This quasi-experimental study was conducted on nursing students from January 5 to March 15, 2022. After approval of the Committee of Ethics in Human Research, the objectives of the study were reflected to the officials of School of Nursing. The statistical population of this study consisted of nursing students in the sixth semester. Based on the results of Keegan's study and considering the confidence interval of 95% and the test power of 90%, the sample size was calculated as 32 students in each group. Considering a 10% subject attrition rate, 36 students were considered as the research sample in each group.
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First, a list of students was prepared, and among the students who qualified to enter the study, 72 subjects were enrolled in the study using the simple random sampling method. The samples were randomly assigned into two groups using the “RANDBETWEEN” command in Microsoft Excel. The inclusion criteria were: studying in the sixth semester of nursing, willingness to participate in the study, and participation in all face-to-face and non-face-to-face sessions (in both groups). Exclusion criteria were: participation in similar training programs and having experience in working with a ventilator. Practical training was given for one group and integrated simulated-practical training was provided for the other group. The objectives of the study were explained to the participants and written informed consent was obtained from them. They were told that they could be assigned into one of the two study groups.
Practical training group
Due to the widespread prevalence of the Covid-19 and in order to comply with health protocols, the students in the practical training group were divided into two groups of 18. Demographic information questionnaire and ventilator knowledge questionnaire were completed by the participants before starting the training. During two consecutive days, each group was theoretically trained on selected ventilator topics during a two-hour session. These topics included the following: basic settings of the ventilator including: turning the power on and off, locking and unlocking the device, 100% oxygen button, holding inspiratory/expiratory button when necessary, button for connecting the nebulizer to the device, turning off device alarms, mode selection, Fio2, respiratory rate (RR), tidal volume (TV), trigger, inspiratory-expiratory ratio (I/E), pressure support (PS), positive end-expiratory pressure (PEEP), minute volume (MV), alarms, sighing, expiratory trigger sensitivity, and P Ramp. Also, explanations were provided on the five selected modes of CMV, SIMV, SPONT, NIV, and PCV. Then, two hours of practical training was done on the real ventilator without the presence of the patient. The students practiced the topics and if they had any problems, they asked the teacher their questions.
Integrated simulated-practical training group
In the integrated simulated-practical training group, the demographic information form and the ventilator knowledge assessment questionnaire were completed during a session before starting the training. Students joined a virtual social media group that was formed for this purpose. The content of the theoretical training was the same as the content taught in the practical training group, with the difference that this content was provided to the students in the form of a voiced PowerPoint file through the social media group. If the students had questions or problems, they would raise them through chat in the group, and the researchers would explain the relevant issues. To provide training on how to operate the ventilator, educational content was prepared in the form of six short educational videos from the simulated software environment and provided to them on different days. In these educational clips, students were introduced to how to set up and work with the software. Subsequently, they were given HamiltonC2 simulator software that can be installed on mobile phones and computers. In terms of appearance, this software was very similar to the original ventilator, so that all its menus were the same as the original ventilator. It is necessary to mention that the original ventilator had a touch monitor and the software also had this capability. The students were asked to watch the content of the educational videos and then have a practical exercise with the simulated software. After this stage, the students were divided into two groups of 18. For two hours, each group participated in a practical session of working with a real ventilator without the presence of the patient, and practiced and solved problems in the presence of the instructor. The instructor of the theoretical and practical part was the same person in both groups. One week after teaching the practical part, the students of both groups were asked to participate in a test. The students completed the ventilator knowledge questionnaire and then the skill of working with the ventilator was measured at the OSCE stations.
Ventilator Knowledge Assessment Questionnaire
This questionnaire was designed in the form of four-choice items about selected ventilator topics based on reliable textbooks and sources. The items included knowing the selected ventilator modes, the use of different modes, how to change the parameters, patient care, and weaning the patient from the ventilator, which were matched with the criteria for developing multiple-choice questions (Milman’s Item Development Criteria). To measure face and content validity, the developed questionnaire was provided to five faculty clinicians of the Nursing school and five nurses with a master's degree in critical care nursing working in the Intensive Care Unit. After receiving feedback, the desired corrections were made. The final questionnaire consisted of 20 items. Each correct answer was given one point. The range of questionnaire scores varied from 0 to 20. Getting a higher score meant more knowledge. After confirming the face validity, the questionnaire was designed electronically and given to 44 eighth semester nursing students who were asked to answer the items. Next, they were asked again two weeks later to answer the questionnaire. The test-retest reliability coefficient in this method was reported as 0.872, which was acceptable.
OSCE Stations
To check students' skills, five stations were considered, including 1: Turning on and initial setup of the ventilator, 2: Setting the required parameters for a hypothetical patient, 3: Setting the SIMV mode, 4: Setting the SPONT mode, and 5: Setting the CMV mode. The scenarios and checklists of each OSCE station were provided to 5 faculty clinicians and 5 nurses working in the intensive care unit so that they could report to the research team if they had an opinion about it. Then, the requested corrections were made in the scenarios and the final checklist. To establish the reliability of the checklist, ten 8th semester nursing students were asked to participate in the practical evaluation. Each student was asked to adjust the ventilator according to the scenario. In each station, two evaluators completed the checklists. The correlation of grades in different stations between two evaluators varied from 92 to 100%, which was considered acceptable. The total scores for these stations were 30. Higher scores and shorter duration indicated greater skill in using the ventilator. The time taken to adjust each mode was also recorded for each individual with a stopwatch.
To comply with ethical considerations, the software and training files of the integrated simulated-practical training group were provided to the students of the practical training group after the interventions were completed.
Data analysis
How the data was distributed was checked with Shapiro-Wilk Test, which indicated the normal distribution of data. The data were subsequently analyzed with IBM SPSS22 using descriptive statistics such as mean and standard deviation, independent t-test, paired t-test, and Chi-square (P < 0.05).