International Journal of

Environmental Research
and Public Health

Review
Basic Life Support Training Methods for Health
Science Students: A Systematic Review
Mario García-Suárez 1 , Carlos Méndez-Martínez 1 , Santiago Martínez-Isasi 2 ,
Juan Gómez-Salgado 3,4, * and Daniel Fernández-García 5
1 University Hospital of León, 24008 León, Spain; [email protected] (M.G.-S.);
[email protected] (C.M.-M.)
2 Health and Podiatry Unit, Department of Health Sciences, Faculty of Nursing and Podiatry,
Universidade da Coruña, Campus de Esteiro, 15403 Ferrol, Spain; [email protected]
3 Department of Nursing, University of Huelva, 21007 Huelva, Spain
4 Safety and Health Posgrade Program, Espíritu Santo University, Samborondón, 092301 Guayaquil, Ecuador
5 Department of Nursing and Physiotherapy, University of Leon, 24071 León, Spain; [email protected]
* Correspondence: [email protected]; Tel.: +34-699-99-91-68




Received: 6 February 2019; Accepted: 28 February 2019; Published: 3 March 2019


Abstract: The acquisition of competencies in basic life support (BLS) among university students
of health sciences requires specific and updated training; therefore, the aim of this review was
to identify, evaluate, and synthesise the available scientific knowledge on the effect of training in
cardiorespiratory resuscitation in this population. A comprehensive literature search was conducted
in MEDLINE, CUIDEN, Web of Science, Wiley Online Library, CINAHL, and Cochrane, including all
randomised clinical trials published in the last ten years that evaluated basic life support training
methods among these students. We selected a total of 11 randomissed clinical trials that met the
inclusion criteria. Participants were nursing and medicine students who received theoretical and
practical training in basic life support. The studies showed a great heterogeneity in training methods
and evaluators, as did the feedback devices used in the practical evaluations and in the measurement
of quality of cardiorespiratory resuscitation. In spite of the variety of information resulting from the
training methods in basic life support, we conclude that mannequins with voice-guided feedback
proved to be more effective than the other resources analysed for learning.

Keywords: training; health students; cardiorespiratory resuscitation; basic life support

1. Introduction
Cardiorespiratory arrest (CRA) has become a major public health problem and one of the leading
causes of death in the Western world in recent years. Cardiopulmonary resuscitation (CPR) is the
technique used in the cases of CRA. It consists of thoracic compressions (which are important for the
perfusion of vital organs) and rescue breaths by means of artificial ventilation [1–7]. The quality of CPR
is vitally important, and it depends on the level of knowledge and skills held by those who carry out the
CPR. Even among healthcare professionals, that level can be inadequate. Therefore, an improvement
in educating healthcare professionals in CPR techniques may increase survival rates in cases of
CRA [2,8,9].
Within a hospital, the nursing staff is usually the first group of professionals to identify CPR,
so competence in basic life support (BLS) is a key factor in recognising cardiac arrest, activating
emergency systems, initiating effective CPR, and safely using the defibrillator [10–13]. Roh and
Issenberg concluded that technical skills in CPR among nursing students are very poor, and that despite
efforts to improve the quality of psychomotor skills, the results obtained are still not encouraging [5].

Int. J. Environ. Res. Public Health 2019, 16, 768; doi:10.3390/ijerph16050768 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2019, 16, 768 2 of 15

As has previously been described, BLS is a fundamental therapy for saving lives, and it requires
a broad knowledge of cognitive and psychomotor skills. [13,14] In spite of this, several studies have
shown that BLS education is difficult: learners’ retention of motor skills is poor (even immediately after
they have completed the course), causing less-than-ideal performance of CPR [6,14,15]. In addition,
if those who have been trained in CPR do not frequently perform it, their skills deteriorate over a
period of between 3 and 6 months. Therefore, it is very important that in addition to developing
different learning strategies, these should be combined with other recycling (retraining) measures
during that period of time [10,16].
Within CPR teaching, different methods have been proposed, such as simulation, classical
instructor-led teaching, and self-directed mannequins with continuous verbal feedback, which
have been shown to be much more effective for retaining knowledge and motor skills [9,12,17,18].
Other methods of learning may be based on interactive videos, high-fidelity 3D simulation scenarios,
and partner-based training, in which very positive results have been obtained [1,19].
With all this, there is a need for a systematic review that includes a comparison in the methods
used (traditional versus alternative) trying to find the most effective for the teaching of BLS, CPR,
and use of automatic external defibrillators (AEDs) in university health science students.
Finally, the research question selected by the authors was what is the most effective method for
teaching of BLS, CPR techniques, and use of AED for health science students?
So that, the main objective of this systematic review was to identify, evaluate and synthesize
what kind of method is more effective of training in basic life support, cardiopulmonary resuscitation
techniques and use of automatic external defibrillator among health science students.

2. Materials and Methods

We undertook a systematic review in line with the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) statement [20].

2.1. Literature Search

The search for articles was conducted during February and March 2017. The scientific databases
searched were MEDLINE, CUIDEN, Web of Science, Wiley Online Library, CINAHL, and Cochrane.
We used both English and Spanish descriptors that were located in the Medical Subject Headings
(MeSH) and in Descriptores de Ciencias de la Salud (Health Sciences Descriptors; DeCS). These included
“health science”, “students”, “cardiopulmonary resuscitation”, “training”, “traditional”, “new
methods”, “motor skills”, “simulation”, and “evaluation of efficacy-effectiveness”. Descriptors that
were synonymous with one another were combined in the search with the Boolean “OR” operator,
while the “AND” operator was used to interrelate different concepts.
As an example, one of the search strategies used in the Medline database was: “health
science students” AND (“traditional cardiopulmonary resuscitation training” OR “new methods
cardiopulmonary resuscitation training”).

2.2. Eligibility Criteria

The studies that were selected for the systematic review met the following inclusion criteria.

• Year of publication: we included all articles published between 2007 and 2017, in order to obtain
the most recent articles on training methods.
• Language: Spanish and/or English.
• Studies: we included full texts of randomised clinical trials (RCTs), because these epidemiological
studies provide more evidence.
• Population: students of both sexes who were pursuing university degrees related to the
health sciences.
Int. J. Environ. Res. Public Health 2019, 16, 768 3 of 15

• Intervention: any method used in the teaching of BLS and the acquisition of technical skills in
CPR in adults.
• Results: we selected studies that contained information about the socio-demographic
characteristics of participants, ones that analysed the effect of training in the acquisition of
theoretical and practical knowledge, and ones that reported on measurement tools for skills
relating to placement of the hands, number of compressions, average depth of compressions,
number of ventilations, or volumes administered.

All articles that did not meet these criteria were excluded.

2.3. Selection of Articles and Data Extraction

Initially, two reviewers independently performed the article search in order to minimise selection
bias. After deleting duplicates, an initial selection of articles was carried out following independent
analysis of the titles.
We then conducted a second review that included the reading of titles, abstracts and key words of
the articles found by the two reviewers, who jointly proceeded to make the final selection of articles.
At this point, a third independent reviewer intervened in the decision-making process in cases of
disagreement. Finally, after obtaining the full-text articles, the third and final selection took place,
in which the articles that were eventually used in the review were chosen.
Because the studies reviewed were very heterogeneous and had different methods of intervention
and assessment, it was not possible to undertake a meta-analysis.
Last of all, and following the final selection of the articles included in the review, we extracted
the following information from each article: first author, publication year, population, study groups,
learning method, evaluation method, immediate results, and results after refreshers/recycling.

2.4. Evaluation of the Studies’ Methodological Quality

The methodological quality of the randomised clinical trials included in the review was evaluated
using the Jadad scale [21].
The validity of this scale has been proven in the scientific literature, and it is simple and quick to
use. In addition, the researchers were already trained in its use, having deployed it in other studies.
The scale gives a score between 0 and 5 points, primarily to three aspects: randomisation, blinding
(double-blind), and description of withdrawals and dropouts during follow-up. A score of 5 represents
the highest possible methodological quality, while a score of under 3 means that the evaluated clinical
trial is of a low methodological quality. Below, we provide the full scale with the items and their
corresponding scores (Table 1).

Table 1. Jadad scale.

Criterion Scores
Yes: 1 point
1 Was the study described as random?
No: 0 point
Yes: 1 point
2 Was the randomisation scheme described and appropriate?
No: 0 points
Yes: 1 point
3 Was there a description of dropouts and withdrawals?
No: 0 points
Yes: 1 point
4 Was the randomisation scheme described and appropriate?
No: −1 point
Yes: 1 point
5 Was the study described as double-blind?
No: −1 point
 Int.J.J.Environ.
Int. Environ.Res.
Res. Public
Public Health
Health 2019,
2019, 16,
16, 768
x FOR PEER REVIEW 4 4of
of 17
15

3. Results
3. Results
3.1. Study Characteristics and Quality Evaluation
3.1. Study Characteristics and Quality Evaluation
Through our search, we obtained a total of 522 articles that were potentially eligible for the
Through
review. Of them,our 371
search,
wereweeliminated
obtained aon total
theof 522 that
basis articles
theythat
werewere potentially
duplicates fromeligible
acrossfor
thethe review.
different
Of them,
databases.371 were eliminated on the basis that they were duplicates from across the different databases.
After
Aftercompleting
completingthe first
the selection
first (reading
selection of titles),
(reading 109 articles
of titles), were excluded.
109 articles We then We
were excluded. analysed
then
the abstracts of the 42 articles that were still potentially valid for inclusion, through which
analysed the abstracts of the 42 articles that were still potentially valid for inclusion, through which a total of
18 were excluded. Finally, and after obtaining the remaining 24 articles in full-text
a total of 18 were excluded. Finally, and after obtaining the remaining 24 articles in full-text form, aform, a total of
11 studies
total of 11were included
studies in the review
were included in the[6,9,11–13,16–19,22,23].
review [6,9,11–13,16–19,22,23].
The
The excluded articles were those which did
excluded articles were those which did not
not meet
meet the inclusion criteria
the inclusion criteria for
for the
the study,
study, which
which
are shown in a flow diagram in Figure
are shown in a flow diagram in Figure 1. 1.

Figure 1.
Figure 1. Flowchart with selection of articles included in the review.

Table
Table 22 presents
presents the
the final
final articles
articles that
that were
were part
part of
of the
the systematic based on
systematic review based on their
their
methodological
methodologicalquality.
quality.
Int. J. Environ. Res. Public Health 2019, 16, 768 5 of 15

Table 2. Methodological quality of studies, calculated with the Jadad scale. BLS basic life support;
AED: automatic external defibrillator.

Jadad Scale Items

Article Jadad Score
1 2 3 4 5
An evaluation of objective feedback in basic life support
1 0 1 1 - 3
(BLS) training [6]
A randomised controlled trial comparing traditional
training in cardiopulmonary resuscitation (CPR) to
1 0 0 1 - 2
self-directed CPR learning in first year medical students:
The two-person CPR study [9]
Effects of two retraining strategies on nursing students’
acquisition and retention of BLS/AED skills: A cluster 1 0 1 1 - 3
randomised trial [11]
Comparison of two instructional modalities for nursing
1 0 0 1 - 2
student CPR skill acquisition [12]
Retention of basic life support knowledge, self-efficacy
and chest compression performance in Thai 1 0 1 1 - 3
undergraduate nursing students [13]
Repetitive sessions of formative self-testing to refresh
1 0 1 1 - 3
CPR skills: A randomised non-inferiority trial [16]
High-fidelity simulation effects on CPR knowledge, skills,
1 0 1 1 - 3
acquisition, and retention in nursing students [17]
Effects of monthly practice on nursing students’ CPR
1 0 1 1 - 3
psychomotor skill performance [18]
Using a serious game to complement CPR instruction in
1 0 0 1 - 2
a nurse faculty [19]
Voice advisory manikin versus instructor facilitated
1 1 1 1 1 5
training in cardiopulmonary resuscitation [22]
Pre-training evaluation and feedback improve medical
1 0 0 1 - 2
students’ skills in basic life support [23]

The scores obtained on the Jadad scale for the analysed articles ranged from 2 to 5 points, with
an average of 2.81 points. Only one article with double blinding [22] obtained the maximum score,
and four articles [9,12,19,23] (which were transversal and involved only one measure) scored 2 points.
All the studies, with the exception of the one conducted by Isbye et al. [22], presented a high risk
of bias, as they involved single blinding, making it impossible for there to be double-blinding for
participants and researchers.
All the data extracted from each article, with general and specific characteristics, are summarised
in Table 3.
Int. J. Environ. Res. Public Health 2019, 16, 768 6 of 15

Table 3. Description of the studies included in the review. VAM: voice advisory mannequin.

Study Groups and Results after

Article Population (Sample) Assessment Methods Immediate Results
Teaching Methods Refresher/Retention Period
Statistically significant
Teaching in BLS and AED At 6 weeks, percentage of
differences since participants
(8 h). Subsequently two correct compressions was
Sequence checklist with practice with skill reporter
groups with loss of two higher in participants who
evaluated by obtained better averages in
An evaluation of objective participants. practised with a skill reporter.
Birmingham health centre instructors and depth and % of correct
feedback in basic life support (1) Control group: CPR Volume administered
students (n = 100) mannequin with a compressions and better
(BLS) training [6] practice without feedback. increased in both groups.
skill reporter. Use of administered air volumes.
(2) Intervention group: There were no differences in
AED not evaluated There were no differences in
CPR practice with a skill terms of execution of the
terms of execution of the
reporter algorithm.
algorithm.
(1) Self-directed learning No statistically significant
with VAM for 2 h. differences were established.
A randomized controlled
(2) Normal mannequins Traditional group obtained
trial comparing traditional First-year medical
and theory on a DVD for Simulations checklist better results for knowledge in
training in cardiopulmonary students (n = 180);
free viewing and practice evaluated by simulations than the others.
resuscitation (CPR) to neligible = 240.
for 2.5 h.Groups 1 and instructors and Main failure: misuse of AED. No
self-directed CPR learning Those who had done BLS
2 could practise 10 days mannequins with a In terms of skills, there were
in first year medical training in the past
prior to the measurement. skill reporter significant differences only in
students: The two-person 5 years were excluded
(3) Traditional group with the compressions: minute ratio,
CPR study [9]
instructor for 4–5 h on the which was higher in the
day of assessment. traditional group.
(1) Self-directed group:
4 h refresher in which Pre- and post-
Effects of two retraining required aspects were intervention At 3 months, there was a new
Nursing students based in
strategies on nursing reviewed. knowledge assessment, in which skills
Almería (Spain) and the Both groups improved their
students’ acquisition and (2) Instructor-led group: questionnaire, and knowledge were
United Kingdom (n = 177). skills, knowledge and
retention of BLS/AED skills: same time frame, but the confidence improved, with the
Prior 3-h course, 3 months confidence
A cluster randomised instructor set goals and questionnaires and self-directed group obtaining
before
trial [11] provided teaching in use mannequins with the better results.
of the material and final skill reporter.
evaluation.
Int. J. Environ. Res. Public Health 2019, 16, 768 7 of 15

Table 3. Cont.

Study Groups and Results after

Article Population (Sample) Assessment Methods Immediate Results
Teaching Methods Refresher/Retention Period
(1) Mannequin-based
group: theoretical class
The sample that undertook
and training with
Comparison of two self-learning with mannequin
mannequin (VAM).
instructional modalities for Nursing students (n = 604) Mannequin with a obtained best results in all of
(2) Traditional instruction No
nursing student CPR skill with prior BLS knowledge skill reporter the individual skills except
group: 4 h with instructor
acquisition [12] frequency and compressions:
who taught knowledge
ventilations ratio.
and trained in skills with
mannequin.
At 3 months, there was a new
One group, comprising No one passed the knowledge knowledge and skills test.
Retention of basic life women only. They had Questionnaire on pre- pre-test but 100% passed the Worse results were obtained
Third-year university
support knowledge, knowledge acquired and post- knowledge, post-test. In terms of for knowledge (30% passed),
nursing students based in
self-efficacy and chest 1 year previously. questionnaire on confidence, an increase with the but there were better results
Thailand (n = 30),
compression performance in 1 h. BLS video followed confidence and pre-test was noted. Motor skills in all skills compared to the
randomised with neligible
Thai undergraduate nursing by CPR practice with mannequin with a were only recorded post-course, other assessment (without
= 180
students [13] 1 and 2 resuscitators for skill reporter with 100% results for hand refreshers). Values were
20 min. placement and decompression. maintained in terms of
confidence.
After excluding from
sample those with
appropriate skills
At 6 months, decrease in the
knowledge, a computer
number of people in both
Repetitive sessions of Third-year medical created two groups: At the end of the first 6 weeks,
groups that performed
formative self-testing to students based in Ghent (1) performed there were no significant
Mannequin with a quality CPR. Despite this,
refresh CPR skills: A (n = 218). People with self-assessments in BLS differences between the groups
skill reporter (2 min). those who did not practice
randomised non-inferiority knowledge excluded: training; that were deemed proficient in
during the first 6 weeks
trial [16] nfinal = 196 (2) same training, and also CPR.
obtained better results in
practised CPR.
depth and ventilations.
Had 6 weeks to be
proficient in CPR skills.
Retention at 6 months
Int. J. Environ. Res. Public Health 2019, 16, 768 8 of 15

Table 3. Cont.

Study Groups and Results after

Article Population (Sample) Assessment Methods Immediate Results
Teaching Methods Refresher/Retention Period
(1) Control Group: 4 h
Pre- and post-
High-fidelity simulation theory and traditional New measurement at
knowledge Significant differences in the
effects on CPR knowledge, training with AED. 3 months, in which
First-year nursing questionnaires and skills and knowledge among
skills, acquisition, (2) Intervention group: 4 h knowledge and skills
students (n = 90) evaluation of skills by groups, with improvements in
and retention in nursing theory and training with remained better in the
instructor during the intervention group.
students [17] high-fidelity simulation intervention group.
cardiac arrest activity.
with AED.
All students were trained
in BLS at their
universities. After this:
(1) Control group: no
practice;
(2) Intervention group: Throughout the study, there
CPR skills practice, 6 min were no differences found in
In the 12R groups, which had
Effects of monthly practice Nursing students from a month, with VAM. the compressions: minute ratio,
a refresher, there were no
on nursing students’ CPR different universities in At 3, 6, 9, and 12 months a Mannequin with a hands placement and volume:
differences, since both groups
psychomotor skill U.S. neligible = 727; nfinal random subgroup of each skill reporter minute. There were differences
received a refresher in CPR
performance [18] = 606 main group underwent in depth and volume
knowledge and skills.
measurement. administered, with decreases in
Another subgroup, 12R, the control group.
was also created, which
was given a BLS refresher
and subsequent
measurement at
12 months.
Int. J. Environ. Res. Public Health 2019, 16, 768 9 of 15

Table 3. Cont.

Study Groups and Results after

Article Population (Sample) Assessment Methods Immediate Results
Teaching Methods Refresher/Retention Period
(1) Three control groups
(A, B, C). Pre-test and
practice with simulation
Improved knowledge among
with mannequins and
those belonging to LISSA
with AED.
Using a serious game to Checklist groups. In terms of skills, there
(2) Five LIfe Support
complement CPR Nursing students based in questionnaires and were no differences between
Simulation Activities No
instruction in a nurse Norway (n = 109) mannequins with a the groups. They conclude that
(LISSA-2) groups (D, E, F,
faculty [19] skill reporter this is a good method to
G, H). Tutorial focused on
support theory but that it does
serious game simulation
not improve skills.
program with problems to
be solved before the
intervention.
(1) Instructor-led group:
Voice advisory manikin Medical students based in received teaching in skills Measurement of skills At 3 months, new 2-min
In the post-measurement,
versus instructor facilitated Copenhagen (n = 43). for 32 min. through a skill measurement, in which no
the instructor-led group
training in cardiopulmonary Students undertook (2) Mannequin-based reporter, pre and post, differences between groups
obtained better results for skills.
resuscitation [22] course 1 year before. group: use of a VAM for 2 min were found.
5 min
(1) Control group: 45 min
theory class followed by
There were no differences upon
45 min of traditional
analysis of theoretical
training with mannequin;
knowledge. After evaluation
Pre-training evaluation and (2) Intervention group: Questionnaires on
Third-year medical with a skill reporter, better
feedback improve medical same theory class, prior knowledge and
students based in Sichuan results with significant No
students’ skills in basic life followed by mannequin with a
(China) (n = 40) differences in the intervention
support [23] pre-assessment after skill reporter
group, except in hand
simulation with instructor
positioning, which was the
feedback for 15 min,
same.
followed by 30 min
training with mannequin.
Int. J. Environ. Res. Public Health 2019, 16, 768 10 of 15

3.2. Study Participants

The participants of the different studies were university students from different branches of
the health sciences, including mainly nursing students [11–13,17–19] and medicine students [22,23].
Only one study did not distinguish the students’ degree titles [6].
The analysed studies included a total of 2175 participants; that by Partiprajak et al. (n = 30) [13]
had the fewest participants, while that by Oermann et al. (n = 606) [19] had the most.

3.3. Participants’ Knowledge Prior to the Undertaking of the Studies

Information about previous knowledge of and technical skills in BLS and CPR was collected
in seven articles [9,11–13,16,18,22]. This meant that some authors excluded a certain number of
participants from studies [9,16], or conversely used this information as a basis when establishing prior
training [11–13,18,22].

3.4. Teaching Methods and Duration

The different teaching methods primarily related to two aspects: theoretical content aspects,
and aspects derived from the acquisition of technical skills in CPR. To this end, the researchers were
guided by the recommendations of the American Heart Association (AHA) [9,12,13,17,18,23] and of
the European Resuscitation Council (ERC) [6,11,19,22]. The exception in this regard was the study by
Mpotos et al. [16], which does not mention any recommendations. These guides were also employed
later to carry out measurements in the evaluations.
For the theoretical level of the training, the authors employed different techniques according to
the different groups that they created within their studies. Accordingly, instructors taught lectures
using visual media such as presentations or videos [6,9,11,12,17,23]. In other cases, the participants
acquired knowledge independently through computer CDs or DVDs provided by the researchers [9,13]
or through different tests with self-assessments [16,19]. In the rest of the studies, training methods
were not specified [18,22].
As for the teaching of skills, the most used method was traditional instructor-led teaching, which
appeared in a total of 6 studies [9,11,12,17,22,23]. In the study by Li et al. [23], one of the group’s first
underwent a pre-assessment (a practical scenario), which after being recorded and reviewed by the
instructors, was subsequently used for training purposes as feedback.
The second-most-used method was training with mannequins that had feedback systems (these
are known as mannequins with a skill reporter). These featured in five studies [6,11,13,16,19].
In addition, in four studies the participants from some groups carried out self-directed learning
with mannequins that, in addition to feedback, had voice prompts that corrected errors (the so-called
voice advisory mannequin, VAM) [9,12,18,22]. It is also worth mentioning that in the studies by Aqel
et al. [17] and Boada et al. [19] high-fidelity simulation programs were used to deliver the training.
Finally, in two studies [6,9], the control groups did skills training without any kind of feedback or
supervision from instructors, and in two others [16,18] no skills practice of any kind was performed.
In terms of the duration of the training undertaken to acquire knowledge and skills, the most
homogeneous approach was the traditional teaching method’s time frame of between four and five
hours, except in the case of the study carried out by Spooner et al. [6], which took place over 8 h.
There were large variations in the other studies.

3.5. Methods Used in the Evaluation

Evaluation methods were organised according to knowledge and skills. To measure
knowledge levels, the methods used were pre-intervention [23], post-intervention [9,19] or pre- and
post-intervention [11,13,17] questionnaires, or a subjective assessment by instructors of performance
in the sequence of BLS steps [6,17]. In addition, two studies included a questionnaire about the
confidence that participants had in executing the skills after the training [11,13]. The measurement
Int. J. Environ. Res. Public Health 2019, 16, 768 11 of 15

of CPR-technique skills during the period in which they were being acquired was taken in 10 of the
11 studies through a skill reporter mannequin [6,9,11–13,16,18,19,22,23].

3.6. Results Obtained after the Intervention

The different results obtained after analysing the articles were divided into two groups for drafting
purposes. We will first discuss the results of the studies in which a single measure was used following
completion of the intervention, and we will then consider the other studies, in which more evaluations
were carried out over time.
Studies that involved a measurement that evaluated theoretical knowledge reported an
improvement in all groups [19,23], with the exception of the study by Roppolo et al. [9], in which the
control group that received theoretical training with an instructor obtained better results. In the study
by Kardong Edgren et al., knowledge was not measured [12].
As for the acquisition of technical CPR skills, the groups that acquired knowledge through a VAM
obtained better results with statistically significant differences relative to the rest of the groups [9,12].
In the study that used high-fidelity simulation, no differences between the groups were established [19].
Finally, in the study by Li et al., in which a group carried out a practical scenario with feedback provided
by instructors to participants, significant results were obtained in CPR technique for all aspects except
for the placement of hands (both groups obtained 100%) [23].
On the other hand, in the first assessment of the studies that applied several measurements [11,13],
knowledge improved in all groups, with the exception of the study by Aqel et al. [17], in which the
improvement was additionally statistically significant in the intervention group. In the study by
Spooner et al. [6], the correct completion of the BLS algorithm was evaluated, with no differences
between the groups. In addition, the studies by Hernández Padilla et al. [11] and by Partiprajak et
al. [13] used questionnaires to analyse the confidence of participants in performing the CPR technique
safely, and they noted an improvement in results after the intervention had been completed.
With respect to skills in performing CPR, in three studies [11,13,16], no differences were
found between the different groups, while in the studies by Spooner et al. and Aqel et al. [6,17],
the intervention groups performed better in both studies. Finally, in the study by Isbye et al. [22],
the instructor-led group obtained better results than the self-directed groups that used a VAM.

3.7. Results Obtained after a Retention Period or Refreshers

Seven studies carried out a subsequent measurement after a refresher or simply by applying
a knowledge retention period [6,11,13,16–18,22] over periods of time ranging from 6 weeks [6] to
1 year [18] after the intervention.
In six studies, a measurement for knowledge retention was used [6,11,13,16,17,22]. In the study
by Spooner et al., after 6 weeks the group that had undertaken practice obtained better results, while
there were no differences when it came to correctly applying the BLS algorithm. [6] In the study by
Hernández Padilla et al., the results were better for the self-directed group at three months. [11] In the
study by Partiprajak et al., after three months, worse results were obtained in terms of knowledge,
similar results were found in terms of confidence of participants when performing CPR, and better
results were obtained in terms of acquisition of CPR skills [13]. The study by Mpotos et al. observed
that the control group that had not received practical skills training obtained better results than
the intervention group at 6 months [16]. In the fifth study in which retention of knowledge was
evaluated, carried out by Aqel et al. [17], it was observed that after 3 months the improvement in
results for knowledge and skills in the group that received the high-fidelity simulation remained.
Finally, the study by Isbye et al. concluded that there were no differences between the groups after
3 months [22].
In the study by Oermann et al. [18] there was no measurement of skills immediately after the
intervention. Out of their control and intervention groups, they produced random subgroups at 3, 6, 9,
and 12 months, which were the ones evaluated. Among these groups, no differences were established
Int. J. Environ. Res. Public Health 2019, 16, 768 12 of 15

in terms of the number of compressions, volume: minute, or hand placements, but there were in
relation to depth and volume administered, which decreased significantly as the measurements were
taken over time. Finally, a fifth subgroup that was given a refresher was also established at 12 months,
and statistically significant differences between the control and intervention groups were not obtained
within it.

4. Discussion
To conduct this review, we drew on a total of 11 randomised clinical trials that were found in
different databases and that aimed to assess the quality of training in CPR and BLS knowledge and
technical skills among health sciences students. Most of the studies were conducted among nursing
and medicine students, in line with the study by López Messa et al., which highlights that BLS training
for future healthcare professionals should be reinforced at the undergraduate level, especially in
nursing and medicine degrees [24].
The studies included in the review were of a low methodological quality according to the Jadad
scale. In view of these findings, one priority that emerges is the need to increase the number of
RCTs with methodological rigour, which would make it possible to minimise biases and facilitate the
identification of progress in scientific evidence regarding BLS training among health sciences students.
To this end, the use of this same scale in other reviews or similar studies would facilitate this process.
The articles are also characterised by the absence of homogeneity in establishing BLS training,
technical CPR skills and use of AEDs. Despite this, the results have shown how studies that used
VAM [9,11,12,18] improved all skills immediately or in the long term, though in the study by Isbye et
al. [22] ventilations were not improved at first.
Moreover, the realisation of practical cases through different simulation programs of high fidelity
provided better results fundamentally in the acquisition of theoretical knowledge [17,19].
Weidman et al. define learning through simulation as an essential part of training, whether
it is high or low fidelity [25]. High-fidelity simulation is very useful when comparing the results
obtained with real outcomes, even though it requires thorough intervention from the instructors [26,27].
In addition, this training provides realistic environments and is more student focused [28].
The use of a skill reporter or VAM mannequins with feedback results in a remarkable rise in the
improvement of the quality of CPR performed by nursing and medicine students, since it allows them
to correct their mistakes or undertake knowledge refreshers independently, making it feasible to not
have an instructor on an ongoing basis. Along this line, the study by Nielsen et al. concludes that this
type of learning improves knowledge and skills [29].
Finally, in the studies included in the review, the use of AED is scarcely mentioned. Although eight
studies included AEDs as part of the theoretical and practical training [6,9,11,13,17,19,22,23], only
Roppolo et al. [9] implemented a measure concerning the use of this device. They obtained
unfavourable results that do not coincide with those of the study by Ahn et al. [30], the main finding
of which was that students reduced intervention times as soon as they had an AED nearby. It has
been shown that courses of between 2 and 4 h in the use of an AED may be enough to operate them
safely [31].
Therefore, and despite the fact that the use of AEDs is a priority when it comes to saving lives,
there is a need for more studies that more comprehensively evaluate training in and handling and
application of these devices in order for there to be fuller performance within BLS.

Limitations
One of the main limitations of the study is that in spite of BLS and CPR training for health science
students, the number of randomised clinical trials is not very high, and studies that have appeared are
very heterogeneous in terms of how they have been produced. Moreover, after reviewing the studies
on a methodological level, we observed that it is necessary to increase their methodological rigour.
Int. J. Environ. Res. Public Health 2019, 16, 768 13 of 15

Another of the limitations of the study is the fact that the recommendations issued by the AHA
and ERC for BLS training evolve continuously, meaning that the inclusion of studies published over
the last 10 years makes it very difficult to assess them in the same way.
In relation to the use of AEDs, it was not possible to describe them because most of the selected
studies did not include measurement results.
Finally, researchers have not included students taking different degrees in their studies, so it
has been impossible to establish differences between students, their degrees, and different training
methods that it may have been possible to use.

5. Conclusions
The studies included in this systematic review are characterised by a low methodological quality
and heterogeneity in terms of their interventions.
Findings have shown that the use of VAMs was more effective for learning CPR skills than
the other resources analysed. With regard to the knowledge acquired, participants did not show
differences between those who received a theoretical session with an instructor and participants who
acquired knowledge independently through computer CDs or DVDs.
Studies did not show results of the use of AEDs, so a comparison could not be made.
Therefore, we would recommend future researchers to include in their research the use of AED,
since we consider it necessary to increase information regarding its use and how students can face
its use in a real case. Finally, we would recommend that future research have a high methodological
quality so that studies can have greater relevance.

Author Contributions: Conceptualization, M.G.-S., C.M.-M., S.M.-I., and D.F.-G.; Data curation, M.G.-S., C.M.-M.,
S.M.-I., J.G.-S., and D.F.-G.; Formal analysis, M.G.-S., C.M.-M., S.M.-I., J.G.-S., and D.F.-G.; Investigation, M.G.-S.,
C.M.-M., S.M.-I., J.G.-S., and D.F.-G.; Methodology, M.G.-S., C.M.-M., S.M.-I., J.G.-S., and D.F.-G.; Project
administration, M.G.-S.; Resources, M.G.-S.; Supervision, M.G.-S., and J.G.-S.; Validation, M.G.-S., C.M.-M.,
J.G.-S., and D.F.-G.; Visualization, M.G.-S., C.M.-M., S.M.-I., J.G.-S., and D.F.-G.; Writing—original draft, M.G.-S.,
C.M.-M., S.M.-I., J.G.-S., and D.F.-G.; Writing—review and editing, M.G.-S., C.M.-M., S.M.-I., J.G.-S., and D.F.-G.
Funding: This research received no external funding.
Conflicts of Interest: The authors declare no conflict of interest.

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