Instructional Design

Simulation-Based CPR Training of Healthcare Professionals in the Workplace

Last Full Review: ILCOR 2025

Simulation-based cardiopulmonary resuscitation (CPR) training is a method of teaching CPR that uses realistic scenarios and high-fidelity manikins or virtual environments to replicate real-life cardiac arrest situations. It emphasizes hands-on practice, decision-making, teamwork and situational awareness in a controlled, risk-free setting. It has become a popular means of training healthcare professionals in situ (in their workplace) in both basic life support and advanced life support (Edelson et al. 2008, 1063). Theoretically, in situ simulation-based CPR training improves skill acquisition, retention and transfer to real-world situations; it may enhance team coordination and communication under pressure; and it allows learners to make and learn from mistakes without harming patients. It can be tailored to specific settings such as hospital wards, emergency medical services and schools. This topic is the subject of a 2025 systematic review by the International Liaison Committee on Resuscitation (ILCOR).

 

Evidence Summary

A 2024 ILCOR systematic review and Consensus on Science with Treatment Recommendations (CoSTR) (Cortegiani et al. 2023; Greif et al. 2025, S205) aimed to determine if in situ simulation-based CPR training of healthcare providers, compared with traditional training, changes:

• Patient outcomes.
• CPR skill performance at course completion and other intervals.
• CPR skill performance in actual resuscitation.
• CPR quality.
• Team competencies, resources and adherence to guidelines.

 

Both randomized controlled trials (RCTs) and nonrandomized studies were eligible for inclusion. Nine studies were ultimately included, with one observational study reporting an association between the in situ simulation period and higher odds of survival to hospital discharge in pediatric cardiac arrest (50/124 [40.3%] pre-intervention period versus 28/46 [60.9%] post-intervention period; OR, 2.06; 95% CI, 1.02–4.25) (Cortegiani et al. 2023; Greif et al. 2025, S205).

For other patient outcomes, one observational study (Xu et al. 2023, 1138633) reported lower incidence of neonatal asphyxia, severe asphyxia, hypoxic-ischemic encephalopathy and meconium aspiration syndrome in the post-intervention period compared with the pre-intervention period.

For clinical performance in actual resuscitation, three before-and-after studies favored in situ training, with one study (Herbers and Heasers 2016, 393) reporting reduced time to call for help, time to initiate chest compressions and time to initial defibrillation. Another study (Hammontree et al. 2022, 42) reported a decrease in nonadherence to pediatric advanced life support guidelines for subsequent epinephrine timing, and Knight et al. (Knight et al. 2014, 243) reported improved chest compressions between rhythm checks with in situ training but no difference in neurological outcome at discharge or for other elements of CPR.

Other outcomes were reported only in individual studies, with in situ training showing advantages such as:

• Greater adherence to resuscitation performance standards among pediatric code teams (Van Raemdonck et al., 2014, 284)
• Improved clinical performance in simulation scenarios (e.g., skill performance measures) (Kurosawa et al., 2014, 610)
• Shorter time to call for help and initiate chest compressions (Sullivan et al., 2015 6)
• Better technical skills and adherence to guidelines (Rubio-Gurung et al., 2014 e790)

 

No difference in teamwork, as assessed by the Behavioral Assessment Score, was reported in the RCT by Kurosawa et al. (Kurosawa et al. 2014, 610), while Rubio-Gurung et al. (Rubio-Gurung et al. 2014, e790) reported better team performance during in situ simulation.

A weak recommendation was made by ILCOR (Cortegiani et al. 2023; Greif et al. 2025, S205) based on very low-certainty evidence, that in situ simulation may be considered as an option for CPR training where resources are readily available.

Insights and Implications

Overall, the ILCOR review identified very limited evidence for patient-centered outcomes, including a single observational study showing a survival benefit with in situ training, and various beneficial neonatal clinical outcomes from a second study. The volume of literature showing a benefit for in situ training comes from four studies of clinical performance and teamwork competencies in actual resuscitation and from additional simulation studies, including outcomes of team competencies and clinical and skill performance. The certainty of evidence was rated as very low across all outcomes, and meta-analysis was not performed due to very high heterogeneity and risk of bias.

Of note, all patient populations were included in this review of in situ simulation-based training: adult (4), pediatric (3) and neonatal (2). No studies were found for the important outcome of resources, including costs, workload and equipment needed for in situ training. The wording of the Red Cross guideline on in situ simulation training is informed by this ILCOR review but reflects the very low certainty of evidence and need for future research studies.

 

CPR Feedback Device Use in Resuscitation Training

Last Full Review: ILCOR 2025
Last Update: 2020

Cardiopulmonary resuscitation (CPR) feedback devices are being used more frequently during skills training for basic life support and advanced life support (Edelson et al. 2008, 1063). The types of devices vary, but all provide immediate feedback or guidance. A 2020 International Liaison Committee on Resuscitation (ILCOR) review (Wyckoff et al. 2022, e645) generally showed positive short-term effects on retention of CPR skills with the feedback devices. Since then, additional published studies have triggered an updated 2025 systematic review.

 

Evidence Summary

A 2023 ILCOR Consensus on Science with Treatment Recommendations (CoSTR) (Lin et al.  2023; Greif et al. 2025, S205) aimed to determine if the use of a CPR feedback or guidance device during resuscitation training of laypersons and healthcare providers in any educational setting, compared with no use of a CPR feedback or guidance device, changes outcomes of patient survival, quality of performance in actual resuscitations, skill retention (performance after course conclusion) and skill acquisition (performance at course conclusion). Twenty randomized controlled trials (RCTs) were included in the systematic review, all in healthcare providers except for three studies conducted in lay providers (Lin et al. 2023; Greif et al. 2025, S205).

The review did not identify any studies that examined the impact of CPR feedback device use during resuscitation training on the outcomes of patient survival or quality of performance in actual resuscitation. For outcomes of CPR skills, meta-analysis of data from 15 RCTs indicated that participants trained with feedback devices had significantly greater mean compression depth compared to those training without them (SMD=0.76; 95% CI, 0.02–1.50; P=0.04) (Lin et al.  2023; Greif et al. 2025, S205).

Meta-analyses of data from included RCTs also demonstrated significantly greater compression depth compliance (the percentage of compressions meeting the resuscitation guidelines during assessment), a lower mean compression rate, improved compression rate compliance, chest recoil compliance and overall CPR quality (assessed by integrated metrics of chest compression depth, rate and recoil) with the use of CPR feedback devices (Lin et al.  2023; Greif et al. 2025, S205).

A revised strong treatment recommendation by ILCOR (Lin et al. 2023; Greif et al. 2025, S205) recommends the use of CPR feedback devices during resuscitation training for healthcare providers and lay providers.

Insights and Implications

Cognitive aids are a valuable tool in studies of simulated resuscitation with enhanced protocol adherence, team performance and timeliness of critical interventions. Further research is recommended to evaluate the effectiveness of cognitive aids in real-world clinical settings and to explore the impact of different types of aids on resuscitation outcomes. For untrained bystanders and those with difficulty remembering CPR processes, the use of cognitive aids may be considered, particularly in regions where Dispatcher-Assisted CPR/Telecommunicator CPR is not available. Efforts should be made to limit any delay in starting CPR.

 

Self-Directed Digital Basic Life Support Training

Last Full Review: ILCOR 2025
Last Update: 2021

Self-directed digital cardiopulmonary resuscitation (CPR) training is any form of digital education or training for CPR that can be completed without an instructor. It may include video, phone application-based, Internet-based and game-based learning, virtual reality and augmented reality. The popularity of self-directed, digital-based learning grew during the coronavirus disease 2019 (COVID-19) pandemic as a means to complete course work without the risk of disease transmission. Self-directed digital-based basic life support (BLS) training for adults and children was compared with traditional instructor-led training by the International Liaison Committee on Resuscitation (ILCOR) in 2021 (Wyckoff et al. 2022, e645). The evidence evaluation led to recommendations for the use of either instructor-led training with manikin practice and feedback devices, or the use of self-directed training with video kits (instructional video) and manikin practice with feedback devices for CPR education and skills acquisition in lay adults and children over 10 years old. This review was updated in 2025 by ILCOR.

 

Evidence Summary

A 2025 ILCOR systematic review and Consensus on Science with Treatment Recommendations (CoSTR) (Eastwood et al. 2024; Greif et al. 2025, S205) aimed to determine if self-directed digitally based CPR training for adults and children undertaking CPR training, compared with instructor-led CPR training, changed patient outcomes, bystander CPR quality during out-of-hospital cardiac arrest (OHCA) and multiple CPR educational outcomes after training. The review included only randomized controlled trials (RCTs) that provided data for outcomes of CPR quality, automated external defibrillator (AED) use, knowledge, and confidence and willingness to perform CPR. No studies included patient-centered outcomes. The review included 29 RCTs that reported educational outcomes and results reported narratively. For details of the individual study designs and findings, the reader is encouraged to read the full CoSTR at: https://costr.ilcor.org/document/self-directed-digital-based-versus-instructor-led-cardiopulmonary-resuscitation-education-and-training-in-adults-and-children-eit-6406-tf-sr.

The populations in the studies ranged from children to university, medical and nursing students. Educational outcomes reported by the RCTs included CPR quality, AED use, knowledge, confidence and willingness to perform CPR, and test scores immediately after to less than 1 month after training, and between 1 to 12 months after training. For the comparison of findings from testing immediately post-training with self-directed interventions versus instructor-led training, most studies found no difference for educational outcomes such as CPR quality and AED use with the use of video plus manikin and video-only self-directed training (Eastwood et al. 2024; Greif et al. 2025, S205).

Instructor-led training was favored in comparison to video plus manikin self-directed training in three studies for hand position (Chung et al. 2010, 165; Einspruch et al. 2007, 476; Marcus et al. 2022, Doc45) and in one study for correct depth of chest compressions (Chung et al. 2010, 165), proportion of chest compressions at the correct depth (Beskind et al. 2016, 28), knowledge, (Dracup et al. 1998, 170), and confidence (Pedersen et al. 2018, 147). For studies of video-only self-directed training, most showed no difference between self-directed and instructor-led training for outcomes of compression rate, depth, fraction, recoil, hand position, ventilation rate, AED use, and knowledge and confidence (Eastwood et al. 2024; Greif et al. 2025, S205). Two studies favored instructor-led training over video-only training for compression rate and depth (Heard et al. 2019, 599) and for knowledge and confidence (Kim et al. 2016, 463).

For educational outcomes, testing occurred between 1 and 12 months of training, and many studies reported reduced quality of skill performance, such as compression rate, depth, fraction, recoil, hand position, ventilation rate and AED use (Eastwood et al. 2024; Greif et al. 2025, S205).

A revised ILCOR weak treatment recommendation for 2025 (Eastwood et al. 2024; Greif et al. 2025, S205) suggests the use of either instructor-led training or self-directed digital training for the acquisition of CPR and AED skills in lay adults and children over 10 years old. It is suggested that self-directed digital training be used when instructor-led training is not available, or when quantity over quality of CPR training is needed in adults and children.

There was insufficient evidence to make a recommendation on game-in-film, virtual reality, computer programs, online tutorials or app-based training as a CPR or AED training method.

Insights and Implications

In creating the updated treatment recommendation, the ILCOR review notes that any form of CPR and AED training is likely to improve knowledge, confidence and willingness to perform CPR in a simulated setting, although this may not translate to real-life situations (Eastwood et al. 2024; Greif et al. 2025, S205). The ILCOR recommendation is directed at the population of lay adults and children over 10 years old. Although study populations were reported to include university, medical and nursing students, there was no subgroup analysis by type of learners described.

The advantages of digital-based, self-directed CPR and AED training include:

• Accessibility and convenience (learn anytime, anywhere, and in remote areas).
• Cost-effectiveness (no need for instructors or classroom space for organizations; scalable for large groups).
• Standardization (ensuring consistent content and delivery without instructor variability).
• Self-pacing and repetition (may improve retention and confidence with review).
• Real-time feedback (with feedback-enabled manikins).

 

The disadvantages of digital-based, self-directed CPR and AED training include:

• Reduced hands-on practice with video-only formats.
• No real-time correction of mistakes and potential to develop improper technique.
• Variable learner motivation and potential to skipping or skimming content.
• Limited scenario practice, such as with team-based resuscitation, communication, and decision-making, and lack of question-and-answer elements found in instructor-led formats.

 

The Red Cross guidelines for BLS training formats remain unchanged. A blended learning course format aims to improve skill performance and skill retention to a greater extent than a video-only format.