and 7.36 ± 1.19 respectively. Following abnormal distribution, Mann-Whitney U test was established to compare satisfaction values. Median value of satisfaction was 7 for both groups. The results of mentioned test suggested that there was no significant difference (P = 0.25).

Discussion
Based on finding, two groups have not shown substantial differences with respect to advanced cardiac resuscitation knowledge and their pretest scores were not significantly different. Although the two groups differed in the number of months they were interns, this difference was not large enough to lead to a significant difference in pre-test scores. After concluding training course, results were analyzed and it was revealed that directly trained group scored higher than WhatsApp group.
Between-groups (pretest and posttest) showed no meaningful difference in any studied group, but, direct (face-to-face) training group obtained a Cohen's effect size of 0.34 resulting to more prominent role of face-to-face group on interns' ACLS knowledge.
Benefits of using applicable smart phone software has been shown in medical education area and for promoting students contribution, better process of feedback delivering, improving student-teacher communication (18)(19)(20). WhatsApp is an instant messaging mobile application that has been utilized in some primary health programs. Benefits of using this application are; a useful way to motivate users to have active collaboration. However, this application may not be useful for all kinds of training, as the current study suggested that slight improvement of interns' knowledge on ACLS can't be regarded statistically significant.
Applications like messengers can potentially improve and facilitate doctors' and students' communications. WhatsApp provides a secure and interactive platform for groups. This matters when students can easily state their questions, which leads to higher levels of motivation for users to be involved in training process.
Goals of learning and its complex concepts may be considered as a potential drawbacks of using messengers like WhatsApp. Another limitation that must be carefully monitored in using WhatsApp is the probability of delivering an incorrect or irrelevant message. Previous studies have announced concerns on distance training, which may be associated with students avoidance in case of presenting contexts out of class environment (18)(19)(20)(21).
According to findings face-to-face training group showed better performance. However, this result may not accord other studies results, but various cases of subjects for training and study theme should be noticed to have more precise inferences. In this study, the critical subject of advanced cardiac resuscitation was chosen for interns' education, where there has never been a study about WhatsApp to be published yet. In addition, some interns in this study had not experienced advanced resuscitation course. There is the chance of different results in case of using WhatsApp for medical studies graduates who have passed these courses in order to be under continuous training in this area. Face-to-face training along with feedbacks allows teachers to identify any kind of problem and understand the content of it. That is a significant  matter, since there are concerns about decrease of active interactions during online learning procedure compared to conventional framework (22,23). This matter is approved in this study. In a study in New York, the impact of face-to-face training (using moulage) and online simulated training (using computer) were studied. Four to 6 members groups of third year of medical college participated in a three-day training course. Second group consisted of those who were trained by computer and remotely. Comparing results of two groups showed more effectiveness of online courses (24).
In another study conducted in India, two conventional and hybrid methods of problem based learning for basic and advanced resuscitation were compared. This study considered learners' satisfaction about their understanding of the concepts, passion and motivation, personal skills and self-esteem for each mentioned method. In this study, lecture was initially performed and as a result, basic and advanced resuscitation practices were educated. All students participated in this part and then divided into two groups.
First group completed problem-based learning process at first day by collective discussion. Next day, second group completed collective discussion. In order to run collective discussions, students were divided into six group where each group included 10 to 12 members and administered by a teacher who has been certificated by American Heart Association. Students filled course-satisfaction poll in two stages, one at the end of conventional training and another at the end of problem-based learning approach of training. Reported results of this research, suggested that the majority of students preferred problem-based learning method rather than conventional lecturing method. Likert scale scores showed that satisfaction level was significantly higher in problem-based learning group. Researchers concluded that simultaneous usage of problem-based learning approach and lecturing, promises higher level of satisfaction for students (25).

Conclusion
Advanced cardiac resuscitation training for face-to-face method was associated with better results in promoting knowledge of rotation interns of emergency medicine department, compared to WhatsApp training group. That's advisable to employ face-to-face training method for interns. In case of need for smart phones applications, other applications with different training approaches can be examined in future studies.

Limitations
The most prominent constraint is about lack of practical sessions on Moulage, the matter that has been focused on other studies. To have more reliable feedbacks, that would be advised to initially design the study in a way that interns could have been contributed in practical sessions and then have collective discussions on WhatsApp platform. Another limitation was short-term presence of interns in emergency medicine rotation, where long time presence is preferred to show up at distance meetings on WhatsApp platform. For example, two more sessions provide an opportunity to introduce more scenarios leading to various outcomes.

Suggestions
Using different applications with other kinds of application as well as establishing other training approaches with more training time and by participating a larger statistical population of emergency medicine interns can be suggested as future studies, to gain better insight into the role of this kind of application in this area.