Faculty Development Approaches for Life Support Courses: A Scoping Review

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Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: Ming-Ju Hsieh, Ying-Chih Ko, Adam Cheng, Kasper Glerup Lauridsen, and Taylor L. Sawyer.

Task Force Scoping Review Citation

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Ming-Ju Hsieh, Ying-Chih Ko, Adam Cheng , Kasper Glerup Lauridsen, Taylor L. Sawyer, Robert Greif on behalf of the International Liaison Committee on Resuscitation Education, Implementation and Teams Task Force. Faculty Development Approaches for Life Support Courses: A Scoping Review and Task Force Insights: International Liaison Committee on Resuscitation (ILCOR) Education, Implementation, and Teams Task Force, 2021 August 27. Available from:

Methodological Preamble and Link to Published Scoping Review

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The continuous evidence evaluation process started with a scoping review of faculty development approaches for life support courses. The search strategy was conducted by the librarian (H.P.C.) at the library of National Taiwan University Hospital, Taipei, Taiwan with involvement of the ILCOR Education, Implementation, and Teams Task Force Scoping Review team (M.J.H., Y.C.K., A.C., K.G.L. and T.L.S.). Evidence for the literature associated with faculty development approaches for life support courses was sought, considered and extracted by a dedicated writing group of the Education, Implementation and Teams Task Force. The final scoping review’s task force insight was discussed and agreed during EIT Task Force meetings and approved by the ILCOR Science Advisory Committee.

Scoping Review

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The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: Instructors of accredited life support courses, including basic life support (BLS), pediatric basic life support (PBLS), advanced life support (ALS), pediatric advanced life support (PALS) and neonatal resuscitation program (NRP)

Intervention: Any faculty development approach to improve instructional competence in accredited life support courses

Comparators: No such approach or any other faculty development approach.


1. Clinical outcome of patients resuscitated by students of the instructors (critical), including

  • · favorable neurologic outcome,
  • · survival to discharge,
  • · short-term survival,
  • · return of spontaneous circulation (ROSC),
  • · sustained ROSC, and
  • · survival to admission

2. Educational outcomes:

  • · Skill performance of students of the instructors in actual resuscitation (critical)
  • · Knowledge, instructional skills, and attitudes of instructors at the end of instructor training course (important)
  • · Knowledge, instructional skills, and attitudes of instructors some period of time after the end of instructor training course (important)
  • · Confidence of instructors to teach students at the end of instructor training course and some period of time after course completion (important)
  • · Knowledge, skill performance, attitudes, willingness and confidence of students of the instructors immediately at end of the provider course or some period of time after course completion (important)

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies, case-control studies), unpublished studies (e.g., conference abstracts, trial protocols), letters, editorials, comments, case series, and case reports are eligible for inclusion.

Timeframe: All years and all languages were included as long as there was an English abstract; Literature search updated to April 23, 2021.

Search Strategies

PubMed (Last search date: April 23, 2021)

("instructor*"[Title/Abstract] OR "coordinator*"[Title/Abstract] OR "educator*"[Title/Abstract] OR "teacher*"[Title/Abstract] OR "train the trainer*"[Title/Abstract] OR "trainer*"[Title/Abstract]) AND ("cardiopulmonary resuscitation"[MeSH Terms] OR ("cardiopulmonary"[All Fields] AND "resuscitation"[All Fields]) OR "cardiopulmonary resuscitation"[All Fields] OR ("resuscitability"[All Fields] OR "resuscitate"[All Fields] OR "resuscitated"[All Fields] OR "resuscitates"[All Fields] OR "resuscitating"[All Fields] OR "resuscitation"[MeSH Terms] OR "resuscitation"[All Fields] OR "resuscitations"[All Fields] OR "resuscitative"[All Fields] OR "resuscitator"[All Fields] OR "resuscitators"[All Fields]) OR ("cardiopulmonary resuscitation"[MeSH Terms] OR ("cardiopulmonary"[All Fields] AND "resuscitation"[All Fields]) OR "cardiopulmonary resuscitation"[All Fields] OR "cpr"[All Fields]) OR ("heart massage"[MeSH Terms] OR ("heart"[All Fields] AND "massage"[All Fields]) OR "heart massage"[All Fields]) OR "cardiac massage"[All Fields] OR "chest compression*"[All Fields] OR ("BLS"[All Fields] OR "PBLS"[All Fields] OR "ALS"[All Fields] OR "NRP"[All Fields] OR "PALS"[All Fields] OR "ACLS"[All Fields]) OR "basic life support"[All Fields] OR "pediatric basic life support"[All Fields] OR "pediatric life support"[All Fields] OR "advanced life support"[All Fields] OR "neonatal life support"[All Fields] OR "neonatal resuscitation"[All Fields] OR "pediatric advanced life support"[All Fields] OR "advanced cardiac life support"[All Fields] OR "simulation"[All Fields]) AND ("skills"[Title/Abstract] OR "skill"[Title/Abstract] OR "clinical competence"[MeSH Terms] OR "clinical skills"[Title/Abstract] OR "teaching"[MeSH Terms] OR "teaching"[Title/Abstract] OR "training"[Title/Abstract] OR "retraining"[Title/Abstract] OR "faculty development"[Title/Abstract] OR "teaching competence*"[Title/Abstract] OR "knowledge"[Title/Abstract] OR "education"[Title/Abstract] OR "educational measurement"[MeSH Terms] OR "assessment"[Title/Abstract] OR "certification"[MeSH Terms] OR "certification"[Title/Abstract] OR "performance"[Title/Abstract] OR "retention"[Title/Abstract] OR "recertification"[Title/Abstract] OR "professional competence"[MeSH Terms] OR "attitude*"[Title/Abstract] OR "confidence*"[Title/Abstract] OR "program development"[MeSH Terms] OR "program evaluation"[MeSH Terms] OR "clinical outcome*"[All Fields] OR (("favor"[All Fields] OR "favorable"[All Fields] OR "favorables"[All Fields] OR "favorably"[All Fields] OR "favored"[All Fields] OR "favoring"[All Fields] OR "favors"[All Fields] OR "favour"[All Fields] OR "favourable"[All Fields] OR "favourably"[All Fields] OR "favoured"[All Fields] OR "favouring"[All Fields] OR "favours"[All Fields]) AND "neurologic*"[All Fields] AND "outcome*"[All Fields]) OR (("mortality"[MeSH Subheading] OR "mortality"[All Fields] OR "survival"[All Fields] OR "survival"[MeSH Terms] OR "survivability"[All Fields] OR "survivable"[All Fields] OR "survivals"[All Fields] OR "survive"[All Fields] OR "survived"[All Fields] OR "survives"[All Fields] OR "surviving"[All Fields]) AND ("discharges"[All Fields] OR "discharging"[All Fields] OR "patient discharge"[MeSH Terms] OR ("patient"[All Fields] AND "discharge"[All Fields]) OR "patient discharge"[All Fields] OR "discharge"[All Fields] OR "discharged"[All Fields])) OR ("short-term"[All Fields] AND ("mortality"[MeSH Subheading] OR "mortality"[All Fields] OR "survival"[All Fields] OR "survival"[MeSH Terms] OR "survivability"[All Fields] OR "survivable"[All Fields] OR "survivals"[All Fields] OR "survive"[All Fields] OR "survived"[All Fields] OR "survives"[All Fields] OR "surviving"[All Fields])) OR ("return of spontaneous circulation"[MeSH Terms] OR ("return"[All Fields] AND "spontaneous"[All Fields] AND "circulation"[All Fields]) OR "return of spontaneous circulation"[All Fields]) OR "ROSC"[All Fields] OR (("mortality"[MeSH Subheading] OR "mortality"[All Fields] OR "survival"[All Fields] OR "survival"[MeSH Terms] OR "survivability"[All Fields] OR "survivable"[All Fields] OR "survivals"[All Fields] OR "survive"[All Fields] OR "survived"[All Fields] OR "survives"[All Fields] OR "surviving"[All Fields]) AND ("admission"[All Fields] OR "admissions"[All Fields])) OR ("mortality"[MeSH Subheading] OR "mortality"[All Fields] OR "survival"[All Fields] OR "survival"[MeSH Terms] OR "survivability"[All Fields] OR "survivable"[All Fields] OR "survivals"[All Fields] OR "survive"[All Fields] OR "survived"[All Fields] OR "survives"[All Fields] OR "surviving"[All Fields]))

EMBASE (Last search date: April 23, 2021)

(instructor*:ti,ab OR coordinator*:ti,ab OR educator*:ti,ab OR 'train the trainer*':ti,ab OR trainer*:ti,ab OR 'teacher'/exp OR teacher*:ti,ab) AND ('cardiopulmonary resuscitation':ti,ab OR 'resuscitation'/exp OR resuscitation:ti,ab OR cpr:ti,ab OR 'heart massage'/exp OR 'heart massage':ti,ab OR 'cardiac massage':ti,ab OR 'chest compression*':ti,ab OR bls:ti,ab OR pbls:ti,ab OR als:ti,ab OR nrp:ti,ab OR pals:ti,ab OR acls:ti,ab OR 'basic life support'/exp OR 'basic life support':ti,ab,kw OR 'pediatric basic life support'/exp OR 'pediatric basic life support':ti,ab OR 'pediatric life support':ti,ab OR 'advanced life support'/exp OR 'als (advanced life support)':ti,ab,kw OR 'advanced life support':ti,ab,kw OR 'neonatal life support':ti,ab OR 'neonatal resuscitation':ti,ab OR 'pediatric advanced life support'/exp OR 'advanced life support, paediatric':ti,ab,kw OR 'advanced life support, pediatric':ti,ab,kw OR 'advanced paediatric life support':ti,ab,kw OR 'advanced pediatric life support':ti,ab,kw OR 'paediatric advanced life support':ti,ab,kw OR 'pediatric advanced life support':ti,ab,kw OR 'advanced cardiac life support'/exp OR 'acls (advanced cardiac life support)':ti,ab,kw OR 'acls care':ti,ab,kw OR 'acls procedure':ti,ab,kw OR 'acls protocol':ti,ab,kw OR 'advanced cardiac life support':ti,ab,kw OR 'advanced cardiovascular life support':ti,ab,kw OR 'cardiac advanced life support':ti,ab,kw OR 'simulation'/exp) AND ('skill'/exp OR skill:ti,ab OR skills:ti,ab OR 'clinical skill'/exp OR 'clinical skill':ti,ab OR 'clinical competence'/exp OR 'clinical competence':ti,ab,kw OR 'teaching'/exp OR teaching:ti,ab OR 'teacher training'/exp OR 'teacher education':ti,ab,kw OR 'teacher training':ti,ab,kw OR 'training'/exp OR training:ti,ab OR retraining:ti,ab OR knowledge:ti,ab OR education:ti,ab OR 'education measurement':ti,ab OR assessment:ti,ab OR 'certification'/exp OR certification:ti,ab OR performance:ti,ab OR retention:ti,ab OR 'recertification'/exp OR 'recertification':ti,ab,kw OR 'professional competence'/exp OR 'professional competence':ti,ab,kw OR confidence*:ti,ab OR 'program development'/exp OR 'program development':ti,ab OR 'program evaluation'/exp OR 'program evaluation':ti,ab,kw OR 'programme evaluation':ti,ab,kw OR 'faculty development'/exp OR 'faculty development':ti,ab OR 'teaching competence*':ti,ab OR attitude*:ti,ab OR 'clinical outcome'/exp OR 'clinical outcome*':ti,ab OR 'favorable neurologic* outcome*':ti,ab OR 'survival'/exp OR 'survival':ti,ab,kw OR 'survival to discharge':ti,ab OR 'survival to admission':ti,ab OR 'short term survival'/exp OR 'short term survival':ti,ab,kw OR 'shortterm survival':ti,ab,kw OR 'return of spontaneous circulation'/exp OR 'rosc':ti,ab,kw OR 'recovery of spontaneous circulation':ti,ab,kw OR 'restoration of spontaneous circulation':ti,ab,kw OR 'return of spontaneous circulation':ti,ab,kw) AND [embase]/lim

CINAHL (Last search date: April 23, 2021)*)+OR+(AB+coordinator*)+OR+(AB+educator*)+OR+(AB+teacher*)+OR+(AB+(train+AND+the+AND+trainer))+OR+(AB+train-the-trainer*)+OR+(AB+trainer*)+OR+(AB+train+N3+the+N3+trainer))+AND+((AB+(skill+OR+skills))+OR+(TX+%26quot%3bclinical+skills%26quot%3b)+OR+(TX+%26quot%3bclinical+competence%26quot%3b)+OR+(AB+training)+OR+(AB+teaching)+OR+(MH+teaching)+OR+(TX+retraining)+OR+(TX+re-training)+OR+(MH+%26quot%3bfaculty+development%26quot%3b)+OR+(TX+%26quot%3bfaculty+development%26quot%3b)+OR+(TX+%26quot%3bteaching+competence%26quot%3b)+OR+(AB+knowledge)+OR+(AB+education)+OR+(AB+assessment)+OR+(MH+%26quot%3beducational+measurement%26quot%3b)+OR+(MH+%26quot%3bcertification%26quot%3b)+OR+(TX+certification)+OR+(AB+performance)+OR+(TX+recertification)+OR+(TX+re-certification)+OR+(MH+%26quot%3bprofessional+competence%26quot%3b)+OR+(AB+attitude)+OR+(MH+%26quot%3bprogram+development%26quot%3b)+OR+(MH+%26quot%3bprogram+evaluation%26quot%3b)+OR+(MH+%26quot%3boutcomes+of+education%26quot%3b)+OR+(TX+%26quot%3bneurologic*+outcome%26quot%3b)+OR+(AB+%26quot%3bsurvival%26quot%3b)+OR+(TX+%26quot%3bsurvival+to+discharge%26quot%3b)+OR+(TX+%26quot%3bsurvival+to+admission%26quot%3b)+OR+(TX+(%26quot%3breturn+of+spontaneous+circulation%26quot%3b+OR+ROSC)))+AND+((MH+resuscitation%2c+cardiopulmonary)+OR+(MH+resuscitation)+OR+(TX+CPR)+OR+(AB+(%26quot%3bcardiopulmonary+resuscitation%26quot%3b+OR+CPR+OR+resuscitation))+OR+(TX+%26quot%3bheart+massage%26quot%3b)+OR+(AB+%26quot%3bcardiac+arrest%26quot%3b)+OR+(TX+%26quot%3bbasic+life+support%26quot%3b)+OR+(TX+%26quot%3bpediatric+basic+life+support%26quot%3b)+OR+(TX+%26quot%3bpediatric+life+support%26quot%3b)+OR+(TX+%26quot%3bpediatric+advanced+life+support%26quot%3b)+OR+(TX+%26quot%3bneonatal+resuscitation%26quot%3b)+OR+(TX+%26quot%3bneonatal+life+support%26quot%3b)+OR+(TX+%26quot%3badvanced+life+support%26quot%3b)+OR+(TX+%26quot%3badvanced+cardiac+life+support%26quot%3b)+OR+(AB+simulation)+OR+(TX+%26quot%3bchest+compression*%26quot%3b)+OR+(TX+(BLS+OR+PBLS+OR+ALS+OR+NRP+OR+PALS+OR+ACLS)))&type=1&searchMode=And&site=ehost-live&scope=site

Cochrane (Last search date: April 23, 2021)

Inclusion and Exclusion criteria

Definition of Inclusion:

(Studies associated with any faculty development approach to improve instructional competence in accredited life support courses, approved by professional organizations (e.g. ERC, AHA). The population of the scoping review will include both instructor candidates and certificated instructors in life support courses. Interventions such as instructor training, re-training and recertification courses will be included. The students of the instructors (students in provider courses) will include not only medical personnel but also medical students and laypersons.

Exclusion: non-English abstracts available, non-accredited life support faculty development programs.

Data tables

Download the data tables here.

Task Force Insights

Why this topic was reviewed

Cardiac arrest has a high mortality rate and affects millions of lives worldwide.{Nolan 2020 A1} As timely administration of correct resuscitation techniques has a significant impact on survival, it is pivotal to train the public and health care professionals to perform cardiopulmonary resuscitation.{Van Hoeyweghen 1993 47}

The International Liaison Committee on Resuscitation (ILCOR) proposed the concept of the formula for survival and regarded educational efficiency as one of three multiplicands which would affect survival. {Søreide 2013 1487} Many strategies have been proposed in order to develop comprehensive cost-effective CPR training, and to improve survival. In the past, the training methods for adult and pediatric life support providers have been well studied. Most of them focused on teaching the CPR providers, either laypersons or health care professionals, in order to increase the awareness of cardiac arrest, to achieve higher bystander CPR rates, and to deliver improved CPR quality. However, the instructors’ training methods, and how these educational methods affect instructional competence, and finally the students’ resuscitation competence (knowledge, skill performance, attitudes, confidence and willingness to perform resuscitation) is understudied.

Instructors play an important role in delivering resuscitation knowledge, skills, and attitudes, in assessing and certifying the students in life support courses, and also providing motivation to act as a rescuer to students. Instructor competence to teach life support courses is supposed to optimize students’ learning. Organizations, such as the American Heart Association (AHA), the European Resuscitation Council (ERC), and the American Academy of Pediatrics (AAP) have developed training programs and courses for instructor candidates. Most of the life support courses are instructor-led, the lectures, workshops, and demonstrations taught by the instructors were assumed to be correct. However, it has been reported that that instructors do not always assess cardiopulmonary resuscitation properly, and inadequately trained instructors have resulted in poor learning outcomes of the students. {Hansen 2019 281;Kaye 1991 67;Wynne 1992 372} Therefore, how instructors are taught translates into the corner stone of transfer of CPR-competencies, which cannot be overemphasized.

No previous review has addressed faculty development approaches to improving instructional competence for life support teaching. The instructors’ training strategy is crucial, yet has rarely been investigated. The topic was chosen for review by the ILCOR Education, Implementation & Teams (​EIT) Task Force in its continuous evidence evaluation and current round of reviews due to the need to identify interventions to support instructors to optimize students’ learning in life support courses.

Narrative summary of evidence identified

An extensive search of the databases yielded a total of 12,365 articles (Figure1). After removing 2,769 duplicates, 9,596 articles were screened by reviewing the titles and abstracts. Overall, 101 articles were included in the full-text assessment and 20 studies, including 6 conference abstracts, and 14 articles, were finally included in our scoping review. After discussion among review team members, a consensus was reached to classify the interventions reported in the articles into four themes:

  • instructor qualification/training, n=9
  • assessment tools, n=3
  • teaching skills enhancement, n=3 and
  • additional course for instructors, n=5.

We grouped the interventions in order to identify organized methods to improve instructors’ competence.

a) Instructor qualification/training

There were 9 studies associated with the new or modified courses to improve instructor qualification/training.

An internet-based instructor course was introduced for BLS {Einspruch 2011 E4}, comparing the performance between an classroom-based course with an internet-based AHA Core Instructor Course. No difference was found in the pretest and posttest practical scores between the two groups, but candidates in the online group had significantly higher adjusted posttest scores.

An analysis of a system-wide PBLS instructor training program {López-Herce 2021 71}, with 24 PBLS accredited instructor courses held over 21 years, revealed a pass rate of 98.9% evaluating the candidates in theoretical and practical tests. The participants had overall very positive ratings of the course. The duration of the course was 26–28 h distributed over 3–4 days. The course was divided into 2 phases: an initial preparation phase and a phase involving face-to-face sessions. In the initial phase, participants receive the Guide for Instructors and were given instructions to prepare for each practice session by distance communication with the director of the course. The face-to-face phase consists of theory and practice sessions.

A modified instructor course for neonatal life support instructors used not only lectures and instructions of practice, but also scenarios developed by the instructor candidates. {Wada 2015 629} The old instructor course asked the participants to practice using the text in advance. Participants in this modified instructor course were more confident to teach neonatal CPR and to instruct resuscitation procedures and practice (>90% vs 50-60%, p<0.001). {Wada 2015 629}

A web-based survey with a 29 item Competence Importance Performance scale identified the educational needs of BLS instructors, followed by a factor analysis. {Kim 2019 198} The result showed that training priorities for novice instructors were communication with learners and instructors, learner motivation, educational design, and qualifications of instructors. For the experienced instructors, the priorities were checking equipment status and educational environment. Assessment was reported as the most important factor in basic life support instructor's competence. {Kim 2019 198}

We identified 5 studies on instructor courses with a train-the-trainer (TTT) design, three prospective non-randomized interventional studies {Ismail 2019 604;Rajapakse 2013 e79491; Feltes 2019 202}, and two conference abstracts {Benthem 2012 e103;Pollock 2011 A75}. Two of them were in pediatric life support (PLS) {Feltes 2019 202;Pollock 2011 A75} and three of them for adult life support courses. {Benthem 2012 e103;Ismail 2019 604;Rajapakse 2013 e79491} For PLS, the knowledge score of the students was improved after the TTT pediatric resuscitation training program in one prospective interventional study published as abstract (overall mean score pre: 10.27 post: 12.48 p= < 0.001), and showed retained improvement compared to pre-course scores after 6 months (mean score: 11.81, p=0.001). {Pollock 2011 A75} In another study, both newly trained ‘‘trainers” (instructors) and their students showed improved comfort level in caring for sick children after the advanced pediatric life support TTT course. {Feltes 2019 202} Students of the new “trained trainers” in ALS had significantly improved multiple choice questions (MCQ) score, and improved specific resuscitation skill. {Rajapakse 2013 e79491} The trained trainers hoped the training would improve their community's response to emergencies and described a sense of belonging and duty to the community in another study. {Ismail 2019 604} Another abstract reports a study where first year medical students were randomized to a BLS course instructed by certified Dutch Resuscitation Council instructors (in-service instructor training + TTT course) or in‐service instructor training only. {Benthem 2012 e103} The certified instructors scored significantly higher on the practical training of BLS assessed by the trainees (p = 0.008) whereas the non-certified instructors (in-service training only) performed significantly better on parts of the theoretical BLS training (p = 0.001). {Benthem 2012 e103} The type of instructor had no effect on the final exam result of the first-year students (p = 0.949). The authors concluded the additional value of a TTT course on top of in-service training for senior medical students is not evident from the trainee perspective. {Benthem 2012 e103}

b) Assessment tools

We identified 3 studies focusing on using assessment tools to improve the assessment skills and confidence of the instructors.

Real-time compression feedback used to determine chest compression quality and the accuracy of compression assessment showed that all included CPR‐instructor/coordinator performed suboptimal chest compressions at baseline, and assessment accuracy remained poor after using real-time compression feedback. {Al-Rasheed 2013 242} Most BLS instructors in the study performed by Nallamilli et al. regarded the use of sensor-equipped manikins as useful to deliver BLS training. {Nallamilli 2012 e40} A motion capture camera evaluated the ability of instructors to assess chest compressions and the self-learning ability using the recorded videos in another study. {Yamahata 2014 S49} The result showed that novice instructors are able to improve the assessment of chest compression after self-training, but cannot catch up to the level of experienced instructors who scored chest compression performance similar with the motion capture camera device. {Yamahata 2014 S49}

c) Teaching skills enhancement

We identified 3 studies associated with new methods to enhance teaching skills.

One randomized crossover study {Baldwin 2015 199} compared the sandwich feedback technique with the learning conversation structured methods as structured feedback delivered in BLS training and found the learning conversation structured methods used by instructors was significantly more favourable in most of the assessed domains. No difference was seen in students’ pass rates regardless of the feedback methods (80.9% sandwich technique vs. 77.2% learning conversation, p=0.29). {Baldwin 2015 199} One randomized controlled trial {Cheng 2013 528} compared debrief with a standardized script by novice instructors with non-scripted debriefing. The standardized script used by novice instructors improved students’ acquisition of knowledge (multiple choice question: mean [95% CI], 5.3% [4.1%-6.5%] vs 3.6% [2.3%-4.7%]; p= 0.04) and team leader behaviour performance (Behavioral Assessment Tool score: median [interquartile range (IQR)], 16% [7.4%-28.5%] vs 8% [0.2%-31.6%]; p = 0.03) during subsequent simulated cardiopulmonary arrests. {Cheng 2013 528} In another study, using videotaping and a subsequent critical view of a lecture was found by all participating instructor candidates interesting, as they appreciated the possibility to compare their subjective impression with the objectivity recordings of teaching, thus improving their skills. {Herrero 2010 S106}

d) Additional course for instructors

Five articles were identified, two randomized control trials (RCTs) and three non-RCTs, with interventions of additional courses or programs aiming to enhance specific instructors’ skills.

An educational program in one RCT {Goldman 1986 163} taught ALS instructors to evaluate team leader performance focusing on commonly observed errors and detection of critical error committed by team leaders during cardiac arrest simulations. The instructors in the educational program found more critical errors (1.70 vs. 1.10, P = 0.006), made more correct grade assignments (2.35 vs. 2.0, P = 0.026), and documented more errors that were emphasized in the educational program (3.61 vs. 2.25, P = 0.0001) compared to the control group. {Goldman 1986 163} Another RCT {Breckwoldt 2014 6} compared whether additional course for instructors may influence the outcomes of students. A 2-day BLS and emergency medicine teacher training program included topics like the ‘role of the teacher’, ‘needs of learners’, ‘providing feedback’. The study found that students taught by untrained teachers performed better in the structured clinical exam when compared to students taught by instructors who had completed the teacher training program. In addition, some domains of specific resuscitation skills and teaching quality was rated significantly better by students of untrained teachers. {Breckwoldt 2014 6}

Two studies {Thorne 2015 58;Thorne 2013 526} with the additional instructor program “Assessment Training Program (ATP)” aiming to improve BLS/AED assessors' decision making over equivocal situations. Instructors of the ATP were less prone to incorrectly failing candidates and were significantly more confident in their assessments. {Thorne 2015 58;Thorne 2013 526}

In an instructor program for neonatal resuscitation composed of lectures, scenario development, video reviewing and debriefing, participating instructors improved their self-perceived ability to conduct simulation, to recognize warning signs (e.g., baby’s cry, expiratory grunting, reduced tone), and debriefing. {Amin 2013 251}

Narrative Reporting of the task force discussions

Our review investigating faculty development approaches to improve instructional competence in life support courses found several themes: instructor qualification/training,

assessment tools, teaching skills enhancement, and additional course for instructors. Many studies only described how to implement regional instructor programs but did not report the outcomes of interest in our review. {Anantharaman 2017 418;Boo 2001 118;Couper 2005 459;González 2012 62;Hosono 2019 634;Kang 2018 4;López-Herce 2017 161;Seraj 1999 180;Smith 1997 15;Strömsöe 2010 211} Therefore, these studies were excluded. Some organizations used generic instructor courses, whereas others opted to design their own specific ones. {Finn 2015 e203;Greif 2015 288; Greif 2021 388; López-Herce 1999 205;Wada and Tamura 2015 629} For rural areas, train-the-trainer models were proposed. {Pollock 2011 A75;Rajapakse 2013 e79491} Lack of training opportunities in the rural hospital setting was identified by the EIT Task Force as a barrier to develop local expertise, and it was suggested that the train-the-trainer models may be effective in these specific contexts. These courses in different systems may not be comparable, as every system may face its own challenges.

Studies found that the instructors’ ability to perform and assess chest compressions are not as good as expected. {Hansen 2019 281;Kaye 1991 67} Therefore, assisting tools, like feedback devices, as well as additional training programs were proposed to sharpen their assessment skills. However, one study recruited BLS CPR-I/Cs (instructor/coordinator) as participants and found objective in-scenario real-time compression feedback did not improve their assessment accuracy. {Al-Rasheed 2013 242} Four out of five included articles with additional training programs had a positive effect. {Goldman 1986 163; Thorne 2015 58; Thorne 2013 526; Amin 2013 251} One study described how adapting new strategies in their teaching styles may have paradoxical effects, and hinted that it is important to evaluate any change you make to training practices. {Breckwoldt 2014 6}

Specific debriefing and feedback methods were suggested for instructors teaching life support courses, which may increase instructors’ confidence. Most of the previous published studies related to resuscitation training analyzed the learning outcomes of their life support course participants, but rarely was the instructor the focus of the assessment. Future research on faculty development of resuscitation instructors should include assessment of core instructor competencies as an outcome of interest.

Our search did not identify any re-certification program, although continuous lifelong learning to retain the teaching and practicing skill is crucial for instructors. To some extent, a reason for suboptimal instructor performance found might be lack of solid and effective retraining or re-certification programs.

Our scoping review has not identified sufficient evidence to prompt a new systematic review, thus highlighting significant gaps in the research evidence, especially for retraining and re-certification program. A recent American Heart Association scientific statement on resuscitation education suggested that instructor training program should include content to improve the key competencies of the instructors through different faculty development approaches. {Cheng 2018 e122} Based on the results of this scoping review and expert opinion, we believe that faculty development for instructors remains an important element contributing to improved teaching (and learner outcomes) for accredited life support courses. Different approaches, including instructor training courses, train the trainer programs, content to teach instructors how to use assessment tools, and additional training on how to integrate feedback devices into instruction are required to maximize learning outcomes. Future work should explore the best ways to maintain (and assess) instructor competency, and define the cost-effectiveness of various different faculty development strategies.

Knowledge Gaps

We identified several knowledge gaps in the literature.

(1) The most appropriate life support instructor training strategy is not defined.

(2) Objective measurement of core competence of instructors needs to be determined as well as its assessment.

(3) No study describes a strategy to build up an effective re-certification or re-training program for life support course instructors.

(4) It is unclear which feedback method or debriefing strategy is effective and how to teach the instructors in using a debriefing method successfully in life support instructor training.

(5) It remained unknown whether continuous assessment and feedback of instructors from others, such as senior instructors or course directors, improve instructor competence and learning outcomes for the course participants.

(5) The effect on patient outcome of instructor training was not addressed, but is the ultimate goal of any educational activity in resuscitation.


The authors acknowledge the assistance provided by Hsin-Ping Chiu, the librarian of the National Taiwan University Medical Library for building up the searching strategy.


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Leonard McFarlan
Because of the covid pandemic , Hospitals are giving their staff a over extended break from taking refresher courses in basic cpr . It’s the wrong time to look at increasing Instructor competence with the health system being so fragile .
Shinichiro Ohshimo
Congratulations on the completion of the Scoping Review! I highly appreciate your Scoping Review. I think this Scoping Review includes an important finding for the training of CPR instructors. One question I have is whether the teaching skills of instructors differ depending on their job title. If there are certain professions that are better suited for teaching, this may provide hints for other professions to improve their skills.
Gerard Meijer
Dear Leonard May I beg to differ on being too late to increase competence. It would seem that the incentive to become more efficient/effective is heightened by the pandemic. As a first aid trainer with SES I have noted a more intense interest in the CPR component. My wish-list includes having the compression measuring device available.
Gerard Meijer
Is there any organisation which is examining the 'retention' aspects of CPR abilities? It would be easy to do in house within organisations I would venture to propose. Training retention of any knowledge is good but how good is it and what makes it better? It is not possible to be quite as regulatory as the national paramedic training which mandates regular reviews - which is why their personnel are so good at it.

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