Which Form of Medical Training is the Best in Improving Interns’ knowledge Related to Advanced Cardiac Life Support Drugs Pharmacology? An Educational Analytical Intervention Study Between Electronic Learning and Lecture-Based Education

Background: Conventional educational systems seem to be improper throughout the cardiopulmonary resuscitation (CPR) teaching process. The most common causes of failed resuscitation are unfamiliarity with cardiopulmonary resuscitation algorithms, poor performance of leader of the CPR team and lack of skilled personnel, coordination among members during resuscitation, and responsibility of staff. Objectives: Electronic learning, as a new educational method is controversial issue in medical education for improving physicians’ practical knowledge and it is inevitable that further research on its effectiveness should be done. Materials and Methods: The present study is a prospective, pre- and post-educational, cross-sectional research, in which 84 interns were randomly divided into two groups. pre- and post- educational interventions that took place in the Department of Emergency Medicine, interns were evaluated by 21 multiple choice questions related to American Heart Association guidelineson cardiopulmonary resuscitation drugs. Questions were assessed in terms of routes for CPR drugs administration, CPR drug dosage forms, clinical judgment and appropriate CPR drug administration, and the alternative drugs in emergency situations. Data were analyzed by generalized estimating equations regression models and P < 0.05 was considered statistically significant. Results: Evaluating the effectiveness of both educational methods revealed that the mean answering score for 21 questions before education was 7.5 ± 2.6 and no significant difference was observed in groups (P = 0.55). However, after education, the average scores significantly increased to 11.0 ± 3.9 (P < 0.001). Electronic learning method was not associated with considerable increase in the knowledge of interns in this group compared with the lecture-based group (P = 0.49). Conclusions: No significant differences were observed between electronic learning and lecture-based education in improving interns’ knowledge of CPR drugs.

skills (8,9). The most common causes of failed resuscitation are unfamiliarity with cardiopulmonary resuscitation algorithms, poor performance of leader of the CPR team and lack of skilled personnel, coordination among members during resuscitation, and responsibility of the staff (10)(11)(12)(13)(14). These facts are indicative of defects in the process of learning cardiopulmonary resuscitation. Thus, paying attention to modern educational methods and applying them may result in the improvement of the process of learning and stabilization of what has already been learnt.
Throughout resuscitation process, the main challenge in patients' survival is that the surrounding personnel, nurses, and even primary health care physicians suffer from lack of required and appropriate knowledge of interventions. Consequently, these groups, especially professionally involved with medical care and treatment, must pass the training courses of resuscitation and prehospital and in-hospital care to increase their skills (15)(16)(17)(18)(19)(20)(21)(22)(23)(24).

Objectives
Since the electronic learning is one of the modern methods of education and it is being implemented in some countries, the present research was carried out to study the effectiveness of this educational method in improving interns' ( introduced to the Department of Emergency Medicine for passing a one-month course) knowledge about advanced pharmacology of drugs in cardiopulmonary resuscitation.

Materials and Methods
This study was a prospective pre-and post-educational, cross-sectional research, conducted to examine the performance of interns, introduced to the Department of Emergency Medicine by Deputy of General Practice (GP) Program, to pass a one-month didactic Emergency Medicine Course. The inclusion criterion was the introduction of interns to the Department of Emergency Medicine and the exclusion criteria were unwillingness to engage in this study and not to take part in the pre or post-educational exams. As no similar studies were found in the literature review, the approximate sample size of 84 interns was considered respecting the average number of 10.5 ± 1.41 interns introduced to our Emergency Department monthly. Accordingly, after confirmation of Ethics Committee of the Tabriz University of Medical Sciences, Tabriz, Iran and obtaining written informed consents, 84 interns were included in this research within 8 months from April 2012 to March 2013. These interns had taken no previous educational courses related to cardiopulmonary resuscitation. The introduced interns were allocated into two groups using simple randomization based on their introduction to the Emergency Department. The names of 8 months were written on balls, later pulled out from a bag that inside could not be seen: Group I included 41 interns who underwent electronic learning and 43 interns were included in group II and underwent lecture-based education. For both groups, the process was initiated by a pre-test in parallel, based on American Heart Association (AHA) multiple choice questions (21 questions as are shown in Box 1) (25). We used a translated questionnaire in the study. In order to evaluate the validity, the questionnaires were distributed among 10 professors of the Emergency Medicine and Cardiology Departments. Their comments were collected and the validity of the questionnaire was confirmed. In order to evaluate the reliability of the questionnaire, a pre-test on 40 students was conducted and alpha of 0.92 was calculated for the study using Cronbach's alpha, indicative of an acceptable reliability. The test was conducted upon the basis of the following areas: 1) Routes for drug administration (questions 1, 7, 12, 17) 2) CPR drug dosage forms (questions 1,9,10,11,14,15,18) 3) Clinical judgment and appropriate drug administration (questions 3,4,11,12,13,14,19,20,21) 4) Alternative drugs in emergency situations (question 8) Then, an electronic software, based on introduction of 45 CPR drugs, confirmed by AHA, was distributed among interns of group I. In this software, for each drug, indications, contraindications, drug dosage, and precautionary principles were explained in a separate electronic format. Additionally, an eleven-minute educational clip was prepared based on AHA guidelines on advanced cardiovascular life support (ACLS) and usage of drugs was included in the curriculum of this software. Also, the manual of the educational software was provided. A sixhour lecture-based educational course relating to use of 45 CPR drugs approved by AHA, was also held for interns of group II within 3 consecutive weeks (2 hours per week). At the end of the courses (after one month), both groups participated in the post-educational exam with the same questions as pre-educational exam. Both pre and post-educational exams were performed for both groups using the pen and paper approach.
The data were analyzed using descriptive and deductive statistical approaches by SPSS version 17.01 (SPSS Inc., Chicago, Illinois) software. Answers were scored as binary; this means that if someone could answer each question correctly, he/she would receive a positive score; otherwise, no score would be given. According to the study, designed based on before and after manner, the estimations were calculated by generalized estimating equations regression. Time (pre and post) and group (electronic learning and lecture-based education) variables were included in the model. In order to compare the mean scores of the two groups before the intervention, we used independent samples t-test and the obtained t-test was reported. Finally, P < 0.05 was considered as statistically significant.

Results
In the present study, 43 interns of group II and 41 interns of group I were studied. There was no significant difference in terms of sex, age, education, and the scores of National Comprehensive Basic Sciences Examination (NCBSE) and National Comprehensive Pre-internship Examination (NCPE) (P > 0.05). The present educational intervention could raise the knowledge of interns about the routes for drug administration in both groups. Although there was an increase in the number of correct answers in the lecture-based education group, there was no significant difference compared with the pre-educational exam results (P = 0.49). According to the analyses, there was a significant difference between these two educational methods in terms of interns' knowledge growth (P = 0.022). In other words, electronic learning was more efficient than lecture-based education regarding routes for CPR drug administration (Table 1).
Generalized estimating equations (GEE) test showed that both interventions could raise the level of knowledge of interns about CPR drug dosage forms (P < 0.001) and a statistically significant difference was observed between two groups (P = 0.039). In other words, electronic learning was a better method in increasing knowledge of CPR drug dosages ( Table 1). Implementation of educational interventions helped interns have more correct answers about clinical judgment and appropriate drug administration. GEE test also revealed that the rate of increase in correct answers of both groups was significant (P < 0.001). This shows that both educational methods may improve the level of knowledge. No significant differenceswere observed (P = 0.11) between these two educational strategies in terms of increased knowledge of students who participated in this study in the field of clinical judgment and appropriate drug administration used in resuscitation (Table 1). According to the GEE test, in the lecture-based group, the rate of improvement in correct answers about alternative drugs in emergency situations was not significantly different from pre-intervention answers (P = 0.62), while the effectiveness of electronic learning on interns' knowledge was significant (P = 0.005). Despite a marked increase in the number of correct answers in the group I, no statistically significant difference (P = 0.49) was observed between the two methods (Table 1). In assessment of effectiveness of the two methods, we found that before educational intervention, the average score of answering to all 21 questions was 7.5 ± 2.6 (lecture-based education: 6.97 ± 2.25 vs. electronic learning: 7.58 ± 2.5) and there was no significant difference between the two groups (P = 0.55). After education, however, the mean total correct answers reached to 11.0 ± 3.9 (lecture-based education: 10.44 ± 3.68 and electronic learning: 11.87 ± 3.66) that had a statistically significant increase (P < 0.001). Though, the average increase in correct answers between the two groups was not statistically significant (P = 0.49).

Discussion
The findings of our study revealed that electronic learning, in comparison with lecture-based education, is not more efficient or effective in terms of improvement of interns' knowledge regarding CPR. Delasobera et al. compared three educational methods of simulation, multimedia, and ordinary teaching in learning advanced skills of CPR. They suggested that learning through computerbased simulation method (multimedia) was more efficient and durable than the two other methods (26). Romero et al. stated that web-based electronic learning played a key role in interns' knowledge of CPR (27). According to Ko et al. in computer-based model, students had better comprehension of ACLS than in traditional method and additionally, the students were more comfortable with it (28).
Moreover, Cook et al. indicated that web-based training might result in improvement of clinical skills, and airway management, administration of defibrillation and other CPR skills (29). On the other hand, Monsieurs et al. believed that although electronic learning is a useful method in medical education, improvement of practical skills requires an alternative method (30). Furthermore, the study of Perkins et al. as the only study with similar results to ours, revealed that teaching advanced CPR interventions through electronic learning methods cannot improve the quality of education (31).
Based on the literature, there are considerable controversies over efficiency of electronic learning in the improvement of the clinical skills, due to the existing distinction between education systems and structures. It should be mentioned that most of these studies were indicators of positive sides of electronic learning in the improvement of the clinical skills of physicians and nurses and consequently the improvement of the provided services of this sector. As mentioned in the results section, mean and standard deviation of interns' scores (from 21 questions) before education was 7.5 ± 2.6 that reached to 10.44 ± 3.68 after lecture-based education and to 11.87 ± 3.66 after electronic learning. Accordingly, mean scores were low, which could be the indicator of the weakness of the educational system as a result of inefficiency of the educational structure and system, inappropriate teaching environment, and incompatibility of curriculums with society's and students' needs. Thus, the current educational system needs drastic and serious revision. Education of the instructions required for CPR, seems to be of low effectiveness regarding the subject of this research. Some factors contribute to the inappropriate knowledge levels of the medical students in the management of patients that need CPR including the educational programs, atmosphere, and high volume of the taught subjects within a short time period, vigorous night shifts, and subsequent exhaustion of the students. We believe that in order to evaluate different educational methods, further influential variables should be taken into consideration. As an example, the effectiveness of an experienced compared with an inexperienced lecturer in using educational tools might be significantly higher, which in turn could contribute to the different results obtained from our study. Since our department is newly established, the lack of long-term follow-up and the small sample size could be considered as the limitations of the present study.
Electronic learning is not of further effectiveness in the improvement of interns' knowledge of advanced CPR drug pharmacology compared to lecture-based method. Regardless of the teaching method, students have poor knowledge of the required interventions. Therefore, particular attention should be paid to this concern and effective measures should be taken in order to improve the curriculums and educational courses.