Applied Nursing Research 30 (2016) 9497

Contents lists available at ScienceDirect

Applied Nursing Research

journal homepage: www.elsevier.com/locate/apnr

The inuence of high delity simulation on rst responders retention of

CPR knowledge
Ruth Everett-Thomas, RN, PhD a,, Vernice Turnbull-Horton, RN, MSN b, Beatriz Valdes, RN, MSN c,
Guillermo R. Valdes, RN, DNP d, Lisa F. Rosen, MA a, David J. Birnbach, MD, MPH e
a

University of Miami Miller School of Medicine, UM-JMH Center for Patient Safety R-370A, Miami, Florida 33136
Ambulatory Services Division, Jackson Memorial Hospital, Miami, Florida 33136
University Of Miami, M. Christine Schwartz School of Nursing and Health Studies, Coral Gables, FL 33146
d
Miami Dade College: Benjamin Leon School of Nursing, Miami Florida, 33132
e
University of Miami Miller School of Medicine, UM-JMH Center for Patient Safety, Coral Gables FL, 33146
b
c

a r t i c l e

i n f o

Article history:
Received 24 June 2015
Revised 6 November 2015
Accepted 8 November 2015
Available online xxxx
Keywords:
High delity simulation
Knowledge
Retention
Training

a b s t r a c t
Introduction: The purpose of this study was to identify the impact of high-delity simulation on the retention of
basic life support cardiopulmonary resuscitation (CPR) knowledge among a group of healthcare providers (HCPs).
Methods: A twenty-ve question exam was completed by nurses and nurse technicians over a two-year period
before and after mandatory CPR training with high-delity simulation.
Results: Most HCPs scored near 50% or below the passing score (80%) with a mean range of scores between 28% and
84%. HCPs missed questions on the exam that requested specic details related to technique or human physiology
during CPR.
Conclusion: The current teaching method for basic life support may be enhanced by using high-delity simulation,
but this modality alone is not enough to support HCPs retention of CPR knowledge. Additional studies are needed
to identify strategies that will help HCPs remember specic and detailed information in the CPR algorithm.
2015 Elsevier Inc. All rights reserved.

1. Introduction

2. Background

During a sudden cardiac arrest (SCA) or heart attack every second

counts. As brain and organ injury increases the chance of survival
decreases (American Heart Association, 2013). Cardiac arrest occurs in
individuals of all ages. Basic life support (BLS) measures are performed
to manually pump the heart and circulate oxygenated blood to vital
organs (American Heart Association, 2013). Unfortunately, the body
may suffer irreversible organ damage after four to seven minutes once
blood ow has stopped and oxygen cannot be transported to the heart
or brain (Niles et al., 2011).This simple cardiopulmonary resuscitation
(CPR) method has proven to be effective when performed correctly by
healthcare providers (HCPs) (American Heart Association, 2013).
The rst ve minutes of cardiopulmonary resuscitation (CPR)
performance is crucial for optimal survival of a heart attack. There is a
direct link between knowledge, actual performance of CPR measures
and poor survival outcomes (American Heart Association, 2013
Updates). Therefore, we evaluated healthcare providers (nurses and
nurse assistants) knowledge after mandatory CPR training to determine
the amount of retention at ve time intervals.

In the US, guidelines for CPR are updated every ve years to include
ongoing research ndings. While researchers agree the technical
aspects of CPR may be simple nonetheless performing them correctly
has proven difcult (Al Hadid & Suleiman, 2012). Chee (2014) suggests
that the retention of CPR skills is closely associated with the instructor,
learner, curriculum, and frequency of timing in which the training takes
place (deliberate practice). Experts in simulation concur with these
ndings and propose that simulated environments may be the future
modality for acquiring and maintaining skills (Issenberg & Scalese,
2007). According to Chee (2014), deliberate practice is one of the best
teaching strategies for adult students to learn and retain information.
This learner-centered experience is embedded in an appropriate clinical
context allowing for deliberate practice after a period of reection
(Chee, 2014; Issenberg & Scalese, 2007). Simulation is unlike traditional
lectures and other formats in which the learner is a passive observer.
Researchers conclude that healthcare simulation is gaining widespread
acceptance as a teaching modality which can be used to enhance any
existing education curriculum (Chee, 2014; Issenberg & Scalese, 2007).
Additionally, high-delity simulation (HFS) including sophisticated
mannequins, updated computer software, high-tech medical equipment
and highly-trained personnel creates a more realistic environment helping
users suspend disbelief (Aqel & Ahmad, 2014; Tawalbeh & Tubaishat, 2013).

Corresponding author.
E-mail address: reverett@med.miami.edu (R. Everett-Thomas).
http://dx.doi.org/10.1016/j.apnr.2015.11.005
0897-1897/ 2015 Elsevier Inc. All rights reserved.

R. Everett-Thomas et al. / Applied Nursing Research 30 (2016) 9497

2.1. High-delity simulation

Using HFS, instructors can control the mannequins life-like responses
by making various adjustments to the scenario depending upon the
students interventions. An interaction between the mannequin, student
and instructor enhances experiential learning. Students are given time
to practice various skills while allowing the instructor to evaluate their
clinical decision-making and critical thinking skills (Nevin, Neill, &
Mulkerrins, 2014). Although CPR recertication skills are still performed
using low-delity or static mannequins (resusci-Anne), many healthcare organizations are beginning to incorporate HFS into their annual
mandatory training courses (Ackermann, 2009; Tawalbeh & Tubaishat,
2013). Despite the signicant data regarding the degradation of CPR
knowledge and skills after standard recertication, limited research mentions a decrease in knowledge after HFS training (Adekola, Menkiti, &
Desalu, 2013; Aqel & Ahmad, 2014; Sankar, Vijayakanthi, Sankar, &
Dubey, 2013). Thus, the purpose of this study was to evaluate healthcare
practioners CPR knowledge and determine the effect of HFS on retention
after mandatory BLS-CPR training.

95

the rate and depth of compressions, number of rescue breaths, and the
amount of time required to take a pulse along with its location. Two
questions were identical and repeated; however, the multiple choice
answers were placed in a different sequence.
The results of the written exam were not reviewed with the staff and
were used as a quality measure for the clinic educators to improve their
training program. At the end of the data collection period, additional
information about CPR was provided to the staff along with pocket
cards, instructional posters in the clinic area, and the AHA 2010 BLS
Quick Reference Guide.
3.3. Data analysis
All data were analyzed using frequency distributions, ANOVA and
the student t-test with the IBM Statistical Package for Social Sciences
(SPSS) version 21, and a 0.05 probability level was used to determine
a statistical difference between the groups.
4. Results

3. Methods
3.1. Sample and setting
A convenience sample of HCPs (registered nurses, licensed practical
nurses, nursing assistants and patient care technicians) from ve specialty
outpatient clinics was included in this study. They were previously
recertied in BLS-CPR skills using the 2010 AHA updated guidelines. As
part of the organizations mandatory BLS training program, all HCPs
were required to participate in at least one mock-code prior to recertication. Over a two year period (7/2011 to 8/2013) HCPs from the outpatient
clinic underwent mandatory CPR training (i.e. mock cardiopulmonary
arrest code) using high-delity simulators in the hospitals simulation
center. Also, one group of participants took the exam nearly two years
later. This test occurred prior to their AHA recertication, and they received only one training session with HFS. All sessions were faculty-led
and videotaped to guide the debrieng process immediately after each
encounter. HCPs participated as small groups in one mandatory session
of two mock code scenarios to enhance training.
3.2. Procedures
One group of HCPs was given the written examination prior to their
annual mandatory training, and all other participants were given the
test after the training period. This study was approved by the Institution
Review Board. A registered nurse obtained informed consent and distributed a 25-question written CPR exam to all HCPs. HCPs volunteered
depending upon their availability to take the test during and/ or
immediately after clinic hours. Information about CPR was not reviewed
prior to taking the test, and no instructional CPR posters were noted in
the clinic area. Individuals were provided 30 to 45 min of uninterrupted
quiet time in a private ofce and were monitored throughout the testing
period. The test was given at ve different time intervals (baseline, b3 months, b 6 months, b 9 months, and at two years after HFS mockcode training but prior to recertication). No identifying or demographic
information was collected on the test. This course of action provided the
HCPs with anonymity and a level of assurance their scores would not be
used either favorably or unfavorably within the organization. Also, all
individuals could only take the test once regardless of the time when
they completed their mandatory training.
The 25-question exam was derived from the AHA 2010 guidelines
for BLS-CPR and emergency cardiovascular care (ECC) recertication;
however, questions about child and infant CPR were excluded. The
exam questions focused on both one and two rescuer performance of
adult BLS-CPR skills and the correct use of an AED device. Five questions
replaced those related to infant and child. These questions addressed

Of the 57 individuals that took the written exam, only two received
passing scores N80%. Five percent of the group members scored (72%)
below the passing score. The range of percent scores for all of the tests
was between 28% and 84%. For each time interval including the baseline,
the mean percent scores were near or below 50%. Total mean scores for
all exams in the b3 month interval were 54%, slightly higher than all
other mean scores. Individuals that took the exam prior to simulation
training and during the b9 month interval after the simulation training
had the lowest total mean percent scores (43% and 44%). There were no
signicant differences between any of the total mean percent scores for
all time intervals (Table 1).
Most HCPs missed 12 of the 25 questions (48%) on the written
exam, and only two answered seven questions correctly (28%). Also,
95% (54/57) of the individuals who took the exam answered the AED
questions incorrectly. A few HCPs remembered the number of seconds
recommended to give a breath in the presence of an advanced airway.
Approximately 80% (45/57) missed both questions about the correct
use of the bag valve-mask (BVM) device for both one and two rescuers.
Nearly 85% (48/57) of the HCPs incorrectly answered the physiology
question related to the reason for performing chest compressions.
Sixty percent (34/57) of this cohort incorrectly answered all three
questions regarding hand placement, depth and rate of compressions.
Two identical questions related to the specic rate and depth of
compressions were repeated. The order of the multiple choice answers
were rearranged, and 50% (29/57) of the HCPs missed all four questions.
Table 1
The difference of the mean percent group score for Healthcare Providers for each time intervals using ANOVA.
Group Type

SS

Group 1 b3 months
Between
728
Within
392
Total
1120
Group 2 b6 months
Between
998
Within
200
Total
1198
Group 3 b9 months
Between
810
Within
16
Total
826
Group 4 b2 years
Between
1513
Within
592
Total
2105
Note the signicance level is 0.05.

df

MS

F-statistic

Signicance

7
2
9

104
196

0.53

.78

7
2
9

142
100

1.43

.48

7
2
9

116
8

14.4

.07

7
2
9

216
296

.73

.69

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R. Everett-Thomas et al. / Applied Nursing Research 30 (2016) 9497

5. Discussion

5.1. Limitations

Our results showed that retention of detailed knowledge for adult

learners is difcult for skills that are rarely used regardless of the time
HCPs were trained using high-delity simulation. Individuals who
completed the exam closest to the time of training scored better on
the written exam. These scores were compared to individuals who did
not receive the training prior to taking the test or nearly one year after
training. Additionally, the total mean scores were not signicantly different from those who were tested two-years post simulation training.
The results suggest that many individuals retained only about 50% of
the information needed to successfully pass the CPR recertication examination. Likewise, the most frequently missed questions were related
to specic details of a particular procedure such as AED use (turn on the
device before using and resume CPR immediately after shocking the patient) or specic hand placement for compressions (on the lower half of
the breastbone and two inches deep). A high percentage of individuals
(85%) incorrectly answered the frequency in which a breath should be
given in the presence of an advanced airway. They also failed to recall
the physiology for chest compressions. Some of these individuals
missed the question related to the purpose of the appropriate depth of
compressions. Others had lower test scores because they did not
remember the pertinent information regarding BVM ventilation for
one and/or two rescuers. These results concur with previous research
that shows CPR knowledge diminishes substantially by three months
post-training unless it is a frequently used skill (Aqel & Ahmad, 2014;
Nori, Saghania, Motamedi, & Hosseini, 2012).
In a study of 90 nursing students, a positive increase in CPR knowledge and skills acquisition favored HFS training over traditional BLS
teaching methods. However, both groups decreased in knowledge and
skills after three months (Aqel & Ahmad, 2014). Nori et al. (2012) had
similar ndings for 112 nurses in which their CPR knowledge and skills
began to show a decrease as early as ten weeks post training. They also
showed a continued decline in both knowledge and skills two years
later. In a study of 78 residents (medical doctors) from nine different
specialties, retention of knowledge after simulation training was poor.
Then yet, the residents self-reported higher perceptions in performing
CPR in this study (Adekola et al., 2013).
The question remains: How do we train individuals to remember
vital sequential information for a procedure that they rarely perform
in their daily work environment? CPR educators and innovators imply
that automated systems may help providers and students remember
the sequence of skills. For example, in both a feasibility and preliminary
study, researchers demonstrated effective and efcient methods to
assess the retention of BLS knowledge and skills using automated CPR
training (Mpotos, De Wever, Valckle, & Monsieurs, 2012; Oreman
et al., 2010). They used an automated testing station to assess 181
medical residents retention of BLS skills six months after training.
Their results showed that the system was able to guide the students
accurately through the testing procedures (Mpotos et al., 2012).
Likewise, Oreman et al. (2010) used a CPR voice assisted mannequin
to help 264 nursing students perform the correct skills of CPR.
This was achieved by providing immediate verbal feedback to the
student while prompting them with corrective actions to improve
their performance.
These studies may predict a future training modality for HCPs in
retaining BLS knowledge and skills without the need of a live instructor.
Freestanding automated CPR stations in healthcare settings may allow
HCPs to practice at their own pace as often as needed. However, servicing these systems may become expensive. HFS has shown to have better
results for the retention of CPR knowledge and skills when compared to
standard training. HCPs continue to show a degradation in knowledge
over time regardless of their teaching modality. Thus, educators must
include strategies to evaluate CPR knowledge at frequent intervals
since the minimum requirements set by the AHA and healthcare organizations may be insufcient for HCPs.

There were several limitations to this study. First, the test was given
to HCPs during or immediately after their work day. Since no identiable information was collected, this may have resulted in a lack of concentration or focus on the exam. Second, the exam was given to all
available nurse and allied healthcare personnel from different specialties with varying levels of education. This mix of education levels may
have produced lower overall scores. Although the participants were
from ve different outpatient clinics, they were still considered to be
from one site (organization). Lastly, the small convenience sample size
was also a limitation.
6. Conclusion
High-delity simulation shows promise to help HCPs retain the
necessary knowledge to successfully perform CPR. Researchers have
shown that more frequent sessions may be required. Since training
large numbers of HCPs can become expensive for any organization,
automated CPR stations may prove to be less expensive and benecial
in the near future. As these systems can be used and incorporated into
any training modality, healthcare organizations should consider
using them. Instructors and researchers must continue to assess the
effectiveness of various CPR training modalities on sustained knowledge
by testing participants at frequent intervals.
6.1. Future implications
With more than fty years of mandatory basic life support training,
HCPs continue to struggle in retaining CPR knowledge and skills. Lives
are lost in non-acute healthcare facilities due to HCPs apprehension
and other barriers related to initiating CPR. Some of these barriers
may become more noticeable due to on-line access of the written
exam. Educators and researchers should support the notion of providing
mandatory spot checks of CPR knowledge by administering the written
exam at frequent intervals within the recertication period.
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