The international resuscitation guidelines were published in 2000 [1,2] and the national in 2002 . According to this all healthcare professionals should be able to perform basic life support including defibrillation with an automated external defibrillator (AED) because of the potential of a cardiac arrest in every healthcare facility [1,2]. The new defibrillators designed for non-trained users are able to automatically detect ventricular fibrillation and provide rapid defibrillation .
Effective education programmes are needed for wide implementation of rapid defibrillation and the use of AEDs [5–8]. As shown in Helsinki, the biggest cost of implementing rapid defibrillation is training . Distant learning can deliver content rapidly to many staff and be individualized to meet pace, language and reading level . An Internet-based CPR-D (cardiopulmonary resuscitation and defibrillation) education has been used for teaching defibrillation as part of basic life support . The Finnish Medical Society Duodecim has developed a distant learning programme based on the national Current Guidelines and our previous studies [3,12], which is used in this study.
Although all members of the healthcare personnel should be able to perform CPR-D, it is often performed working as a pair. During resuscitation team working skills are valuable. The team member should be able to co-ordinate activities with team, exchange information, use authority and assertiveness, assert capabilities and support the other . Internet-based education programmes have been reported to increase self-confidence in managing a critical situation, decision-making and ability to prioritize tasks .
Fifty-six nurses working in a geriatric hospital volunteered for the study. They were randomized into three groups. A Finnish resuscitation Council instructor gave 16 nurses a single small-group CPR-D course and 20 nurses were given the Internet-based CPR-D course. A third group (n = 20) without specific training in CPR-D served as a control group. There was no AED in the geriatric hospital and the participants were chosen because they were without previous institutional CRP-D training.
The Internet-based CPR-D course based on the national guidelines was published 2 months before the study. The course was accomplished as a self-directed study. To motivate the learner the course starts with a case or a question intended to reveal the possible gaps between the current and needed knowledge. The theoretical content of the course has three stages: content by multimedia (video clips and pictures), a short written explanation of the multimedia, links to the databases extending the amount of information if needed (European Resuscitation Council and Finnish Resuscitation Current Care Guidelines [1–3]). The interactive part of the course is carried out by questions between the content pages. Correct answers are presented. It takes approximately 15–30 min to finish the course. The nurses had free access to it and they were encouraged to re-visit the site as many times as they wished.
For the traditional CPR-D course, a certified trainer gave a 4-h CPR-D course proved by the Finnish Resuscitation Council  to the 16 nurses in the group. The nurses were divided into two groups and each pair had its own manikin and an AED. The training began with a theoretical session (30 min) and was followed by several hands on sessions during which the trainees were assigned to practice in pairs with a manikin and an AED training defibrillator (Laerdal Medical Corporation®) with self-adhesive defibrillation pads.
An objective structured clinical examination (OSCE) was performed 2 weeks after the traditional course . The participants knew in advance that they would be tested. The test was built up in a scenario with a typical cardiac arrest with ventricular fibrillation as the initial rhythm. Each pair had 2 min to read the instructions at the OSCE station door before entering the room: ‘a patient calls you after seeing her neighbour collapse. The diseased patient does not answer any more’. There was an AED at the door. A clothed manikin and two anaesthesiologists as observers were waiting inside. The pair had 5 min to perform the task. One of the observers was simulating the eyewitness and recording time. The other was able to move freely around the scene while recording the checklist. The observers were blinded to the educational method of the groups.
The skills checklist used for grading has been described in detail in our previous study . The skills included recognition of unresponsiveness, calling for help, moving the patient to an open place, opening the airway, electrode pad positioning, the time using AED safely, using a ventilation device, delivering technically correct compressions and inflation with the correct frequency and sequence and reporting the event to professionals arriving to the scene. The correct checklist items and time were defined as primary learning outcomes. The group-working skills  were defined as the secondary learning outcomes.
The patient characteristics data was acquired after the OSCE using a questionnaire, which was returned by mail.
Statistics. The OSCE scores of the three groups were compared by using U-test. Crohnbach's alpha was used to test the reliability of the questionnaire. Spearman's rank correlation was used to test correlation between clinical performance and group-working skills.
The study group consisted of 56 nurses, 16 received a traditional CPR-D course, 20 received the Internet-based CPR-D course and 20 served as the control group. Only 44.6% (25/56) of the participants returned the questionnaire. The group receiving a traditional CPR-D course had a slightly longer interval between the previous CPR training than the other two groups. None of the nurses had previous experience of the AED.
Data were collected with a checklist with a total score range from 0 to 49. The reliability of the checklist was adequate (Cronbach alpha 0.77). The median score of all participants was 31/49 (range 21–38) (Fig. 1). Nurses receiving traditional CPR-D training performed better than those receiving the Internet-based course (median score 34 vs. 28, P < 0.05) and the control group (median score 34 vs. 26, P < 0.0001). Nurses receiving the Internet-based course performed similarly as the control group (median score 28 vs. 26).
The traditional group performed better than the other two groups in shaking the patient for a response, checking that emergency medical team (EMS) has been called, placing lower AED electrode in the right place, checking that ventilation was effective and compressing in the correct place with a correct technique and rate. The Internet-based group performed similar as the traditional group in checking breathing, placing the upper AED electrode correctly and opening the airway as well as compressing with the correct technique but not rate (Table 1). The control group placed the electrodes correctly and used the correct compression technique. However, their overall performance was significantly weaker compared to the traditional group (Fig. 1). All participants in the Internet-based group and in the control group forgot to check that the emergency medical team had been called. Only one pair in the Internet-based group continued CPR after the team had arrived on the scene.
All groups were able to use the AED but failed to defibrillate the patient within 60 s (Table 2). One pair in the traditional group and one in the control group performed defibrillation in under 60 s (mean 1 min 30 s and mean 1 min 46 s, respectively). The Internet-based group was weak, mean time for to defibrillation being 2 min 45 s (mean). The differences between the groups were not statistically significant. The group-working skills correlated with the clinical performance (P < 0.01) (Table 3).
The performance of the distant learning group did not differ from the control group. The participants had volunteered to participate the study. Only 44.6% returned the background questionnaire. Some nurses receiving the traditional course did not pass the OSCE. In the Internet-based group there was the widest variation of performance, which could be due to different learning or unrecorded previous experience. On the other hand, 65.0% of the participants in the Internet-based group returned the background questionnaire, which increases the reliability of the result.
In previous studies, the performance  but not knowledge  has improved after computer simulation compared to theoretical textbook review. A video-self-instruction with a manikin has been more effective than a traditional CPR training . A busy instructor is responsible for 20 students and it is hard to give individual instruction for those needing more practice. On the other hand, a distant learning programme can be repeated according to individual needs. Our web course was designed to focus around the problematic issues found in previous studies, e.g. right placing of the lower electrode and checking that the ventilation is effective [12,19]. The Internet-based group performed as well as the traditional group in skills based on knowledge, but the practical cardiopulmonary resuscitation (CPR) skills were deficient compared to the traditional group. It seems that a video showing the correct performance alone cannot substitute for hands-on practise.
All study groups successfully used the AED, but they equally failed to defibrillate within 60 s. They also used too much time to check vital signs. Previous research has shown that an AED, when the patient is attached correctly to this device, will analyse the cardiac rhythm and advise appropriate treatment and it can be used successfully by lay people [6,20–22]. In professional use, safe but slow defibrillation is not enough.
Training nurses in immediate life support skills is both expensive and time consuming [9,20]. A traditional CPR-D course takes 4 working hours for each participating nurse and instructor. The course should be repeated once a year, but it is rather unlikely that nurses working in a non-acute ward will retain such a schedule. In non-acute hospitals the instructors are usually nurses with very little experience in resuscitation. The benefit from a distant learning programme would be that it is designed to deliver the facts of resuscitation exactly as recommended in the guidelines. After passing a traditional CPR-D course the performance should be evaluated once a year . For those not having satisfactory performance, the distant learning programme could serve as a refresher course.
Our Internet-based course with its multimedia and links to the databases was designed to deliver knowledge. After this study, a clock will be added to the web course to stress the importance of rapid defibrillation and the right compression rate. There will be also figures strongly pointing out the correct place for compression and placing the lower AED electrode. However, both knowledge and skills are needed to perform effective CPR. Distant learning cannot substitute for traditional small-group learning. Interactive programme alone can be used to deliver knowledge, but a manikin is needed to practice the CPR skills.
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