Hrev_master Healthcare in Low-resource Settings 2024; volume 12(s1):13049 Improving cardiopulmonary resuscitation skills for layperson in cases of heart attack: a scoping review Muh. Iwan Zulhan, Kumboyono Kumboyono, Retno Lestari Department of Nursing, Faculty of Health Sciences, Brawijaya University, Malang, East Java, Indonesia Abstract The proficiency of trained individuals in effectively adminis- tering Cardiopulmonary Resuscitation (CPR) is paramount in mit- igating the impact of out-of-hospital cardiac arrest incidents. Inadequate CPR skills among laypersons can result in missed opportunities to save lives. Therefore, it is imperative to prioritize unified efforts to enhance CPR competencies within the general populace. This scoping review aims to consolidate literature dis- cussing the enhancement of laypeople’s CPR skills using various methodologies. This scoping review employed the PRISMA methodology and encompassed an extensive search across four critical databases (Science Direct, Proquest, Pubmed, and Google Scholar) for literature published between 2013 and 2023. The search utilized the keywords “CPR Teaching,” “Skill,” and “Layperson.” Out of 487 collected articles, 20 were deemed rele- vant. The findings of all relevant articles consistently indicated an improvement in laypeople’s CPR skills following training. Incorporating concise CPR instructional videos and smartphone applications has shown potential for enhancing CPR knowledge and improving emergency responsiveness. Nonetheless, integrat- ing these modern technological approaches with traditional simu- lation methods has demonstrated greater efficacy in CPR training, resulting in enhanced compression quality and depth. In conclu- sion, Integrating traditional and technology-based learning methodologies improves the capability of individuals without spe- cialized medical training to administer CPR effectively. Introduction Cardiopulmonary Resuscitation (CPR) is a crucial component in the chain of survival for individuals experiencing out-of-hospi- tal cardiac arrest.1 Presently, nearly 80% of cardiac arrests occur outside of hospital settings, with 30-50% of victims in the United States receiving CPR directly from lay members of the public.2 The active involvement of laypersons in delivering initial aid to out-of-hospital cardiac arrest (OCHA) victims has been demon- strated to elevate the rate of CPR administration before the arrival of emergency services at the scene. Multiple prehospital systems utilized by laypersons for treating out-of-hospital cardiac arrest victims globally, including in Indonesia, adhere to the guidelines established by the American Heart Association (AHA) and the Emergency Response Commander (ERC).3 Laypersons hold a sig- nificant role as first aid providers in cases of out-of-hospital car- diac arrest. However, the current participation of laypersons in performing CPR remains low due to insufficient knowledge and skills in first aid.4 Additionally, limited knowledge and skills can undermine the confidence of lay individuals in delivering CPR.5 The acquisition of CPR skills aims to sustain circulation and heart function, ultimately enhancing patient prognosis and reduc- ing morbidity and mortality rates in cardiac arrest cases.6 Various methods exist to enhance laypersons’ CPR proficiency.7 The sim- ulation-based approach and instructor guidance stand out as a commonly employed technique.8 While effective, this method demands face-to-face training, qualified instructors, and substan- tial equipment, presenting challenges such as limited instructor availability, high training costs, and the need for numerous props, including mannequins.9,10 In addition to simulation-based training, technology-based methods, such as videos and applications, offer an alternative for enhancing layperson CPR skills.11 The develop- ment of CPR applications for smartphones opens up convenient and flexible learning opportunities, with the potential to signifi- cantly improve CPR education.10 While its effectiveness in skill improvement remains to be determined, the integration of techno- logical methods with conventional training, as advocated by inter- national resuscitation guidelines, offers a hopeful future for CPR education.12 This combined approach not only offers cost savings but also capitalizes on the prevalent use of technology among laypersons, thereby increasing the potential for technology-based CPR education.13,14 Furthermore, study have shown that a com- bined approach involving technological and conventional methods yields comparable compression quality to traditional methods while enhancing laypersons’ awareness and skill acquisition in delivering first aid during cardiac arrest incidents.10 Given the documented low proficiency in layperson-performed CPR, a hybrid approach encompassing technological methods and con- ventional training is essential for skill enhancement and must be considered as a viable means to this end.15 Various research studies have indicated that integrating both technological and traditional methods can significantly improve the ability of non-professionals to perform cardiopulmonary resuscitation (CPR). Consequently, this approach is a valuable technique for enhancing the CPR proficiency of laypersons. This scoping review seeks to synthesize existing literature on improv- ing non-professionals’ Cardiopulmonary Resuscitation (CPR) pro- ficiency through diverse methodologies. [Healthcare in Low-resource Settings 2024;12(s1):13049] [page 139] Significance for public health Using technology as an educational medium offers numerous advantages, particularly its accessibility to the general populace. Employing technology to learn essential life support can enhance lay people's understanding of first aid; refining skills necessitates simulation-based learning. Thus, integrating technology and simulation-based learning approaches proves efficacious in enhancing lay individuals' knowledge and skills in administering essential life support during cardiac arrest. Non -co mmerc ial us e o nly Materials and Methods The research employed the scoping review analysis method to compile, synthesize, and report published research aimed at enhancing layperson CPR skills, a topic of great interest to our audience of researchers, educators, and healthcare professionals. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA- ScR) guidelines, an online electronic search was conducted across four databases: ScienceDirect, PubMed, Proquest, and Google Scholar, using the keywords “CPR Teaching,” “Skill,” and “Layperson.” Selection criteria included: i) studies published with- in the last ten years (2013 onwards) in Indonesian or English; ii) focusing on CPR learning methods for lay people; iii) being freely accessible. Four hundred eighty-seven articles were found across the databases, with 220 articles screened based on their titles and abstracts. Following further evaluation, 20 research publications met the criteria, as depicted in Figure 1 of the review literature search approach. Data extraction and synthesis The researcher collected data from selected research articles to conduct a comprehensive analysis. Subsequently, the researcher organized this data by creating a table with information such as the author’s name and year of publication, research objectives, research design, research methods, research samples, research location, and research results and conclusions. After compiling this information, the researcher independently analyzed the data from each article that met the necessary criteria. The findings were then thoroughly discussed, analyzed, and concluded. For your refer- ence, Supplementary materials Table 1 provides a concise overview of the literature investigating methods for teaching CPR to laypeople to improve their ability to perform CPR in instances of cardiac arrest. Results and Discussion The review incorporates research articles (n=20) sourced from a range of countries, including the United States (6), India (1), Brazil (1), Sweden (1), Germany (1), Taiwan (1), Korea (1), France (1), Netherlands (1), and Indonesia (5). The predominant research approach employed quantitative methods within a randomized controlled trial framework.16-21 The study’s participant numbers varied significantly, spanning from 24 to 50,000. Improving CPR skills using video/audiovisual Based on a comprehensive review of twenty studies, it has been established that CPR training utilizing video media can sig- nificantly enhance the skills of laypersons in performing CPR. Combining video-based CPR training with hands-on practice using a mannequin has proven to be particularly effective in improving the CPR skills of ordinary individuals. Furthermore, several stud- ies have indicated that CPR training through video media increases laypersons’ sensitivity and responsiveness in real-life CPR situa- tions, thus improving the quality and effectiveness of their CPR delivery. Additionally, evidence from four separate studies has shown that CPR training via video media enhances laypersons’ knowledge and skills, particularly regarding the quality of chest compressions. However, it should be noted that sole reliance on video-based CPR training may only partially improve CPR skills in ordinary individuals. Independent CPR training using video guidance may primarily enhance theoretical knowledge related to CPR implementation, as per the findings of one study. Recent research has underscored the significant impact of pro- viding Basic Life Support (BLS) health education through video on high school students’ knowledge levels. The process of watch- ing educational videos has been identified as an effective method to foster a more nuanced understanding of basic life support, espe- cially among laypeople. Importantly, a study has indicated that CPR training using video media is a powerful tool for enhancing public knowledge and preparedness in delivering basic life sup- port. Based on are view of twenty studies, learning CPR using video media can improve layperson skills in performing CPR.6,22 Apart from that, the results of other research conducted in the United States explain that CPR training using videos combined with practice using a mannequin has been proven to improve the skills of ordinary people in carrying out CPR.23 In three studies, CPR training using video media can increase the sensitivity of layperson to carry out CPR in real incidents, one of which is the research,20 explaining that CPR training form layperson using video media is proven to in crease sensitivity, ability, responsive- ness, speed, and depth of compression. Four other studies show that CPR training using video media is proven to be able to increase CPR knowledge and skills in laypeople (increasing the quality of compressions), such as the research10 that explains that CPR educational videos are proven to be able to increase laypeo- ple’s knowledge about CPR.CPR training using only video media can not fully improve CPR skills in ordinary people. This is in line with research, explaining that independent CPR training using video guidance can only increase theoretical knowledge related to the implementation of CPR.20 Apart from that, another research project (Fauzan, Kahtan, and Herman 2021) explains that there is a significant influence on the provision of Basic Life Support (BHD) health education via video on the level of knowledge of high school students.13 Additionally, video-viewing process pro- vides a new nuance in efforts to understand the management of basic life support, especially for laypeople.6 Furthermore, CPR 4th International Nursing and Health Sciences Symposium Figure 1. Flowchart of scoping review with selection process using PRIS-MA. [page 140] [Healthcare in Low-resource Settings 2024;12(s1):13049] Non -co mmerc ial us e o nly training using video media can increase public knowledge in car- rying out basic life support.4 Improved CPR skills by using the app Various research studies have underscored the effectiveness of CPR training facilitated through mobile applications in augment- ing individuals’ proficiency and capabilities in executing CPR. This approach has been shown to heighten the general public’s pre- paredness to administer initial aid during instances of cardiac arrest. Moreover, it provides valuable insights into pioneering CPR training methodologies, the determinants impacting CPR perfor- mance, and its enduring influence on attitudes toward resuscita- tion. A study by Wirasakti in 2020 revealed that CPR training via applications substantially enhanced proficiency in chest compres- sion speed and depth and minimized interruptions, thus ensuring the delivery of high-quality CPR. Users have expressed satisfac- tion with this method owing to its pragmatic nature and resource efficiency. This is consistent with previous study which showcased elevated satisfaction levels among participants in CPR training through applications. They found this learning mode to be produc- tive without compromising the quality of chest compressions com- pared to traditional training methods.5 Metelmann recommended the use of applications as CPR training tools to enhance the CPR skills of laypersons for effective intervention during cardiac arrest. However, the study also stressed the inadequacy of relying solely on applications for CPR training. It advocated for a balanced approach that combines innovation with traditional training meth- ods. This aligns with Blewer’s research, which highlighted the need for innovative approaches, such as integrating digital systems with traditional learning methods, to address the lack of CPR skills among laypersons.19 Several other studies explain the effectiveness of application- based CPR training in increasing people’s knowledge and skills in performing CPR. Application-based CPR training can increase awareness of lay people in providing first aid in cases of cardiac arrest. Apart from that, this training can also provide important insight into innovative CPR training methods, as well as factors that influence CPR performance and its impact on long-term atti- tudes towards resuscitation.2. Other research conducted by Wirasakti (2020) explains that training using the CPR application method affects increasing skills in performing chest compression speed, chest compression depth, and minimal interruptions of high quality12. Furthermore, application-based CPR training provides satis- faction for its users due to its practical use and saving of resources required for training.This is in line with research conducted by Lee where, CPR training using the application has its own satisfaction for the training participants. This is because the learning method is effective, and in terms of training skills using the application, it is not inferior to conventional training methods in terms of the qual- ity of chest compressions.5 Another research was also conducted by Metelmann et al. explaining that the use of applications as a CPR learning medium is highly recommended in order to improve CPR skills in lay people so that they can provide assistance in cases of cardiac arrest.24 Currently, using applications alone is not effective as a CPR training method. There needs to be innovation and a combination of conventional training with application-based training. This is in line with research conducted by Blewer, explaining that the skills of lay people in carrying out CPR are still low. Therefore, innovative methods are needed in the form of a combination of learning between digital systems and traditional learning (instructor’s guide).19 Improved CPR skills using mixed methods (simu- lation and technology) Currently, conventional training methods or simulation-based training with guidance from trained instructors are still the only standardized CPR training for both health workers and lay people. In its development, innovation in CPR learning or training is very important. This makes it easier for lay people to be able to learn easily and effectively. The role of technology in the form of appli- cations and videos as a media for CPR learning will make it easier for people to increase their knowledge about CPR10. However, in improving skills, there needs to be a combination of simulation- based training with technology-based training, as explained in the previous research9 . A combination of learning between digital sys- tems and traditional learning (instructor guides and simulations)is needed to improve CPR skills in laypeople. Apart from that, the use of tools in the form of mannequins as training media is needed. This is in line with the previous researc, explaining that CPR train- ing using mannequin aids can improve CPR skills and quality.25 In addition, simulation-based training is an effective CPR learning method for lay people. The results of research conducted by Kuswanto and Suyanto explain that CPR learning using the demonstration method is effective in improving students’ skills in performing basic life support14. Video or audiovisual is an alternative that can be used by the public in learning CPR, this is because its use is practical and can be done anywhere. This is in line with research conducted by Panchal et al explaining that playing short CPR videos online has potential as a learning media that can be carried out in public places to help increase the response of ordinary people to perform- ing CPR in cases of cardiac arrest.20 Apart from that, CPR learning can be done using applications by utilizing smartphones. Developing applications on smartphones makes it easier for people to learn CPR at any time. However, this convenience does not nec- essarily improve the skills of ordinary people in performing CPR.2 The results of several studies explain that technology-based CPR training cannot fully improve the skills of ordinary people in performing CPR.In this case, innovation is needed in the form of combining conventional (simulation) and technology-based meth- ods so that CPR learning becomes more effective and structured.9 In addition, an alternative approach involves offering supplemen- tary treatments such as butterfly hug therapy. Following simulated bystander CPR and butterfly hug therapy, there was a noticeable improvement in bystander CPR performance during specific car- diac arrest scenarios.26 Many studies have been conducted to see the effectiveness of mixed training methods (conventional and technological) in improving CPR skills. Training using a combination of technology with instructor guidance has been proven to improve CPR skills including the depth and quality of compressions. Apart from that, with the mixed method participants will be directed to simulate the implementation of CPR using assistive devices in the form of a mannequin.This can improve the quality and depth of compres- sions produced.3,27 Conclusions In conclusion, it is evident that a combination of traditional and technology-based learning, known as mixed methods, can enhance the CPR skills of laypersons. Integrating technology into CPR edu- cation facilitates accessible learning, enabling individuals to acquire theoretical CPR knowledge conveniently. The technolo- 4th International Nursing and Health Sciences Symposium [Healthcare in Low-resource Settings 2024;12(s1):13049] [page 141] Non -co mmerc ial us e o nly gies utilized encompass smartphones, televisions, and personal computers, with corresponding software such as applications, web platforms, and visual videos. These tools have been developed as educational mediums for laypersons to learn CPR effectively. However, to truly enhance CPR skills, more than mere guidance from applications or videos is required; direct practice in the form of simulations is essential for proficiency in CPR implementation. When combined with technology, simulation-based methods rep- resent an innovative approach to improving laypersons’ CPR skills. Such an integration allows for assessing compression depth and quality, thereby contributing significantly to advancing CPR proficiency among laypersons. References 1. Högstedt A, Thuccani M, Carlström E, et al. Characteristics and motivational factors for joining a lay responder system dis- patch to out-of-hospital cardiac arrests. Scand J Trauma Resusc Emerg Med 2022;30:22. 2. Nas J, Thannhauser J, Vart P, et al. Rationale and design of the Lowlands Saves Lives trial: a randomised trial to compare CPR quality and long-term attitude towards CPR performance between face-to-face and virtual reality training with the Lifesaver VR app. BMJ Open 2019;9:e033648. 3. Ghazali DA, Rousseau R, Breque C, Oriot D. Effect of real- time feedback device compared to use or non-use of a checklist performance aid on post-training performance and retention of infant cardiopulmonary resuscitation: A randomized simula- tion-based trial. Australas Emerg Care 2023;26:36-44. 4. 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Effectiveness of Demonstration Education on Improving Hand-Only Cardiopulmonary Resuscitation Skills in PMR Members. JGD 2022;4:1–8. 15. Beskind DL, Stolz U, Thiede R, et al. Viewing a brief chest- compression-only CPR video improves bystander CPR perfor- mance and responsiveness in high school students: A cluster randomized trial. Resuscitation 2016;104:28-33. 16. Shende TC, Battaglia MR, Nuno T, Beskind D. Efficacy of a five-minute compression-only cardiopulmonary resuscitation class compared to thirty-minute instruction among college stu- dents. Resusc Plus 2020;3:100012. 17. Ali S, Athar M, Ahmed SM. Basics of CPB. Indian J Anaesth 2019;49:257-62. 18. Nord A, Svensson L, Hult H, et al. Effect of mobile applica- tion-based versus DVD-based CPR training on students' prac- tical CPR skills and willingness to act: a cluster randomised 4th International Nursing and Health Sciences Symposium [page 142] [Healthcare in Low-resource Settings 2024;12(s1):13049] Correspondence: Muh. Iwan Zulhan, Department of Nursing, Faculty of Health Sciences, Universitas Brawijaya, Jl. Puncak Dieng, Kunci, Kalisongo, Kec. Dau, Malang, East Java Indonesia. Tel.: +62341569117 -9 Fax: +62341564755. E-mail: iwangadar@student.ub.ac.id Key words: CPR; layperson; learning methods; skills Contributions: all authors contributed equally to this study. Conflict of interest: the authors declare no conflicts of interest. Funding: none. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Ethics approval and informed consent: not applicable. Conference presentation: part of this article was presented at the 4th International Nursing and Health Sciences Symposium, from 27th-28th of October 2023, Universitas Brawijaya, Malang, East Java, Indonesia. Acknowledgements: the authors would like to express their appreciation to all individuals who have contributed to elevating the quality of this academic article. Received: 5 November 2023. Accepted: 10 June 2024. Early view: 10 September 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12(s1):13049 doi:10.4081/hls.2024.13049 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Non -co mmerc ial us e o nly study. BMJ Open 2016;6:e010717. 19. Blewer AL, Putt ME, McGovern SK, et al. A pragmatic ran- domized trial of cardiopulmonary resuscitation training for families of cardiac patients before hospital discharge using a mobile application. Resuscitation 2020;152:28–35. 20. 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Smartphone apps to support laypersons in bystander CPR are of ambivalent benefit: a controlled trial using medical simulation. Scand J Trauma Resusc Emerg Med 2021;29:76. 25. Blewer AL, Putt ME, Becker LB, et al. Video-Only Cardiopulmonary Resuscitation Education for High-Risk Families Before Hospital Discharge: A Multicenter Pragmatic Trial. Circ Cardiovasc Qual Outcomes 2016;9:740-8. 26. Soeli YM, Pomalango ZB, Hunawa R, Arsad SFM. Simulation of Bystander Cardiopulmonary Resuscitation and Butterfly Hug Therapy Towards the Ability to Perform Emergency Assistance for Cardiac Arrest. Malaysian J Nursing (MJN) 2023;15:101–6. 27. Lin L, Ni S, Cheng J, et al. Effect of synchronous online vs. face-to-face cardiopulmonary resuscitation training on chest compression quality: A pilot randomized manikin study. Am J Emerg Med 2021;50:80-4. 4th International Nursing and Health Sciences Symposium [Healthcare in Low-resource Settings 2024;12(s1):13049] [page 143] Online supplementary materials Table 1. Summary of articles. Non -co mmerc ial us e o nly