Original Article

High-Fidelity Simulation Effects on CPR

Knowledge, Skills, Acquisition, and Retention
in Nursing Students
Ahmad A. Aqel, RN, PhD • Muayyad M. Ahmad, RN, PhD

ABSTRACT
Keywords Background: There is a gap in the literature regarding learning outcomes linked to the use of
high-fidelity high-fidelity simulators compared to that of traditional teaching methods.
simulator, Aim: To examine the effect of using high-fidelity simulators on knowledge and skills acquisition
cardiopulmonary and retention with university students.
resuscitation, Methods: A randomized two-arm trial using two different educational approaches on 90 nursing
acquisition and students assigned randomly to two groups was used at two points of time.
retention,
Findings: The results showed significant differences in favor of the participants in the high-
knowledge and skills
fidelity simulator group on both the acquisition and retention of knowledge and skills over time.
However, a significant loss of cardiopulmonary resuscitation knowledge and skills occurred at 3
months after training in both groups.
Conclusions: The findings of this study may assist educators in integrating high-fidelity simula-
tors in education and training. In addition, the findings may help nursing educators to arrange
additional cardiopulmonary resuscitation training sessions in order to improve cardiac arrested
patients’ outcomes.
Linking Evidence to Action: High-fidelity simulation (HFS) provides students with interactive
learning experiences in a safe controlled environment. HFS enables teachers to implement critical
clinical scenarios, such as cardiac arrest, without risk to patients. Integrating the simulation training
into nursing curricula will help to overcome the challenges that face many courses, specifically
the shortage of clinical areas for training and the increase in numbers of nursing students.

BACKGROUND
High-fidelity simulation (HFS) provides students with inter-
active learning experiences in a safe, controlled environment
where they can practice with no harm to patients (Decker,
Sportsman, Puetz, & Billings, 2008). HFS is a new trend in
education that has been introduced by the nursing community
(Nehring & Lashley, 2010; Sarac & Ok, 2010). Although many
health educators continue to rely on the traditional classroom
lecture as the primary method for presenting clinical knowl-
edge, experimental learning through simulation can enhance
students’ knowledge and skills (Brannan, White, & Bezanson,
2008). Traditional teaching using a lecture format means that
students rely on memory rather than a deep understanding
of the content (Jefferies, 2007). Although there are some ad-
vantages of traditional lecturing to novice students, such as
clarifying unfamiliar concepts, using a lecture format in con-
junction with experimental active learning helps students with
the acquisition and retention of knowledge (Kaddoura, 2011).
HFS consists of an interactive manikin driven by comput-
ers, and has many features that replicate physiological parame-
ters, such as the ability to produce pulse, breathing, and blink-
ing (Lasater, 2007). In addition, HFS enables educators to im-
plement clinical scenarios that give students the opportunity
to practice critical situations, such as cardiac arrest without
risk to patients (Alinier, Hunt, Gordon, & Harwood, 2006).
Furthermore, HFS enhances experimental learning, giving
students the opportunity to practice skills in a safe environ-
ment, demonstrate clinical decision-making, observe other stu-
dents, and learn from feedback during debriefing sessions
(Brannan et al., 2008). However, there is a gap in literature
related to the effectiveness of using HFS as a supportive ap-
proach to a traditional lecture-teaching method (Nehring &
Lashley, 2010).
Simulation has become an important element in nursing
education, specifically in teaching the necessary skills and
knowledge to prepare competent nurses (Ahmad & Safadi,
2009; Luctkar-Flude, Wilson-Keates, & Larocque, 2012). In-
structors can control the manikin’s responses and the HFS
can respond to interventions provided by the student (Lasater,
2007). Furthermore, HFS allows nursing students to practice,

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C 2014 Sigma Theta Tau International

develop, and apply knowledge and skills in a realistic clinical
situation and safe environment as they participate in interac-
tive learning experiences without risk to patients (Alasad &
Ahmad, 2005; Gates, Parr, & Hunghen, 2012). Simulation is
used to support teaching, promote critical thinking among stu-
dents, and enhance the quality of patients’ care (McFetrich
& Price, 2006). The high-fidelity simulator METI-emergency
care manikin was used in this study (METI, 2011). It is a
full-size manikin; has the ability to check airway, breathing,
circulation, chest compression, and defibrillation; respond to
pharmacological intervention; and is designed with multiple
scenarios for clinical situations with the ability to build more
scenarios within it.
Many nursing colleges have used different teaching meth-
ods to improve the retention of students’ cardiopulmonary
resuscitation (CPR) knowledge and skills (Yuan, Wiverly,
Fang, & Ye, 2012). Nursing students have positively valued
simulation-based learning as effective as learning in real set-
tings in terms of increasing confidence in the ability to perform
CPR (Leighton & Scholl, 2009; Tawalbeh & Ahmad, 2013b).
Furthermore, adding simulation as a clinical teaching
method proved to be a valuable experience for learning psy-
chomotor skills and developing critical thinking over time
(Brannan et al., 2008).
Other researchers investigated the retention of CPR knowl-
edge and skills after repeated virtual simulation training over
18 months and 6 months apart (Luctkar-Flude et al., 2012).
The intervention group attended 2-hr virtual simulation train-
ing sessions 6 months apart, while the control group only had a
traditional CPR training. The researchers found no significant
difference in knowledge between the groups, and a drop in
knowledge and skills over time for both groups. However, the
small sample size in this study increases the risk of type II er-
ror. Thus, more research is needed to investigate the outcome
of HFS as an alternative method of teaching that enhances
retention of CPR knowledge and skills. The purpose of this
study was to examine the acquisition and retention of CPR
knowledge and skills by using two methods of teaching: (a)
traditional didactic CPR lecture accompanied with low-fidelity
simulation (LFS), and (b) didactic CPR lecture accompanied by
HFS training.
RESEARCH HYPOTHESES
This study has three research hypotheses:
1. There is no difference in CPR knowledge between
the control and the intervention groups before initi-
ation of CPR training.
2. The intervention group that received HFS CPR train-
ing will demonstrate a higher level of CPR knowl-
edge and skills acquisition than the control group
that received LFS CPR training.
Worldviews on Evidence-Based Nursing, 2014; 11:6, 394–400.

C 2014 Sigma Theta Tau International
Original Article
3. The intervention group will have a higher level of
knowledge and skills retention at 3 months after
training in comparison to the control group.
METHODS
Study Design
An experimental, pretest-posttest design was conducted to ex-
amine the effectiveness of HFS training versus LFS CPR train-
ing on the acquisition and retention of CPR knowledge and
skills among second-year nursing students. Participants were
randomly assigned into two equivalent groups. The control
group participated in a 4-hr session of traditional training,
which consisted of a PowerPoint presentation of AHA adult
basic life support (BLS), including automated external defibril-
lator (AED), and demonstrations on a LFS CPR manikin. The
intervention group received the same PowerPoint lecture in
addition to training on a HFS.
Sample and Setting
The inclusion criteria were that participants: (a) were nurs-
ing students enrolled in the first adult health nursing course,
(b) agreed to participate in the study, and (c) had no pre-
vious experience with CPR. Students who had previous ex-
perience with CPR, who held a BLS certificate, or who
were bridging from an associate’s degree to a baccalaureate
degree were excluded from participating in this study.
This study was conducted in the nursing laboratory at the
University of Jordan. The nursing laboratory is well-equipped
with dolls, materials, static manikins, and high-fidelity
simulators.
Sample size was calculated by using G* power 3.0 software
(Faul, Erdfelder, Lang, & Buchner, 2007). In this study, com-
parisons between groups with t tests (one tail) for independent
samples, medium effect size (d = .50), a sample of 51 par-
ticipants in each group was needed to provide 80% power to
detect difference at 0.05 significance level (Polit, 2010). The
final number of participants who completed the phases of the
study was 90.
Ethical Considerations
The study method and protocol were reviewed by the ethical
committee in the Faculty of Nursing at the University of Jor-
dan. Target students willing to participate in this study received
both oral and written information about the purpose, content,
and duration of the study. A code number was provided to each
participant, which protected the confidentiality of the partici-
pants. The participants were assured that withdrawal from the
study at any time carried no penalty. Students were asked to
sign the informed consent if they agreed to participate in the
study. Permission to use the skill and knowledge checklists
was obtained from the AHA.
395
HFS and CPR Knowledge and Skills
Instrumentation
The instrument used in this study had two sections. The first
section was the demographic data sheet used to identify any
potential group variances. The demographic data sheet con-
sisted of a checklist and gap-fill questions on variables, such as
age, gender, grade point average (GPA), CPR experience, and
whether bridging to baccalaureate. The second section was 14
multiple choice questions on CPR knowledge (American Heart
Association [AHA], 2012). This test was used to evaluate the
participants’ CPR knowledge at the baseline and acquisition
phase. Questions related to infants and children as well as
those related to stroke and foreign body airway obstructions
were removed as this study was focused on adult CPR only.
The most important aspects of CPR knowledge questions re-
lated to knowledge of the correct sequence of CPR, rate and
depth of compression, rescue breathing, ratio of compression
to ventilation, performance of compression and breath, and
use of AED.
To measure CPR skills, mock codes were conducted; the
students were asked to respond to a full-body CPR manikin
lying on the floor. Their responses were recorded on the AHA
final evaluation skill sheet for adult CPR, which the AHA has
made publicly available (AHA, 2012). The adult CPR skills
checklist was designed by AHA to evaluate CPR skills on adult
victims. Permission to use the tools was obtained from AHA.
The CPR skills checklist is composed of 14 items covering the
assessment of the victim, correct delivery of compression and
ventilation, in addition to operating the AED.
Data Collection
At the baseline phase, all the participants in the two groups
filled the demographic data and a pretest for CPR knowledge.
The participants in the control group then attended a lecture
on CPR. The acquisition phase consisted of a demonstration
on a LFS with static manikin (traditional teaching method),
and training on a HFS manikin for the intervention group. A
posttest was immediately conducted to evaluate CPR knowl-
edge and CPR skills within a cardiac arrest scenario. Both
groups were evaluated on a static manikin.
Procedure
All participants completed a pretest for CPR knowledge exam-
ination, then all participants received the CPR lecture. Next,
the CPR knowledge test was completed for all participants.
Participants were then randomly assigned to either the control
group or intervention group. Participants in each group were
divided randomly into 15 small groups, each composed of three
students. Each student represented the main three CPR roles:
chest compression, rescue breathing by using the Ambu-bag,
and defibrillation by using AED. Each small group participated
in a cardiac arrest scenario, which began with a full report on
a simulated patient condition. After 60 s, simulated patients
went into cardiac arrest. The researcher observed the actions
396
of students as a team, and how they performed and followed
the sequence of CPR skills. After 15 min, the researcher ended
the scenario and started an oral debriefing session, which took
about 10 min. The debriefing session provided the students the
opportunity to review their response to the cardiac arrest sce-
nario and to learn from mistakes. After training on CPR with
HFS for intervention group and LFS for the control group, the
posttest to assess knowledge and skills was performed.
The researcher who holds an AHA instructor certificate was
the only trainer in this study. Furthermore, a panel of experts,
who hold AHA instructor certificates, validated the CPR sce-
nario. For confidentiality purposes, the CPR knowledge test
was under control of the AHA instructors at the AHA training
center at King Hussein Cancer Center in Amman.
Knowledge and skills retention tests were conducted 3
months after training for the control and intervention groups.
The participants received one mark for each correct response
on the CPR skills and knowledge checklists. Contamination of
the study results may have occurred if the participants in both
groups were exposed to a CPR experience from any source
during the 3 months from pre- to postassessment.
Data Analysis
Data coding and analyses were carried out using the Statisti-
cal Package for Social Sciences for Windows (IBM Corpora-
tion, 2012). The researchers used descriptive statistics (mean
median, standard deviation, percentage, and frequency) to
analyze the demographic data of the study sample. Indepen-
dent sample t tests were used to compare the mean differences
in acquisition and retention of CPR knowledge and skills be-
tween the intervention and control groups at two time points.
Paired t test was conducted to find significant differences the
study groups.
RESULTS
Sample Characteristics
The 124 nursing students enrolled in the first adult health
nursing course completed the demographic data sheet. Only
90 students completed all phases of the study. Based on the
inclusion and exclusion criteria, 30 students were excluded. In
addition, four students did not sign the informed consent to
participate.
The majority of the participants were female (N = 71,
78.9%). The participants’ ages ranged between 18 and 28 years
(M = 19.87, SD = 1.78). Approximately 60% of the participants
reported their GPA as being better than “good.” All participants
indicated that they had neither previous CPR experience nor
HFS training. The mean GP for the participants in the control
group was higher than the intervention group (M = 3.09, 2.82,
respectively); both groups were almost equal in terms of gender
and age (see Table 1).
Worldviews on Evidence-Based Nursing, 2014; 11:6, 394–400.

C 2014 Sigma Theta Tau International
 Original Article
Table 1. Sample Characteristics: Means, Standard Table 2. Paired t Test on the Level of CPR Knowledge
Deviations, and Percent for the Participant Groups Acquisition within Groups

Control Intervention Pretest CPR Posttest CPR

Variable group group Total Variable knowledge knowledge
*
Age M(SD) 19.6 (1.6) 20.1 (1.9) 19.9 (1.8) M (SD) M (SD) t statistics
N (%) N (%) N (%) Control group 5.93 (1.15) 11.22 (0.90) −38.56*
Gender Intervention group 5.78 (1.18) 12.67(1.06) −59.60*
Male 9 (20.0) 10 (22.2) 19 (21.0) *p ࣘ .001
Female 36 (80.0) 35 (77.8) 71 (79.0)
GPA
Weak and 11 (24.4) 18 (40.0) 29 (32.2)
ranged from 7 to 14. A dependent sample t test revealed a sig-
satisfactory
nificant difference (t = 8.05; p ࣘ .001) between the intervention
Good 20 (44.4) 14 (31.1) 34 (37.8) group (M = 12.27; SD = 1.13) and the control group (M = 10.07;
Very good and 14 (31.1) 13 (28.8) 27 (30.0) SD = 1.43) in the retention of CPR knowledge after 3 months
excellent of training.
A paired t test was conducted to examine the difference
Note. *M, mean; SD, standard deviation.
N = Number of participants. of CPR knowledge and CPR skills within each group in the
retention level. The results revealed that both groups suffered
a loss of CPR knowledge at 3 months after training (p < .001;
see Table 4).
The analysis of the differences in the retention of CPR skills
Analyses of the Research Hypotheses showed that the scores for the participants in the control group
Research hypothesis 1. An independent sample t test was ranged from 7 to 13 out of 14, while the participants’ scores in
used to examine if there was a difference in CPR knowledge the intervention group ranged from 8 to 14. An independent
between the two groups before commencing CPR training. The sample t test revealed a significant difference in CPR retention
result revealed that there was no significant difference (p = .53) skills between the groups (p ࣘ .001; see Table 5).
in the baseline CPR knowledge between the intervention group
(M = 5.78, SD = 1.2) and the control group (M = 5.93, DISCUSSION
SD = 1.15). Although many researchers support the theory that HFS en-
hances critical thinking of the participants (Wotton, Davis,
Research hypothesis 2. First, the researchers examined if
Button, & Kelton, 2010), knowledge acquisition through HFS
each group had a significant CPR knowledge and or skills
has not been well integrated in teaching programs (Jefferies,
acquisition after training. A paired t test revealed that both
2007; Levett-Jones, Lapkin, Hoffman, Arthur, & Roche, 2011).
groups gained CPR knowledge from their respective teaching
The findings of this study support the effectiveness of using
and training methods. The posttest scores of CPR knowledge
HFS over the traditional static manikin as LFS CPR knowl-
for the participants in the control group ranged between 9 and
edge acquisition. In this study, knowledge and skills acquisition
13 out of the 14 possible points; while in the intervention group,
were evaluated immediately after training. It could be argued
the scores ranged between 10 and 14. The posttest scores of CPR
that further research is required to ascertain the appropriate
skills for the participants in the control group ranged between
time for posttraining evaluation.
8 and 14 out of 14, while scores of those in the intervention
The baseline phase of this study aimed to evaluate the
group ranged between 10 and 14 (see Table 2).
participants’ CPR knowledge before initiation of CPR train-
To examine if the gained knowledge and skills differed sig-
ing for control and intervention groups. The results showed
nificantly between groups, an independent sample t test was
no significant differences between the two groups. This find-
used. The results revealed the existence of a significant differ-
ing supports the homogeneity in the knowledge variance at
ence in the posttest CPR knowledge as well as the CPR skills
the baseline level. Furthermore, this study showed that the
in favor of participants in the intervention group (see Table 3).
participants in both groups had a low level of CPR knowledge
Research hypothesis 3. The knowledge retention scores for the at baseline.
participants in the control group ranged from 7 to 12 out of 14, The results of this study showed a significant difference in
while for the participants in the intervention group the scores CPR knowledge and skills at the acquisition phase between the

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C 2014 Sigma Theta Tau International
HFS and CPR Knowledge and Skills

Table 3. Independent Sample t Test on Level of CPR Knowledge and Skills Acquisition between Groups

Variable Control group Intervention group

M (SD) M (SD) t statistics Cohen’s d
Knowledge acquisition 11.22 (0.90) 12.67 (1.07) −6.94 *
−1.47
Skill acquisition 11.58 (1.63) 13.13 (1.01) −5.44 *
−1.14

*p ࣘ .001

Table 4. Paired t Tests for CPR Knowledge and Skills Retention within Groups over Time

Variable Time Control group Intervention group

M (SD) t statistics M (SD) t statistics
*
Knowledge Direct after training 11.22 (0.90) 8.14 12.67 (1.06) 4.97*
Three months later 10.07(1.44) 12.27 (1.14)
Skills Direct after training 11.58 (1.63) 10.50* 13.13 (1.01) 3.71*
Three months later 10.31(1.88 12.80 (1.44)

*p ࣘ .001

Table 5. Independent Sample t Test on the Level of
CPR Skills Retention between Groups
Variable Control Intervention t statistics Cohen’s d
M (SD) M (SD)
Retention of 10.31 (1.88) 12.80 (1.44) −7.05* −1.49
CPR skills
*p ࣘ .001
two groups as an effect of the different teaching methods. After
teaching and training, CPR knowledge and skills were signif-
icantly increased in both groups; however, the participants in
the HFS group gained greater knowledge and skills than those
of the LFS group. These results are consistent with the find-
ings of previous studies (Nehring & Lashley, 2010; Gates et al.,
2012; González et al., 2013).
Findings from this study emphasize the effectiveness of
HFS on students’ acquisition of knowledge and skills. These
benefits enhance learning outcomes for nursing students.
Furthermore, educators should determine the best practice of
integrating HFS into nursing curriculum. They should use
simulation scenarios that are suitable for students’ levels. To
gain the maximum possible benefit from HFS, different sce-
narios should be used according to the level of the students
using the simulation.
Significant differences were found between the interven-
tion and control groups in CPR knowledge and skills retention.
It is noteworthy that CPR knowledge and skills were signifi-
cantly decreased in both groups after 3 months of training.
However, the participants in the intervention group showed
more retention of knowledge and skills than participants in
the LFS group. This result is consistent with the findings of
previous studies that examined CPR knowledge and skills re-
tention (Ackermann, 2009; Tawalbeh & Ahmad, 2013a). Smith
and colleagues found that nurses who received CPR training
on a static manikin had a nearly 37% deterioration of their
skills and knowledge within 3 months of training and 42% at
12 months. Furthermore, a high percentage (85%) of the inter-
vention group in this study retained these skills 3 months after
training. This finding emphasizes the value of HFS training
over LFS training.
LINKING EVIDENCE TO ACTION
r Simulation in nursing education has become an
important educational strategy, specifically teach-
ing students the necessary skills and knowledge to
develop as competent nurses.

398 Worldviews on Evidence-Based Nursing, 2014; 11:6, 394–400.


C 2014 Sigma Theta Tau International

r HFS allows nursing students to practice, develop,
and apply knowledge and skills in a realistic clini-
cal situation and safe environment.
r Nurse educators in both academic institutions and
healthcare facilities need to implement special
CPR review courses for nurses and nursing stu-
dents to maintain their CPR skills and knowledge.
r The results of this study provide strong evidence
that clinical educators should incorporate HFS in
the clinical curricula to maintain and refine nurs-
ing students’ knowledge and skills.
IMPLICATIONS FOR EDUCATORS
The findings of this study underscore the effectiveness of HFS
on students’ acquisition and retention of knowledge and skills.
As a result, it is suggested that nursing educators integrate sim-
ulation training in their curricula. This will help to overcome
challenges that face many courses, specifically the shortage of
clinical areas for training and the increase in the number of
nursing students.
RECOMMENDATIONS
The replication of our study in more than one university, with
a larger sample size, is recommended. Additional research that
examines the use of HFS with other nursing courses to mea-
sure learning outcomes is needed. Nurse educators in both
academic institutions and healthcare facilities must implement
special CPR review courses for nurses and nursing students
to maintain and update their knowledge and skills. This will
improve the safety of nursing interventions, specifically in crit-
ical situations. Follow-up assessment at 6 and 12 months after
training is recommended. WVN
Author information
Ahmad A. Aqel, Assistant Professor, Clinical Nursing Depart-
ment, University of Jordan, Amman, Jordan; Muayyad M. Ah-
mad, Professor, Clinical Nursing Department, Faculty of
Nursing, University of Jordan, Amman, Jordan
The authors acknowledge the partial funding from the Uni-
versity of Jordan.
Address correspondence to Muayyad Ahmad, Clinical Nurs-
ing Department, Faculty of Nursing, University of Jordan, Am-
man, Jordan 11942; mma4jo@yahoo.com
Accepted 30 May 2014
Copyright 
C 2014, Sigma Theta Tau International
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