International Journal of Advanced & Applied Sciences Volume 03, Issue 06, Pages 209-215, 2015 Integrating Simulation Innovatively: Evidence in Teaching First Aid for Cabin Crew a Faculty of Education, National University of Malaysia Email: kamisah@ukm.edu.my,zoology87@gmail.com A b s t r a c t Farid Abdul Aziz a, Kamisah Osman a* Keywords: Cabin Crew, First Aid, Simulation Based Learning. This study investigated the effectiveness of simulation-based learning by using role-playing activity compared to the conventional approach in enhancing first aid skill among Malaysia Airlines (MAS) cabin crew, as well as their level of confidence in providing first aid treatment in Malaysia Airlines Academy. Therefore, by using pretest-posttest control group design, 40 cabin crews were randomly assigned to two different groups (n = 20), whereby each underwent conventional and simulation-based learning. The achievement and the level of confidence were measured by using a 50-multiple-choice-item test and survey. The data obtained were analyzed by using analysis of covariance (ANCOVA), which indicated that the mean for simulation group in terms of achievement and confidence level had been significant and higher than the mean retrieved from conventional group. In addition, this research proved the effectiveness of simulation-based learning in enhancing achievement among cabin crew and their level of confidence. Based on the present findings, the researchers have been tempted to suggest the integration of this learning method into the first aid program. Accepted:30 December 2015 Academic Research Online Publisher. All rights reserved. 1. Introduction Air travel has emerged as one of the most popular, the safest, and the most convenient forms of travel. Today, most Malaysians prefer to travel for leisure or work via air travel due to its time saving and cost efficient aspects. Furthermore, with the rapid growth of low cost airline companies, such as Malindo Airlines and Air Asia, together with Malaysia Airlines subsidiary, Firefly and MasWing, which offer excellent low fares, they are likely to increase the number of passengers throughout the country. It has been estimated that by the year 2030, half of the aircraft passengers would be over 50 years of age [1]. In addition, along with the continuous increase in the average age of passengers, flight stress and changes in the cabin environment, together with other additional factors associated with travel such as flight delay and retime, would likely to trigger medical emergencies onboard. Moreover, a research conducted by [2] pertaining to the outcomes of medical emergencies on commercial airline flights across Europe showed that there were 11, 920 in-flight emergencies resulting in calls to the center (1 medical emergency per 604 flights). The most common problems were syncope or presyncope (53.5 %), digestive problem (8.9%), heart condition (4.9%), fear of flying (4.3%), and general diseases (4.1 %). Nonetheless, when flight emergencies occur, access 209 P a g e
to care is limited. Physicians and other medical professionals are often called to assist when traveling despite limited training or experience and such situation could result in a negative impact towards the patient s life. Nevertheless, with the presence of cabin crew onboard the commercial airlines, most of the cases reported above could be handled accordingly, as most of the cabin crew have been properly trained and certified as First Aider. In addition, [3] study showed that on one airline, the cabin crew alone handled almost three quarter of the emergency cases. Besides, most airlines now ensure that their cabin crews at induction are fully trained for first aid, cardiopulmonary resuscitation (CPR), and the use of AED. Unfortunately, studies carried out by [4] in testing the basic knowledge among experienced cabin crew in performing CPR with Automated External Defibrillator (AED) showed a low level of satisfactory. Most of the crew members failed to position their hand on the patient s chest accordingly, performed wrong usage of AED, as well as low self-confidence. These findings turned into serious issues as most crew members were fully certified before they were given a safety license to operate the flights. Moreover, the Wellington School of Medicine has suggested a competency examination accompanied with practical training to be taken regularly within a year to ensure knowledge retention. Unfortunately, this, in the long run, would affect the number of operating crew available to operate the flights. As such, a new teaching and learning program should be introduced for the first aid initial cabin crew training, such as simulationbased learning; a method widely used in emergency medicine that would cater the need to overcome the problem. Simulation is a technique for practice and learning that can be applied to many different disciplines and types of trainees [5]. It is a technique, (not a technology) to replace and amplify real experiences with guided ones, often immersive in nature that evokes or replicates substantial aspects of the real world in a fully interactive fashion. Since it has been widely applied in the medical field, this technique is highly suggested in the first aid program for all cabin crew in Malaysia. Since not many researches have been conducted in Malaysia to investigate the competency of airline crew as a first aider, as well as the effectiveness of teaching and learning method used to train airline crew, as such the purpose of this study was to propose a new method of teaching and learning by using simulation-based learning for initial cabin crew of Malaysia Airlines (MAS) in Malaysia Airlines Academy (MAA) in enhancing their knowledge and level of confidence concerning the first aid subject. These findings would innovate a new teaching and learning method that could be integrated in the first aid program. 2. Methodology The study included 40 initial flight stewardesses enrolled in the cabin crew training in Malaysia Airlines Academy. All students were randomly assigned to two groups and each consisted of 20 cabin crew members. The first group was known as the control group that underwent the conventional method, whereas the other group was known as the experimental group that underwent the simulationbased learning method. The teaching and learning of first aid was conducted for 5 days [6], which focused on basic theory and practical assessment by using Computer Based Teaching @ CBT, followed by equipment 210 P a g e
assessment onboard in the aircraft [7]. Upon completion, both groups were given a pretest assessment that consisted of 50 objective questions to measure students learning. All questions were designed accordingly from the syllabus content, which was taken from the Academic Question Bank of Flight Safety Department in Malaysia Airlines Academy. The exam was conducted online in the computer lab, and upon completion, immediately all the students were given a 15-item survey to measure their level of confidence. Next, an intervention was conducted on the experiment group by applying the concept of roleplaying based on the actual case scenario from a module, which was prepared earlier. The intervention consisted of 2 sessions, which had been carried out for 3 hours. In preparation for the simulation classroom experience, a first aid trainer from the flight safety department was selected and briefed accordingly before the whole session was carried out. All students were equally divided into 4 different groups: each was assigned with an envelope that consisted of case scenario, passengers documentation, guided answer sheets, together with name card for each role. Each group was given 25 minutes to discuss among group members. As the simulation was carried out, the observer and the participant group discussed and provided feedback to figure out the answer, which was assisted by the first aid trainer to ensure that each case was conducted accordingly. Once completed, a debriefing was carried out immediately with the students to obtain feedbacks and answers based on the case scenarios acted earlier. In the following week, all students from both groups were called upon for a posttest assessment with the same content but with different arrangement of questions. Upon completion, all students were required to answer the same 15-item survey. All data retrieved were used to compare the effectiveness between simulation-based learning and conventional method in enhancing students achievement and their level of confidence. 3. Results and Discussion A pretest assessment and a survey were conducted for both groups to determine the existing knowledge among the respondents concerning first aid upon completion of the syllabus and prior to intervention. Based on Table 1 below, the mean differences between control and experiment groups for achievement scores and confidence level were (1.30) and (0.35). The minor differences indicated similarity between each respondent in terms of knowledge content and confidence level. Table 1: Scores for achievement and confidence level in first aid subject based on existing knowledge Test Control Experiment Achievement (Pre) 87.60 86.30 Confidence level (Pre) 3.67 4.02 Apart from that, Analysis Of Covariance (ANCOVA) was employed to analyze the scores for posttest assessment and confidence level after intervention by using pretest assessment and confidence level before intervention as a covariate. According to [8], ANCOVA could overcome the existing differences between groups by reducing the effects of the existing differences by adjusting 211 P a g e
the compensation of posttest mean and confidence explained the differences for each posttest score for level after intervention for both control and both groups towards pretest scores. As for groups, experiment groups. However, before the analysis there was a significant difference for posttest scores was conducted, all data were assessed accordingly between control and experiment groups after to ensure normality and to fulfill the criteria of controlling the scores for pretest, [F (1,37) = using ANCOVA. 30.60, p <.05, partial eta squared =.453]. Based on the value of adjusted mean for posttest scores Based on Table 2 below, the covariate, which was for control (87.77) and experiment (94.72) groups, the pretest achievement, was significantly related to the simulation-based learning exposed to the the posttest achievement for each group [F (1,37) = experimental group had been more effective in 29.97, p <.05, partial eta squared =.448]. This enhancing test scores for the first aid subject. Table 2: The results of ANCOVA posttest based on groups ANCOVA Analysis Source Sum of Square df Mean Square F Sig 2 p Group 475.80 1 475.80 30.60.000.453 Pre (Covariate) 466.10 1 466.10 29.97.000.448 Error 575.29 37 15.54 Adjusted Mean for Posttest Based On Groups Covariate Post Test Adjusted Group N Mean Mean SD Mean Experiment 20 86.95 94.30 3.62 94.72 Control 20 86.95 88.20 6.45 87.77 Total 40 Meanwhile, based on Table 3 below, the covariate, which was the confidence level (before intervention), was not significantly related to the confidence level (after intervention) for each group [F (1,37) =.815, p >.05, partial eta squared =.022]. This explained the similarities for each confidence level (after intervention) for both groups towards confidence level (before intervention). However, as for groups, there was a significant difference for confidence level (after intervention) between control and experiment groups after controlling the confidence level (before intervention), [F (1,37) = 13.20, p <.05, partial eta squared =.263]. Based on the value of adjusted mean for confidence level (after intervention) for control (3.85) and experiment (4.22) groups, significant learning had been proven to occur through simulation exposed to the experiment group in enhancing the level of confidence for the first aid subject. 212 P a g e
Table 3: The results of ANCOVA confidence level (after intervention) based on groups ANCOVA Analysis Source Sum of Square df Mean Square F Sig 2 p Group 1.381 1 1.381 13.20.001.263 Pre (Covariate).085 1.085.815.373.022 Error 3.471 37.094 Adjusted Mean for Confidence Level (after intervention) Based On Groups Covariate Confidence Level Adjusted Group N Mean Mean SD Mean Experiment 20 4.01 4.22.326 4.22 Control 20 4.01 3.84.319 3.85 Total 40 On top of that, based on the respondents achievement, previous studies have shown that simulation-based learning provides students the chance to apply theory, develop critical skills, and offer a welcome relief from the everyday tasks of reading and preparing for classes [9]. An additional benefit of many of these simulations by using the role-playing technique is the introduction of realism into the students experience, which helps to promote long term retention of course material [10]. Furthermore, as mentioned in [11], most of the benefits generated through role-playing in simulation learning are that this concept promotes active learning that helps to develop effective high level thinking processes, greater environment for effective learning, greater retention of knowledge, and higher level of confidence. These benefits are supported by Kolb s experiential learning theory in which for effective learning to occur, the knowledge gained and stored within the short term memory should be transferred immediately to the long term memory to ensure greater retention [12]. Therefore, greater knowledge retention gained via simulation learning among the respondents from the experimental group helped them to prepare for the assessment as they managed to obtain greater score compared to those from the control group. On the other hand, by using case scenario based on actual emergency cases reported onboard, this concept has actually helped to bridge theory and practical assessments. Apart from providing an actual scenario that can be hardly explained through reading, the concept of role-playing provides a platform for the students to practice their skills in a realistic situation facilitated by the facilitator. In addition, the students are free to repeat any technique as instructed by the facilitator based on actual or modified case scenario in order to meet the learning objective. Some of the advantages of this learning are that it helps to enhance the level of confidence among students and prepare them for the actual working environment in the future [13]. Moreover, the results portrayed positive enhancement for achievement and level of confidence among the initial cabin crew for the first aid subject through simulation-based learning via role-playing technique. However, some 213 P a g e
limitations within this study were that this research utilized a small sample size, which limited the number of cases used for learning purpose. Besides, in this research, only four cases were employed to meet the teaching and learning objective in assessing students knowledge and level of confidence. With bigger sample size, more detailed cases could have been developed with more scenarios. Hence, such details would enable students to learn better, thus obtaining more knowledge and effectively apply theoretical and practical aspects. 4. Conclusions The simulation-based learning has successfully proven its effectiveness in enhancing achievement among the cabin crew and their level of confidence for the first aid subject. Therefore, it is highly recommended that this learning technique to be integrated into the conventional method in teaching and learning of this program in Malaysia Airlines Academy as this helps to train the cabin crew at the initial stage to be more confident, knowledgeable, and to possess excellent practical skills as far as first aid is concerned, which is a necessary requirement for the aviation industry worldwide. Acknowledgments The authors would like to express their gratitude to Madam Maria Lim, First Aid facilitator and trainer from the Flight Safety Department, for facilitating the intervention, as well as the Malaysia Airlines Academy, for their cooperation and generosity in providing access throughout the period of conducting this research. References [1] Buehrle EG. Notfalimediz in the plane: First Aid via the cloud. Dtsch Arztebl 2005; 102:338-42. [2] Peterson CD. Outcomes of Medical Emergencies on Commercial Airline Flights. N Eng Jmed 2013; 368:2075-83. [3] Dowdall N. Is there a doctor on the aircraft? Top 10 in-flight medical emergencies. BMJ 2007; 321:1336-7 [4] Mahony PH. Retention of knowledge and skills in first aid and resuscitation by airline cabin crew. European Resuscitation Council 2008; 76(3):413-418. [5] Gaba D. The future of simulation in health care. Qual Saf Health Care 2004; 13:210. [6] ICAO s Competency based Approach to Cabin Crew Safety Training. http://www.icao.int/cabinsafety.com [23 November 2014]. [7] Daniel J. Sampling essentials: Practical guidelines for making sampling choices 2012. London: SAGE Publications Ltd [8] Borg WR, Gall MD. Educational research 1983. NY: Longman Press [9] Kanner MD. War and peace: Simulating security decision making in the classroom. PS: Political Science & Politics 2007; 40(4): 795-800. [10] Bernstein JL, Meizlish DS. Becoming Congress: A longitudinal study of the civic engagement implication of a classroom simulation. Simulation & Gaming 2003; 34(2): 198-219. [11] Montero B, Rising B, Perez SC. Research on the assessment of individual contribution to groupwork. Games: Virtual Words and Reality. Proceedings of the 39 th Conference International Simulation and Gaming Association 2008; pp. 20-31 University of Katinas: Lithuania. [12] Kolb A, Kolb DA. The learning way: Metacognitive aspects of experiential learning. Simulation & Gaming: An Interdisciplinary Journal of Theory, Practice and Research 2009; 40(3): 297-327 214 P a g e
[13] Nehring WM, Ellis WE, Lashley FR. Human Patient Simulators in nursing education: An overview. Simulation and Gaming 2001; 32(2):194-204. 215 P a g e