**Experiences of Nursing Students during the Abrupt Change from Face-to-Face to e-Learning Education during the First Month of Confinement Due to COVID-19 in Spain**

**Antonio Jesús Ramos-Morcillo <sup>1</sup> , César Leal-Costa 1,\* , José Enrique Moral-García 2,\* and María Ruzafa-Martínez <sup>1</sup>**


Received: 4 July 2020; Accepted: 29 July 2020; Published: 30 July 2020

**Abstract:** The current state of alarm due to the COVID-19 pandemic has led to the urgent change in the education of nursing students from traditional to distance learning. The objective of this study was to discover the learning experiences and the expectations about the changes in education, in light of the abrupt change from face-to-face to e-learning education, of nursing students enrolled in the Bachelor's and Master's degree of two public Spanish universities during the first month of confinement due to the COVID-19 pandemic. Qualitative study was conducted during the first month of the state of alarm in Spain (from 25 March–20 April 2020). Semi-structured interviews were given to students enrolled in every academic year of the Nursing Degree, and nurses who were enrolled in the Master's programs at two public universities. A maximum variation sampling was performed, and an inductive thematic analysis was conducted. The study was reported according with COREQ checklist. Thirty-two students aged from 18 to 50 years old participated in the study. The interviews lasted from 17 to 51 min. Six major themes were defined: (1) practicing care; (2) uncertainty; (3) time; (4) teaching methodologies; (5) context of confinement and added difficulties; (6) face-to-face win. The imposition of e-learning sets limitations for older students, those who live in rural areas, with work and family responsibilities and with limited electronic resources. Online education goes beyond a continuation of the face-to-face classes. Work should be done about this for the next academic year as we face an uncertain future in the short-term control of COVID-19.

**Keywords:** COVID-19; pandemics; students; nursing; teaching; education; distance; schools; Life Changing Events; qualitative research

### **1. Introduction**

The fast propagation of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) led to its definition as a pandemic on 13 March 2020 by the WHO [1], as it met the epidemiological criteria and had infected more than 100,000 people in 100 countries [2–4]. The main public health recommendation was to remain at home and stay safe within it [5]. The world, in a globalized manner, is facing an extraordinary public health emergency in which the nurses are, as always, on the front line. Challenges are even greater in this period of pandemic [6,7], and nurses have the knowledge and aptitudes for providing the care necessary in the different clinical scenarios [5] that are emerging.

However, this pandemic is not only affecting the area of health. A great part of the nursing activity is affected as well. In Spain, as well as in other countries, the presence of nursing students in health care centers has been suspended [5]. It has been observed how, at great speeds, schools and universities have closed in the world, affecting more than 1.570 million students in 191 countries [8]. It has been necessary to decide how to continue the education of future nurses, and multiple education solutions have been deployed, all of which are based on distance learning. The professors, experts in the subjects and knowledgeable about the didactics of traditional classes, have found themselves compelled to deal with e-learning overnight, although not all of them were prepared. The same has occurred with the students, who have had to change from a model based on obligations and face-to-face learning, to a model in which the students will have to freely and voluntarily become involved in their learning [9]. All of this aside from finding themselves in a context of expectation and uncertainty.

Nursing educators (teachers, managers) must guarantee that the students meet the academic requirements, and at the same time, recognize the current conditions faced by the health services and the needs of simultaneously satisfying the demands from students, parents, brothers, partners, and the multiple roles every individual play in their day-to-day lives. Internationally and locally, a great variety of criteria for learning and evaluation, etc., have appeared, which are adapted to their national, work and social contexts. For example, and with respect to evaluation, in Berkeley (California, USA), a pass/fail grading has been proposed [10], and in Spain, the Association of Spanish Universities (CRUE) has recommended adapting the evaluation tests utilizing distance learning evaluation procedures [11].

Understanding the experiences and expectations of the students when faced with this important change, is necessary for helping the education and teaching authorities to assign sufficient resources and re-orient university education for nursing students. To be able to manage this situation in an imminent future, it is necessary to learn from these experiences and to define the strong and weak points. The objective of this study was to discover the learning experiences and the expectations about the changes in education of nursing students enrolled in the Bachelor's and Master's nursing degrees in two Spanish public universities, when faced with the abrupt change from face-to-face to e-learning education during the first month of confinement due to the COVID-19 pandemic.

### **2. Materials and Methods**

### *2.1. Study Design*

A qualitative approach was utilized, and an inductive thematic analysis [12] was conducted to understand the experiences and expectations of the participants.

### *2.2. Settings and Participants*

This research study was conducted in its entirety during the first month of the state of alarm in Spain (which began on 14 March 2020). The state of alarm implied the confinement of the entire population, the closing of all the schools and universities, closing of non-essential businesses, closing of borders and ceasing all non-essential activities. The people were only allowed to go out to the street for essential matters: shopping of food, going to pharmacies, banks, and to care for older people who were dependent, etc.

In Spain, Bachelor's degree in Nursing has a duration of four years (240 European Credit Transfer System, ECTS) and it is common for a Master's degree to have a duration of one year (60 ECTS). The reference population in this study was students from every academic year in the Bachelor´s degree in Nursing, or nurses who were conducting their Master's studies, enrolled in universities in Murcia and Granada (Spain). The participants were selected through the use of a maximum variation sampling strategy [13] to obtain heterogeneous and rich information that represented the main sociodemographic variables: gender, age, academic year, rural/urban, children, Bachelor's/Master's, university of Murcia and Granada. The maximum variation strategy is utilized to find the greatest diversity of

discourses possible to identify and analyze the largest volume possible of expressions/presentation of the phenomenon studied to explain conditions/contexts where each one of them takes place.

If one did not answer the request, the students themselves proposed a replacement with another participant with similar characteristics. None of the students contacted disagreed to participate.

The students were invited to participate through the Student Delegation at the university, utilizing snowball sampling. This technique allowed us to build the sample by asking each interviewee for suggestions of people who had a similar or different perspective. This is an approach for locating information-rich key informants [13]. The saturation criterion was applied to establish the number of informants needed, an accepted method to estimate the sample size [14].

### *2.3. Data Collection*

Semi-structured interviews were conducted to obtain the information. The semi-structured interview is normally based on a script, where the subject matter and part of the questions have been planned before starting, but it also offers the possibility of changing or adding new questions as the interview and/or the research study moves forward, with new interviews conducted. It is the most common type of interview utilized in qualitative research on health. Data were collected from 25 March to 20 April 2020. This was done in the first month as it the period of time with the greatest cognitive and social impact on learning and to obtain results that could be used to support, or not, the education measures that were utilized. All the interviews were individual and were performed online through electronic resources after agreeing on a day and time. The interviews were recorded and notes were made after each interview. All the interviews were conducted by researchers who had sufficient training and experience in semi-structured interviews (A.J.R.-M., M.R.-M.). The interviewers did not have an academic relationship with the informants. The interview followed a script which shifted from general to specific matters, and dealt with general aspects of the confinement, teaching methodologies utilized, learning and expectations (Table A1). A prior pilot study of the script was conducted [15].

### *2.4. Data Analysis*

The 6 phases proposed for the thematic analysis were followed [16]: (1) Familiarizing yourself with your data; (2) Generating initial codes; (3) Searching for themes; (4) Reviewing themes; (5) Defining and naming themes; (6) Producing the report. The recorded interviews were transcribed verbatim. Once transcribed, the interviews were imported to the MAXQDA 12 program for its posterior analysis. A.J.R.-M., M.R.-M., C.L.-C. and J.E.M.-G. coded the data. The transcriptions, coding and themes-subthemes were discussed by the research team for their verification. Finally, participants provided feedback on the findings. The study was reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) [15].

### *2.5. Ethical Considerations*

This research study was approved by the Research Ethics Commission from the University of Murcia (ID: 2800/2020). All the participants received an informational electronic document about the purpose and research process, which they later kept. They were advised that their participation was voluntary. They could ask and reflect prior to the interview. Each participant was given a code to maintain anonymity.

### **3. Results**

A total of 32 interviews were conducted, and they lasted between 17 and 51 min. The shortest interviews corresponded to the more advanced academic years (3rd and 4th year students). Of these participants, 75% were women and 25% men. The age of the participants oscillated between 18–50 years old, with an average age of 25.3, and with a participation rate of 69% for the students from the University of Murcia, and 21.8% for the University of Granada students. The sample was composed by 18.75% of the students enrolled in their 1st or 2nd academic year or in the Master's program, which

accounted for about 57% of the sample, and 21.8% from the 3rd and 4th academic years, for a total of about 43%. Of those interviewed, 21.8% had children and 21.8% lived in a rural setting. Some of the characteristics of the participants are found in Table 1.


**Table 1.** Characteristics of the participants and duration of the interviews.

Six major themes were defined: (1) practicing the nursing care; (2) uncertainty; (3) time; (4) teaching methodologies; (5) the context of confinement and the added difficulties; (6) face-to-face education win. A detailed description of the themes and sub-themes can be found in Table 2.


### **Table 2.** Themes and subthemes.

### *3.1. Practicing Nursing Care*

The outstandingly practical component of care in nursing education was the most emotional aspect for the students. The experiences found were differentiated according to the group of students, depending if they had or not practice-based subjects during the education period affected by the state of alarm, the proximity to ending their training as nurses, or if they were health professionals who were conducting post-graduate studies.

### 3.1.1. The Value of Clinical Training

For 1st and 2nd year students, the learning is normally done with courses that are eminently theoretical or theory/practical. The informants indicated that this transitory e-learning will not have a special influence on their training, as long as all the clinical training on health care institutions is present:

*"In think that it's not something that will a*ff*ect us excessively for good or bad. In my year [1st]. In other years it will, because they have clinical training" P5*

By contrast, 3rd and 4th year students whose coursework is mainly based on clinical training in health care institutions placed value on clinical training. They linked it with the acquisition of competences and referred to it as being an essential part of health sciences degrees:

*"My education would not be good if clinical training was missing" P15; "without the clinical training, we can't acquire competences" P19; "Especially in our degree, the clinical training* . . . *" P21*

Clinical training provides them with security in the learning of nursing care in health care services. Part of the students in their last year (4th year) indicated that they would rather not graduate in July to do all the clinical training, therefore graduating later:

*"I don't feel prepared. My Erasmus in Italy was really bad because I was a nursing student and a foreigner. At the hospital, I don't feel confident" P10; "Some of us prefer not to graduate in June and to do the clinical training" P14*

The Master's students indicated that not being able to do the clinical training implied the loss of job opportunities:

*"If you cannot do the clinical training, you will lose job opportunities" P22*

### 3.1.2. To Help

All the participants expressed their wish to help during the pandemic. They expressed their desire to be nurses to help. At the University of Granada, a list of volunteers in their 4th year was even created. The expectation was present that the government could mobilize them in case of need. Independently of the academic year, for all the students, this crisis re-enforced their wishes to become nurses:

*"I wish I already had my degree" P17; "I wish to be a nurse already, too bad I wasn't in 4th year so I could go" P16; "If this happens in the future, I would like to be helping" P25; "I feel like left out, I can't be in the battlefield helping" P21; "Now I really feel like being a nurse. It is a shame that we cannot help. In Granada there is a list of volunteers. I really feel like helping" P14*

Master's students who work feel satisfied to be able to help (aside from being satisfied because they can work):

*"I feel very well with myself because I can help, even though is very di*ffi*cult* . . . *" P23; "I really feel like being in the middle of it and help. I've seen that help is really needed, it is very important work, although not very much appreciated." P24*

### *3.2. Uncertainty*

The lack of concretion about the different aspects related with their studies is mentioned by all the interviewees. This uncertainty is accompanied by unpleasant situations due to the possible outcomes. They are mainly related with matters that could not be resolved relatively fast, such as the clinical practice and the adaptation of evaluation processes:

*"We don't know how they are going to evaluate us. They will for sure evaluate what we have done in the last month of clinical practices" P6; "We don't know what's going to happen. I hope they don't give a general pass. I want to take the exams and the other things. I don't want them to evaluate me with just one work submitted" P5; "Not knowing how things will be done. Not getting the grades I want to get because of these circumstances" P16*

This is especially important for the 4th-year students, who reported a great feeling of wasting time. They cannot go to the clinical practices and they only have, as well, one subject: the final project (TFG). One of the alternatives to not waste time completely and that is being done by the participants is to prepare for the access exam for clinical nurse specialist training (national post-graduate residency program, EIR). Some of the participants indicated that preparing for the EIR exam was a means of escape from a situation of wasting time and total paralysis:

*"It takes my motivation away, and (finishing my degree) is getting really hard, because I don't see the end of it" P10; "I am not taking advantage of the time" P3; "I'm preparing for the EIR exam at the academy as a means of escape. With the only the TFG* . . . *I need something else. Right now all my time is TFG and the subjects from the EIR" P4*

The 3rd-year students find themselves in the same situation but without any subjects:

*"The 3rd years clinical training has been abandoned. They don't know if we are going to recover them" P6*

The Masters' students have a different point of view. The differences are many. The Masters' degree can provide job opportunities, the change from traditional education to e-learning practically affects an entire trimester (half of the Master's program), and in their discourse, they have fewer demands and less pressure for obtaining the degree. At the same time, they are the only ones who speak about the teaching guidelines, indicating that they are truly being followed. In comparison, only one Bachelor's degree student referred to the teaching guidelines:

*"If the clinical training cannot be done, you miss job opportunities" P22; "I don't know how the teaching guidelines have changed" P16; "The clinical training have been postponed until September, and it bothers me some because it interferes with the summer contract for working as a nurse" P24*

### *3.3. Time*

Time is a determinant transversal aspect. Two differentiated phases are observed as the state of alarm moved forward (1st shock and 2nd normalization). Besides, participants reflected regarding a necessary time management and the influence in the future.

### 3.3.1. Phases: 1st Shock and 2nd Normalization

Two well-differentiated phases are distinguished in the timeline. On the first days, the shock phase appears (1st phase), within which we find "disorientation". This first phase lasts between 7–10 days. During this first week, it is observed that mental performance decreases, along with the ability to concentrate. This is a subtle expectant phase, where the situations are not well defined:

*"You think that the first week is for you, for resting, you take care of unfinished business and uncertainty increases" P11; "The first week was not assimilated, I didn't have routines" P19; "During the first week, I had less concentration and studies less" P5; "The timetable is di*ff*erent, it's more chaotic" P21*

After the first phase, the students enter a normalization phase (2nd phase) in which they acquire new routines, attend online classes and seminars. The conditions of confinement start to be assimilated and the new everyday life is normalized:

*"Now I do more things than before, I take more notes. It is very di*ff*erent from the first week, now it is easier" P25; "Now I have the habits. Before I didn't do anything, and now I do everything, it is as if I'm getting used to it" P28*

The first phase, as well as the second phase also coincide with the period in which the university ensured that the online tools were fully functioning and instructions were given to the professors about how to continue with their teaching tasks:

*"Only 2 out of 5 teachers give online classes, the rest upload presentations that we have to understand" P13; "The teachers do not agree with each other. One says one thing and another something else" P6*

### 3.3.2. Time Management

The 1st and 2nd year students, as well as the Masters' students, have classes. This forces them to manage their time differently. The 1st and 2nd year students interviewed indicated that time management was necessary. They indicated that this was beneficial for having good "mental health", and that having due dates helped them with managing their time:

*"Having self-discipline and a timetable. Not rigid, but saying that the mornings were for University and the afternoons for watching T.V. series or exercising. If you don't organize your time, work accumulates" P20; "My planning is Monday to Friday mornings for work, and the afternoon for group work or leisure. I rest on the weekends. Having due dates has helped me organize" P13; "The homework is good, because they help with following the course" P11*

All of the participants, except for the ones who worked, indicated that they had changed their sleep schedule and go to bed much later, between 1:30 and 3 a.m. The main reason mentioned was that the lack of activity did not make them tired, although this argument was ambivalent, as they went to bed later and got up later as well, so they slept the same number of hours:

*"It takes me longer to fall sleep. I'm not tired because I don't do anything during the day" P11; "I go to bed later and I get up later. I go to bed at 2–2:30 a.m. and I get up at 10" P5; "I fall sleep very late. At 2:00 a.m. The hours have changed, you sleep when you shouldn't" P19*

### 3.3.3. The Future

The participants indicate that this situation affects their future plans and expectations related with obtaining their degree and work. They believe that they can be singled out for being the promotion with missing education, their international training is paralyzed, and they are afraid. Their professional expectations are also affected:

*"I'm afraid of having bad training and that the work exchange says that this year's promotion from the University of Granada do not have the competences necessary" P6; "The plans for earning money to go to an Erasmus program are cancelled* . . . *" P13; "The practices have been postponed to September, and yes, it bothers me because it interferes with the summer contract for working as a nurse" P24*

### *3.4. Teaching Methodologies*

The participants indicate that as for the teachers, different teaching methodologies are being utilized: real-time videoconferences (including chats), lessons recorded on video and uploaded to the e-learning platform, audio podcast, chat (exclusively), homework and uploading of documents (Word, PPT, PDF). They also mention that as time goes on, the teacher's adaptation to the online resources continuously improve.

### 3.4.1. Videoconference

It is without a doubt the best evaluated. This is because they think it is the most similar to a traditional class (face-to-face), and allow interaction with the professor, and provides them with nearness. Another aspect they indicate as being valuable is that this methodology helps with the teacher's explanation of the subject that is more comprehensible as compared to other methodologies. The interaction is also valued, as it allows them to say that something has not been understood and that it should be explained in another way. Lastly, they would like all the videoconferences to be recorded so they could be watched again whenever needed. This last aspect was pointed out by the students who were also working:

*"The interaction in the videoconferences is not the same, because the questions are written and it is not the same to write something than when you talk" P26; "The videoconference is where we receive feedback. You can say that you don't understand something and if it could be explained once again" P16; "It is a way to stay in touch. Doubts emerge and the teacher can resolve them" P7*

The Master's students indicate that on some occasions, the duration of the videoconference classes is excessive. It is interesting to highlight that the Bachelor's students did not state this at any time:

*"We've had videoconferences that lasted 5 h. This can be done better. We had one who did a good summary and it lasted 2 h. This is more relaxing, and then you broaden the knowledge with the documents provided" P24*

Despite the value of the videoconferences, the discourse is ambivalent, as negative aspects are identified, especially related with the quality of interaction with the professor. The traditional classwork contributes fundamental elements in the quality of communication, and this how it is felt by the participants.

*"It is worse. When the teacher sees you asking about a doubt, she*/*he knows where you are coming from. This is lost with e-learning. Information is lost and the student does not obtain the same information as in the face-to-face class. The teacher doesn't see your face." P24; "I'm much more in favor of traditional classes. I always obtain more information in them and I'm more comfortable." P24*

### 3.4.2. The Rest of the Methodologies

Except for the recorded lessons, the rest of the methodologies are catalogued as sub-standard. The chats (exclusively) and the homework are not attractive, although they value them as positive aspects because it lets them stay connected with the subject and the university:

*"The worse thing is when they only upload class notes, no one forces you to read them" P25; "In the homework, there are questions because they are not easy to understand, with the explanation it is easy, but when you are going to do it, it is more di*ffi*cult" P25*

Among the limitations, they point out that in some asynchronous methodologies and with a rigid format, limited learning is obtained, interaction is needed for explanation, and a certain amount of pressure is needed. Another limitation is the lack of feedback with the homework:

*"We are going to learn the minimum, but not all, because they don't explain it to you, they don't explain it in di*ff*erent ways. The text [from the documents] is only written in one way* . . . *" P7; "the works that don't have feedback give you half the knowledge" P13; "If you only upload notes, no one is forcing you to read them. It is very easy to fall into laziness when they only upload notes" P25*

A limitation of e-learning that was pointed out by all the participants was that everything that was practice-related could not be learned. They identified this as a great limitation, and point out that in nursing, practice was vital:

*"Many things are not understood through the computer. For example, the basic care laboratories have to be observed and practiced" P7; "The practical things not, but the theoretical yes. They can make a video, but it's not the same. They can tell us how to give a bath on a bed, but if you don't do it* . . . *" P5; "It is impossible to learn the practical part. Until you are not in that role, it is impossible to learn" P24*

The students are not able to propose other methodologies that are distinct from the ones offered. Two students pointed out that it could be completed with gamification (kahoot):

*"Gamification would be good, for example when calculating the dose" P19*

3.4.3. Use Profile of the Methodologies by the Teachers

Within the methodologies, it was found that the least complex, for example, providing Word, PPT or PDF documents, were related to the older teachers. The videoconferences and recorded classes were given by younger teachers in general. At the same time, they indicated that teachers from other non-nursing departments utilized the least complex methodologies:

*"It depends on the di*ffi*culty of the course. Physiology has only uploaded documents" P16; For example, Pharmacology is a very dense and complicated subject, and you need someone to explain it to you, and until now, we have not received anything, only notes. I don't think it's enough, they are too schematic and hard to understand". P1; "The younger ones (teachers) feel like doing more things" P19; "It is more di*ffi*cult for some teacher, especially those who are older" P5*

### 3.4.4. Interaction with the Teachers

They pointed out that it is good in the videoconferences. An inconvenience is that sometimes the teacher is not aware of the doubts posted on the chat if there are too many messages. In the chat, the interaction is good, but the interruptions, even though they may be short, makes it impossible to follow it. Lastly, the students are surprised about how fast the teachers answers the e-mails:

*"The chat, if you miss 5 min, you get lost" P22; "There is a good reception by the teacher for communicating" P11; "[tutoring} they are good, the answer sooner. They have improved" P21*

### *3.5. The Context of Confinement and the Added Di*ffi*culties*

The context of confinement has created some limitations for following e-learning education. These are related with internet access, access to electronic devices, and work and family responsibilities.

In rural environments, situations exist where internet access is lacking, which creates problems with being up to date with the classes. Another problem indicated is that not all had internet at home, and situations exist in which a person only has the limited amount of data available from a smartphone: *"Some people do not have all the means" P25; "I don't have internet at home, I only have data from the smartphone" P27 "I live here in the countryside, and the internet does not always work well, and if my kids are connected, then I can't do anything" P17*

The confinement has obliged working from home whenever possible. This implies that it is possible for a family with three children to need an internet connection at the same time and the availability of five electronic devices simultaneously to be able to work and follow the classes. This availability is not very common. Another limitation that was pointed out was working in the presence of children/siblings at home:

*"With the children at home, things cannot be done [mothers]" P25; "Studying at home when the entire family is at home, it is very hard to concentrate sometimes, they make noise, I can't print, etc." P25*

Part of the students pointed out that is inconvenient, as they are used to studying in public libraries and have had to study at home:

*"I always study at the library, not at home" P19; "I used to go to the library to study or do homework. No one bothers me there. At home, I set the washer, put on my pajamas and go to sleep" P28*

Another difficulty added by the confinement is that one is not "trained" for shifting to e-learning. One has experience with an education system that has never been 100% online and where the traditional class is the learning stage. With respect to online exams, they do not feel secure either:

*"We are used to traditional classes. This has been di*ffi*cult for everyone, and more for the bachelor students than the Masters ones" P23; "I supposed they will give multiple-choice exams in a short time. It is the first time it will be online and one could be tense" P13; "If I hear it from the teacher beforehand, I understand it better, and now it's di*ff*erent. You take notes and then you have to understand them* . . . *" P16*

### *3.6. Face-to-Face Win*

### 3.6.1. Face-to-Face is Better . . . for Everything

The participants clearly preferred face-to-face to e-learning education. When faced with the possibility that some percentage of online classes will be provided along with traditional classes in future academic years, they do not think it is an option that will contribute much or needed. An exception is provided by students who have family or work responsibilities, who, exclusively for the theoretical classes, prefer them to be online and recorded, in order to be able to watch them at any time. Another aspect that was underlined was that the traditional system of education is the one they know and are used to, and changing it is difficult:

*"Face-to-face is better* . . . *for everything" P17; "The University of Murcia is traditional, and we come from the same type of learning. It takes some time to adapt" P22; "Face-to-face is better in every aspect. For example, you learn the lesson and the teacher can provide examples, it can go further than the PowerPoint presentation. It is better to be face-to-face with the professor than through a screen" P23*

### 3.6.2. Older and Female: Face-to-Face is Better

The older students seem to be the most vulnerable group, and various problems are observed. On the one hand, they have to tend to their children now that they are all at home, they have more responsibilities at home, plus certain digital competences that they have yet to incorporate. The management of their time is a great problem, which is influenced by the use of time, space and the electronic devices by the rest of the family, to which they grant them priority without being aware:

*"For me the chat is not good, because I can't write that fast. I see the limitation in me. I miss the traditional classes. Face-to-face classes are better* . . . *for everything" P17; "You have to be very alert* *with the online classroom, that you do not ignore the messages. Yesterday there was a class, and did not know" P9; "Some classmates are much older, and this is di*ffi*cult. They write to the group [WhatsApp] sending pictures, and asking "What do I do? Where should I click?"" P25; "I'm much more in favor of face-to-face classes. I always obtain more information in them and I'm more comfortable" P24*

### **4. Discussions**

It is necessary to underline that all the results and discussion are centered on the first month of confinement after the start of the state of alarm, and this brings with it very specific cognitive and social states that are needed for the proper understanding of the discussion of the present research study.

Although the sample included a greater number of students from the University of Murcia as compared to those from the University of Granada, and different percentages of men and women of different ages, we believe that the main sociodemographic variables were well represented through the use of maximum variation sampling.

The nurses usually become nurses due to their desire to help other people to recover and maintain optimal health, and here we find ourselves in a situation in which not many options are available to help those who are severely sick due to COVID-19 [5]. Vocation is a determinant factor for those who decided to study nursing, and the main drive is the opportunity to care for others [17]. Our results support these two ideas in two ways: (1) they indicate that this attitude towards their professional life is still true in the new generations, with the remarkable fact that all the participants are so committed and wishing to help. (2) the pandemic has positively re-enforced their wishes to become nurses, obtaining similar results as other authors [18]. Although, the state of alarm decree includes the possible mobilization of students in their last year at university, their mobilization was principally needed in a small scale in Madrid and Catalonia, the areas greatly affected by COVID-19 [19].

The fast shift to e-learning education has not ceased to be a continuation of teaching and education through online resources, although it has not been clearly planned and adapted for e-learning [10]. Our results clearly present various relevant ideas related to this. In first place, and related with the clinical training, the health science degrees and more specifically the nursing degree have an essential need to be developed in clinical context. This element clearly cannot be substituted, and is perceived by all the students as being essential. Nevertheless, at present, a discussion exists about how high-fidelity clinical simulation could substitute the clinical training in real-world environments [20,21]. This methodology, which facilitates an intermediate learning between the theoretical dimension and the practical dimension, is proposed, aspiring to construct a real environment. However, and despite it being a type of learning established and known by the student body at the University of Murcia as well as the Granada, it is striking that this type of learning has not been described as an alternative. We interpret this finding as the clinical training being indispensable for the students.

Also, it forces us to reflect if this is the new reality of health care, and if the future nursing professionals should learn how to navigate in these conditions. The debate regarding the return of the nursing students to clinical environments is open and some recommendation has been provided [22]. The question now for the universities and nursing educators is that if as soon as the resources are provided and an adequate organization and adaptation occurs, the students should return to the health care services, what is the balance between the potential risk for the students and the importance of the clinical training? In second place, and related with the teaching of theory, the students prefer face-to-face teaching as opposed to the e-learning. They believe that the interaction is higher in quality and learning is greater. At present, another debate is open, as shown by two systematic reviews that do not provide concluding results on the existence of the greater learning linked to e-learning education of health professionals and students, highlighting the poor quality of existing studies and the importance of contextual factors [23,24]. Perhaps due to these reasons, the videoconference, distance learning, but synchronous and bi-directional, is the best assessed.

Another critical aspect is that the change to the online methodology was not chosen by the students, and the expectations they have with respect to their studies have been clearly disrupted. Their entire academic life has been marked by a specific style of teaching, and they have become organized to continue with it, but the pandemic has imposed a different one with which they do not feel comfortable yet, thereby creating uncertainty and little security. This worries a great part of the Health Science academics [25]. It therefore absolutely necessary to start to work on the adaptation to e-learning that takes into account the previously-mentioned aspects so that the student's uncertainty decreases, especially in light of the evaluations. Academics have already expressed awareness of the students' concerns that are centered on their future degree and career progression [25]. The university counted with a technological infrastructure that has been able to deal with a drastic and fast change to distance teaching. However, the urgency of adapting this type of teaching has highlighted some situations of disadvantage. Thus, the older students, as compared to the younger ones, and in great part women and mothers, do not possess the most basic digital competences. This finding is robust, as the older students themselves, as well as the younger ones, are able to point this out in agreement with each other. They also point out that there is a small percentage of students who do not have the electronic resources or a connection to the internet necessary for adequately following the teaching.

Universities are trying to provide answers to some of these problems. It could be said that the phases of shock and normalization described by the students coincided with the period of reaction and acts of implementation by the institutions. There are activities that allow for fast implementation. For example, the Universities of Murcia and Granada freely loaned laptop computers with software to 100% of the students who requested them [26], with this number being more than 300 students in Murcia alone, as well as mobile internet-access devices [27]. However, the implementation of activities related with the evaluation has required conscientious reflection and consensus that has forced their implementation later in time [11].

In any case, once this first stage has been overcome, and faced with the absence of permanent solutions for this pandemic in the short term, it is necessary to propose distance learning strategies with a robust design, with the time necessary to create study plans that are well thought-out and durable [10,28]. We should be aware that we are currently undergoing an "emergency" education, a temporary shift of instructional delivery to an alternate delivery mode due to crisis circumstances [29]. The reality is that this transition to e-learning under these circumstances has nothing to do with a design that takes the maximum advantage and possibilities of the online format. We should reflect on the differences in the rhythm, the student-instructor relationship, pedagogy, the role of the instructor, the role of the student, the synchronicity of online communication, the role of online evaluations, and the source of feedback [30].

### *Limitations*

Among the limitations of the study, we find that a thorough discussion and comparison with the opinions of other authors has not been possible, given the novel and exceptional situation we are currently living in. On the other hand, we should be aware that the sample studied cannot be representative of the reference population, and this can evidently affect the generalization of the results.

### **5. Conclusions**

After the first week of adaptation to the conditions of confinement and the establishment of new online teaching systems, the students begin a new normality. The imposition of e-learning brings more limitations to students who are older, with work and family responsibilities, living in a rural environment and with limited electronic resources. Online teaching has allowed substituting the teaching of theory, although face-to-face teaching is preferred, at the same time it has shown that clinical practices are indispensable for the training of the nursing students. Online education goes beyond the online continuation of the classes. The parties responsible should already be working on this for the next academic year, in light of the uncertain future of a short-term control of COVID-19.

**Author Contributions:** Conceptualization, A.J.R.-M., J.E.M.-G. and M.R.-M.; Data curation, A.J.R.-M.; Formal analysis, A.J.R.-M., C.L.-C. and M.R.-M.; Investigation, A.J.R.-M., C.L.-C.and M.R.-M.; Methodology, A.J.R.-M., C.L.-C., J.E.M.-G. and M.R.-M.; Project administration, A.J.R.-M.; Supervision, A.J.R.-M.; Validation, A.J.R.-M.; Writing—original draft, A.J.R.-M. and M.R.-M.; Writing—review & editing, A.J.R.-M., C.L.-C., J.E.M.-G. and M.R.-M. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Acknowledgments:** Our most sincere thanks to the people who agreed to participate in this research.

**Conflicts of Interest:** The authors declare no conflict of interest.

### **Appendix A**




**Table A1.** *Cont*.

### **References**


© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).

International Journal of *Environmental Research and Public Health*

### *Article* **Relief Alternatives during Resuscitation: Instructions to Teach Bystanders. A Randomized Control Trial**

**María José Pujalte-Jesús 1 , César Leal-Costa 2,\* , María Ruzafa-Martínez 2,\*, Antonio Jesús Ramos-Morcillo 2,\* and José Luis Díaz Agea <sup>3</sup>**


Received: 30 June 2020; Accepted: 26 July 2020; Published: 30 July 2020

**Abstract:** To analyze the quality of resuscitation (CPR) performed by individuals without training after receiving a set of instructions (structured and unstructured/intuitive) from an expert in a simulated context, the specific objective was to design a simple and structured CPR learning method on-site. An experimental study was designed, consisting of two random groups with a post-intervention measurement in which the experimental group (EG) received standardized instructions, and the control group (CG) received intuitive or non-standardized instructions, in a public area simulated scenario. Statistically significant differences were found (*p* < 0.0001) between the EG and the CG for variables: time needed to give orders, pauses between chest compressions and ventilations, depth, overall score, chest compression score, and chest recoil. The average depth of the EG was 51.1 mm (SD 7.94) and 42.2 mm (SD 12.04) for the CG. The chest recoil median was 86.32% (IQR 62.36, 98.87) for the EG, and 58.3% (IQR 27.46, 84.33) in the CG. The use of a sequence of simple, short and specific orders, together with observation-based learning makes possible the execution of chest compression maneuvers that are very similar to those performed by rescuers, and allows the teaching of the basic notions of ventilation. The structured order method was shown to be an on-site learning opportunity when faced with the need to maintain high-quality CPR in the presence of an expert resuscitator until the arrival of emergency services.

**Keywords:** cardiopulmonary resuscitation; chest compression; method; experiential learning; observation; CPR

### **1. Introduction**

The out-of-hospital cardiorespiratory arrest (OHCA) is a frequent health problem in developed countries, and only a small percentage of the victims receive cardiopulmonary resuscitation (CPR) by the bystanders [1]. Early and high-quality resuscitation maneuvers can double, or even quadruple, survival [2], however, CPR training of the general population is scarce. The current protocols differ depending if they are directed towards professionals or laypersons, and the health services continue exploring alternatives to improve bystander CPR rates when witnessing out-of-hospital cardiorespiratory arrests. Among these alternatives, we find mass training and telephone-based CPR, to such an extent that in 2015, the European resuscitation guidelines [3] recognized the important role of dispatcher-assisted CPR in the diagnosis and providing of telephone-assisted, early cardiopulmonary resuscitation.

From that point on, the attempts to combine standardized communication in CPR have increased [4,5], with supporters [6] and critics [7] until 2019, when the International Liaison Committee on Resuscitation (ILCOR) [8] recommended that the dispatchers provide instructions to the bystanders. From that point on, many research studies provided information about the increased survival rate [9,10], and affirmed that the provision of dispatch cardiopulmonary resuscitation instructions, instead of no instructions at all, improved the results from cardiopulmonary arrest [11].

However, all of these studies suggest that the clinical results after out-of-hospital cardiac arrest have a greater possibility of improving when dispatcher assistance is available; the scientific societies identify, in their knowledge gap, the preferred CPR instruction sequence for Dispatcher-Assisted Cardiopulmonary Resuscitation (DA-CPR) [8], because an optimal sequence of orders is not yet available for those who are limited to receiving instructions from emergency services personnel. At present, the ILCOR is still seeking the best evidence through the Consensus on Science with Treatment Recommendations (CoSTR) [12].

Between the CPR observed by an expert and telephone-based CPR, we find real-life situations where only one expert/healthcare worker performs resuscitation maneuvers surrounded by people without training, but who could play an important role in maintaining high-quality CPR if they could learn how to do so on-site. These possible scenarios would need to have certain essential elements, described by Bandura [13,14], when learning a skill through observation: attention and motivation. If motivated people were available who are willing to relieve the expert resuscitator, then this expert could provide the necessary instructions to teach CPR to the bystanders for the benefit of the patient. The exhaustion of a single resuscitator could reduce the possibilities of maintaining high-quality CPR until the arrival of the emergency services.

Recent studies back the use of standardized communication in resuscitation maneuvers to improve the communication and care of the patient during life-support maneuvers [15], and other research studies have associated the use of "action-linked phrases" such as "shock delivered, start compressions" with a decreased start time of the chest compressions [16].

The general objective of our study was to analyze the quality of the CPR, performed by individuals who had no prior knowledge on resuscitation, after receiving a set of instructions (structured and unstructured/intuitive) from an expert within a context of simulated CPR. The specific objective was to design a simple and structured method for the fast learning of CPR on-site.

### **2. Materials and Methods**

### *2.1. Study Design and Settings*

A post-intervention two-group post-test-only randomized experiment [17–20] was designed, in which the experimental group (EG) received standardized instructions, and the control group (CG) received intuitive, unstructured instructions. This is one of the simplest experimental designs [21]. The groups (experimental and control) were randomly assigned. One group received the training; the other group did not receive the training, and was used for comparison. A previous trial was not required for this design, as participants were randomly assigned to the groups, and thus it was assumed that both groups were statistically equivalent. In this design, the objective was to determine whether differences existed between the two groups after the training program. Therefore, a prior trial was not considered for this study design. Although this test could have been used to determine whether the groups were comparable before the experiment, this was not done, to avoid the possible negative effects entailed by the trail to the internal validity, which could be detrimental for the participants' learning. On the other hand, the participants were randomly assigned to the groups and the experimental conditions, ensuring that the groups were equivalent (they had the same socio-demographic characteristics, particularly not having any previous training or prior knowledge about resuscitation).

### *2.2. Selection of Participants*

The target population was the university population from the Region of Murcia (Spain); volunteers were solicited through announcements in the virtual campus among the students from the Catholic University of Murcia. The collection of data was performed between the months of November 2019 and February 2020.

The study included all the volunteer participants older than 18 who had signed the informed consent form and who did not comply with the exclusion criteria. These exclusion criteria were: physical limitation that could impede them from performing chest compressions and ventilation for 2 min, intellectual limitation that could impede them from following and performing the orders, refusing to participate in the study, being a healthcare worker or a healthcare student, and having received CPR training at least 5 years prior. The participants were informed about the purpose of the study to evaluate the efficacy of a method to teach CPR on-site in the least amount of time. The participants were not informed about the results of their intervention until the end of the study. The expert resuscitators were selected from clinical simulation teaching staff volunteers at the university. The inclusion criteria were: being an instructor in basic life support (BLS) and automated external defibrillation (AED) accredited by the European Resuscitation Council (ERC), and/or being a CPR professor for more than 2 years. Ultimately, this group was comprised of eight experts, of which six were women and two were men.

### *2.3. Intervention*

After complying with the eligibility criteria to participate in the study, the participants were randomly assigned to the experimental group "structured orders" or to the control group "unstructured orders". This assignment was performed using a random assignment tool (sealedenvelope.com, London, UK). Likewise, once assigned to a group, the roles of ventilation (VR) or chest compression (CR) were randomly assigned. Participants were blinded to the allocation until randomization. For performing the mouth-to-mouth ventilations, face protection devices (Laerdal® Face Shield, Laerdal Medical Corporation, Stavanger, Norway) were made available to the participants. When the research was conducted, knowledge about the COVID-19 pandemic was unknown in Spain.

A total of 138 individuals comprised the final sample. Of these, 12 were excluded because they had received CPR training in the last 5 years. Of the remaining 126 participants, 64 were randomly assigned to the structured orders group (experimental group, EG) and 62 to the unstructured orders group (control group, CG). Of the 64 EG participants, 32 were assigned the ventilation role (VR) and 32 to the chest compression role (CR); after the randomization, two VR participants were excluded when they refused to perform mouth-to-mouth ventilation, one CR participant was excluded for fatigue which impeded concluding the trial, and one participant was excluded due to loss of data. From the 62 participants in the GC group, 30 were assigned to the VR group and 32 to the CR group; after the randomization, two CR participants were excluded due to fatigue that impeded them from finishing the trial. Lastly, the 120 remaining participants received the training planned, and the results were analyzed. A CONSORT study flow diagram is shown in Figure 1.

### *2.4. Experimental Group: Structured Orders*

Before starting, the participants were told that they were dealing with a simulated scenario on the street, and that they were witnessing how an expert performed CPR on a person in OHCA. They were told that the expert would ask for their help after two cycles of 30 compressions/2 ventilations (30:2) after their arrival. After this period, they would receive a series of orders that they had to follow to provide CPR for the next 2 min.

Only compressions were performed during the time the expert gave orders. The orders provided (adapted from the main guides in CPR terminology) [16,22–25] to the participants with the chest compressions role (CR) were:


The orders provided to the participants with the ventilation role (VR) were given, while the CR participants performed the first chest compressions. These orders were:


In this sequence of instructions, to warn the rest of the participants and the resuscitators that the end of the compressions was near and to minimize the interruptions, the expert had the added requisite of counting the last five compressions aloud.

The expert who participated in the experimental group was trained in the structured learning method, and had previously practiced in simulation. The expert was the same for the completely experimental group.

### *2.5. Control Group: Structured Orders*

To conduct the trial with the unstructured orders group (CG), the expert and the participants were informed about the same simulation scenario. The experts were told that they could ask for help after two cycles of 30:2, and they were asked to give the sequence of orders they thought to be faster and more opportune, following their intuition and previous knowledge, in order for the participants to relieve them in the following 2 min.

To eliminate the learning effect [13], meaning the familiarization of the experts with the procedure, and therefore improving the results in later trials, the pretest trials were dispensed with [26], and eight different experts were selected to interact with the CG participants, so that they were not allowed to repeat the trial more than four times. The experts were not study participants, and they did not have prior knowledge of the structured orders utilized with the EG or the hypothesis of the study.

Comments, corrections, or explanations were not allowed in any of the two groups once the orders were given and the CPR started by the participants.

### *2.6. Analysis Parameters*

The main result of the study was the time needed for giving orders (seconds). The secondary result variables were: pauses between compression and ventilation (seconds), depth (mm), rate (compressions/minute), effective rate of ventilation (% between 500–600 mL), rate of chest recoil (%), positioning of the hands (% of success with respect to the center of the chest), scores reached in the mannequin (compression score (0–100), of ventilation (0–100), total/final (0–100)), age (years), sex (male/female), weight (kg), height (meters), and body mass index (BMI) (kg/m2).

### *2.7. Measurements*

The demographic data were collected in questionnaires after the informed consent. For collecting the data relative to the quality of the CPR, the Resusci Anne QCPR® manikin (Laerdal Medical Corporation, Stavanger, Norway) was utilized, which was calibrated and checked before conducting the experiment, and periodically during the experimental phase.

### *2.8. Analysis*

The continuous variables with a normal distribution were expressed as mean and standard deviation (SD); the data without a normal distribution were described as median and interquartile range (IQR). A difference in means analysis was performed for independent samples with the Student's *t* test or the Mann–Whitney U test, according to the distribution of the data. The categorical variables were described as frequencies and percentages (%). The results were considered statistically significant at *p* < 0.05. The data were reported according to the CONSORT guidelines [27]. The processing and analysis of the data were conducted with the statistical package IBM SPSS® for Windows version 22.0 (IBM Corporation, Armonk, DA, USA).

*Int. J. Environ. Res. Public Health* **2020**, *17*, x 4 of 12

**Figure 1.** Study CONSORT flow diagram. **Figure 1.** Study CONSORT flow diagram.

#### *2.4. Experimental Group: Structured Orders 2.9. Ethical Considerations*

to provide CPR for the next 2 min.

Before starting, the participants were told that they were dealing with a simulated scenario on the street, and that they were witnessing how an expert performed CPR on a person in OHCA. They were told that the expert would ask for their help after two cycles of 30 compressions/2 ventilations (30:2) after their arrival. After this period, they would receive a series of orders that they had to follow All the participants gave their informed consent for inclusion before participating in the study. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of Catholic University of Murcia (CE031901).

### **3. Results**

The mean age of the participants was 21 years old (SD 4.75), the mean height was 1.71 m (SD 0.08), the mean weight was 66.1 kg (SD 12.14), and the mean BMI was 22.5 kg/m<sup>2</sup> (SD 2.92). Of these, 60% (n = 72/120) of the participants were women. Table 1 shows the demographic data according to groups (CG and EG).



Statistically significant differences were obtained (*p* < 0.0001) between the EG and CG for the variables: time needed to give orders (Figure 2A), pauses between chest compressions and ventilations (Figure 2B), depth, overall score, chest compression score, and chest recoil.

**Figure 2.** Figure 2. (**A** (A ) Time needed to give orders. ( ) Time needed to give orders. (B **B** ) ) Pauses between chest compressions and ventilations. Pauses between chest compressions and ventilations.

The mean depth was 51.1 mm (SD 7.94) for EG, and 42.2 mm (SD 12.04) for the CG (Table 2). The median of the variable rate for the EG was 121 compressions per minute (IQR 110, 130), and 121 compressions per minute (IQR 113, 132) for the CG. The median of effective ventilation (% between 500–600 mL) was 20% (IQR 5, 50) for the EG, and 40% (IQR 0, 60.42) for the CG. The median for chest recoil was 86.32% (IQR 62.36, 98.87) for the EG, and 58.3% (IQR 27.46, 84.33) for the CG. From the participants, 83.3% (25/30) correctly positioned their hands in the EG, and 80% (24/30) in the CG (Table 2).

No statistically significant differences were found according to sex, age, height, weight, or BMI between the CG and the EG, or the VR or CR groups.

1

As for the scores achieved (Figure 3), the means/medians obtained were: 67 points (IQR 49, 83) for the EG, and 65 points (IQR 34, 81.5) for the CG in ventilation; 78.5 points (IQR 61.5, 87.25) for the EG, and 53 points (IQR 37.25, 61) for the CG in compression; 73 points (SD 14.5) for the EG, and 45 points (SD 22.47) for the CG in the overall CPR score. *Int. J. Environ. Res. Public Health* **2020**, *17*, x 8 of 12



**Figure 3.** Comparison of the scores reached by each group, with respect to the maximum score.

Ventilation Score Chest Compression

**Figure 3.** Comparison of the scores reached by each group, with respect to the maximum score. As for ventilation, 40% (12/30) of the CG participants correctly performed the head-tilt/chin-lift As for ventilation, 40% (12/30) of the CG participants correctly performed the head-tilt/chin-lift maneuver to ventilate. In the EG, this maneuver was performed by 66.67% (20/30) of the participants. Statistically significant differences were found in effective ventilation after performing the head-tilt/chin-lift maneuver (*p* < 0.0001).

maneuver to ventilate. In the EG, this maneuver was performed by 66.67% (20/30) of the participants.

#### Statistically significant differences were found in effective ventilation after performing the head-**4. Discussion**

Score

tilt/chin-lift maneuver (*p* < 0.0001). **4. Discussion**  Increasing the rates of resuscitation when witnessing cardiorespiratory arrests is still a challenge Increasing the rates of resuscitation when witnessing cardiorespiratory arrests is still a challenge in Spain [28]. This study intended to demonstrate the efficiency of a fast and structured method of communication on-site for situations in which an expert is performing CPR in the presence of bystanders who are willing to provide relief, either in the compression, or in ventilation maneuvers.

in Spain [28]. This study intended to demonstrate the efficiency of a fast and structured method of communication on-site for situations in which an expert is performing CPR in the presence of bystanders who are willing to provide relief, either in the compression, or in ventilation maneuvers. Observation-based, vicarious, or through-demonstration learning [13] are some one of the mostcommonly utilized methods for learning motor skills [29]. Diverse studies have suggested that visual orientation can accelerate the acquisition of complex motor skills [30]. In our case, we believe that this visual guide offered advantages over instructions that were not provided in person (such as through Observation-based, vicarious, or through-demonstration learning [13] are some one of the most-commonly utilized methods for learning motor skills [29]. Diverse studies have suggested that visual orientation can accelerate the acquisition of complex motor skills [30]. In our case, we believe that this visual guide offered advantages over instructions that were not provided in person (such as through the phone, for example). We also believe that observational learning had effects (in both the experimental groups as well as the control group) on the quality of resuscitation; this is the reason why the co-variation of the results attributed to the independent variable (structure method) is even

the phone, for example). We also believe that observational learning had effects (in both the

more powerful, as this observational learning was found in both groups (experimental and control). Therefore, it is thought that there could be a causal attribution of the structured method towards the improvement of CPR. Thus, it can be concluded that the use of structured orders results in the better more powerful, as this observational learning was found in both groups (experimental and control). Therefore, it is thought that there could be a causal attribution of the structured method towards the improvement of CPR. Thus, it can be concluded that the use of structured orders results in the better performance of CPR, compared to intuitive or unstructured orders of individuals without prior knowledge of CPR.

The main finding of our study consisted of the statistically significant decrease in the time needed to provide the orders that allowed relieving the expert and performing high-quality CPR. The time invested by the expert in the experimental group was significantly less compared to the unstructured orders group. The pauses between compressions and ventilations also decreased. In addition, an improvement was registered in the mean depth and the chest recoil, compared to the set of unstructured orders.

From our point of view, the decrease in these times could be related to the simplicity of the orders, in agreement with the results from Hunt et al. [16], insofar as it was suggested that there was a greater chance that the appropriate action could occur when short, easy, and specific phrases were utilized. The pauses between compression and ventilation were significantly reduced in the experimental group, with this result possibly due to the implementation of improvements proposed by Lauridsen et al. [15], such as the use of backwards counting before the relief, or counting out loud of the last five compressions.

The simplification of the orders can also improve the quality of the chest compressions [31]. This could help in the understanding and discussion of the results from other studies [32] that suggest that non-trained bystanders are not useful during CPR.

As for ventilation, achieving the volunteer's relief of the compression expert relies on a margin of 30 compressions (between 15–17 s) for the ventilation volunteer to receive the indications correctly. The participants who performed the head-tilt/chin-lift maneuver performed effective ventilations (500–600 mL) that were significantly better than those who did not. However, for the ventilation skills, no significant differences were found between the groups; in fact, the scores reached by the unstructured orders group were higher. Thus, it seems possible that although a layperson resuscitator performs the head-tilt/chin-lift maneuver correctly, this does not ensure proper ventilation, but could result in mistakes in the volume ventilated (hyperventilation or hypoventilation).

This makes us believe that on the one hand, ventilation is a skill that requires more training time compared to compression, and on the other hand, that compression-only CPR in the presence of an expert is also a valid alternative; not only for those people who are reticent about performing mouth-to-mouth ventilation [33], but also for the notable public interest in learning CPR [34]. All of these improvements resulted in higher scores, provided by the simulator, of the experimental group than the control group.

The variables rate and hand positioning did not show significant differences between both groups, and were within the range accepted by scientific societies [35].

Our study was conducted with the aim of assessing the effectiveness of providing orders. However, this method has an added benefit, in that in a real-life situation in which the expert has to be relieved, a layperson could be properly corrected fast. Thus, during the resuscitation procedure, the strong points could be emphasized, and the weak points improved, in order to provide high quality CPR until the arrival of the emergency services. This advantage is shown in studies, such as those from González-Salvado et al. [36], which affirms that practical learning guided by an instructor provides better results.

In conclusion, the learning of technical skills seems to be greatly simplified when the layperson or beginner is allowed to observe an expert, as pointed out in other studies [37,38], which associate a greater ability of response and performance of the layperson after viewing ultra-brief videos.

### *Limitations*

Among the main limitations of the study, we find the extrapolation of the results due to the characteristics of the sample and the type of experiment. The external validity could be improved with a representative sample of a real population, not only with a healthy university population. In the second place, we believe that the validity of the experiments with simulation is limited, as it does not occur in a real-life context, and other variables, such as stress or the interference from other spectators, could not be taken into account. Another limitation that should be mentioned is the lack of a pre-test to assess the resuscitation skills of the participants, beyond their statement of being a layperson. In this case, the design of the study would have been more complex. Thus, this was not done, to avoid the threat to the internal validity known as learning. However, if properly managed, it could have provided a greater internal validity of the study, which could have helped establish, with greater precision, if the groups were homogeneous for their comparison.

### **5. Conclusions**

The use of a sequence of simple, short and specific orders, together with observation-based learning, makes possible the execution of chest compression maneuvers that are very similar to those performed by rescuers, and allows the teaching of the basic notions of ventilation.

Improvements were identified in the variables "time needed to give orders", "pauses between chest compressions and ventilations", and "chest recoil" when CPR was performed by laypersons in the experimental group.

The method of structured orders was shown to provide an on-site learning opportunity when faced with the need to maintain high-quality CPR in the presence of an expert resuscitator before the arrival of emergency services, and after their arrival, in case further help is needed.

More research studies are needed to assess these findings in a non-university population, and to measure other variables that could have an influence on the results, such as the role of the layperson's stress when facing this situation in a non-simulation context.

**Author Contributions:** Conceptualization: M.J.P.-J. and C.L.-C.; formal analysis: M.J.P.-J., C.L.-C., M.R.-M., A.J.R.-M., and J.L.D.A.; investigation: C.L.-C. and J.L.D.A.; methodology: C.L.-C., M.R.-M., A.J.R.-M., and J.L.D.-A.; project administration: C.L.-C. and J.L.D.-A.; resources: M.J.P.-J.; supervision: J.L.D.A.; validation: C.L.-C., M.R.-M., and J.L.D.A.; writing—original draft: M.J.P.-J.; writing—review and editing: M.J.P.-J., C.L.-C., M.R.-M., A.J.R.-M., and J.L.D.A. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Acknowledgments:** Our most sincere thanks to the people who agreed to participate in this research.

**Conflicts of Interest:** The authors declare no conflict of interest.

### **References**


© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).

International Journal of *Environmental Research and Public Health*
