Self-learning Versus Instructor-led Learning in Basic Life Support Training - A Randomized Controlled Trial
Phase: NA
Conditions: Basic Life Support
Sponsor: Insel Gruppe AG, University Hospital Bern

INSELSPITAL 
Self-learning versus 
Instructor-led Learning in 
Basic Life Support 
Training 
A Randomized Controlled Trial 
 
Tina Pedersen, Roman Hari, Robert Greif 
08.01.2017 
 
 
 
 
 

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Index 
1. INTRODUCTION ............................................................................................................................... 2 
2. AIM OF STUDY ................................................................................................................................. 3 
3. HYPOTHESIS ..................................................................................................................................... 4 
4. OBJECTIVES AND OUTCOMES .......................................................................................................... 4 
4.1. Objectives ................................................................................................................................. 4 
4.2 Outcomes .................................................................................................................................. 4 
5. PROJECT DESIGN .............................................................................................................................. 5 
5.1. Type of research and general project design ........................................................................... 5 
5.2. Procedures ................................................................................................................................ 5 
6. METHODS OF MINIMISING BIAS ..................................................................................................... 6 
6.1. Randomization .......................................................................................................................... 6 
6.2. Blinding ..................................................................................................................................... 6 
7. PROJECT POPULATION .................................................................................................................... 6 
7.1. Participants ............................................................................................................................... 6 
8. PROJECT ASSESSMENT .................................................................................................................... 7 
8.1. Assessment of primary outcome .............................................................................................. 7 
8.2. Assessment of secondary outcomes ........................................................................................ 7 
8.3. Assessment of other study variables ........................................................................................ 8 
9. STATISTICAL METHODOLOGY .......................................................................................................... 9 
9.1. Determination of Sample Size .................................................................................................. 9 
9.2. Planned analysis ....................................................................................................................... 9 
10. TIMELINE ....................................................................................................................................... 9 
11. ETHICS ............................................................................................................................................ 9 
12. PUBLICATION ............................................................................................................................... 10 
13. REFERENCES ................................................................................................................................ 11 
 
 
 
 

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1. INTRODUCTION 
Basic life support (BLS) skills are essential in the care of cardiac arrest victims, but unfortunately only 
a minority of cardiac arrest victims receive bystander or first responder cardiopulmonary 
resuscitation (CPR) (1, 2). For cardiac arrest victims the quality of CPR delivered by healthcare 
professionals is critical, because poor compliance with recommended guidelines has been associated 
with lower survival rates (3, 4). Healthcare professionals usually receive their first training in BLS in 
the beginning of their professional education, but the long-term retention of their learning is a more 
important outcome parameter than learning assessed at the time of the training (1). There is 
insufficient evidence to recommend the optimal interval or method for BLS retraining (1, 2),  
however there is low-quality evidence of skills decay within 3 to 12 months after BLS training (5-7) 
and evidence that frequent training improves responder confidence (5, 8) and willingness to perform 
CPR (8).  
Traditional BLS training is given in groups of various sizes, with one or more instructors. It has been 
shown that groups of three, five, and eight students do equally good in a post-test, however the 
group with eight students had significantly less hands-on time, asked fewer questions, conducted 
more unrelated conversations and ranked themselves lower in self-assessment than groups of 
three(9). A alternative method to teach BLS is via computer and/or video. Students in a computer-
based learning BLS course have been shown to perform with a significantly higher accuracy rate on 
60 chest compressions, 12 ventilations and 3 cycles of CPR than students in an instructor-led group 
(10), and another study showed that skills acquired in a self-learning station combining video-
instruction with training using voice feedback were not inferior to instructor-led training (11).    
The advantages of self-learning compared to instructor-led training are many. When no instructor is 
needed, the training can take place when it fits the student best; the student only needs a computer 
and a manikin. Retraining can take place more often because a course does not have to be planned, 
and salary for the instructor is saved.  The disadvantage of self-learning is the lack of feedback from 
an instructor, but with voice feedback from the manikin, the student receives feedback regarding the 
quality of the CPR. The manikin assesses compression depth, correct hand position, correct 
decompression, compression rate, respiratory volume, respiratory frequency,  gastric ventilation (12) 
and gives voice feedback on those parameters.      
A method to assess the quality of CPR is by using the Resusci Anne SkillReporter™ (Laerdal Medical, 
Stavanger, Norway). The Resusci Anne SkillReporter™ (LSR) is an adult CPR training manikin that 
focuses on student performance through printed reports on ventilation and compression 

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compliance. Regarding ventilation trainees obtain measurements on ventilation volume, number of 
ventilations per minute, overall ventilation volume, number of ventilations, percentage of correct 
ventilations, number of ventilations with too much volume, number of ventilations with too little 
volume, number of ventilations that were too fast, and the relation between ventilations and 
compressions. Regarding compression  the Resusci Anne SkillReporter gives feedback on  
compression depth, number of compressions per minute, compression frequency, total number of 
compressions, percentage of correct compressions, number of compressions that were too deep, 
number of compressions that were too shallow, incorrect hand position, incorrect decompression.  
Another method to assess the CPR is to check if all steps in the CPR-algorithm are fulfilled. A BLS/AED 
provider assessment record is available via the European Resuscitation Council(13) (fig.2). 
Mini Anne CPR & AED (Laerdal Medical, Stavanger, Norway) is a manikin developed to train CPR 
skills. This innovative self-directed learning programme allows people to learn the core skills of CPR 
and automatic extern defibrillation (AED) use in 30 minutes. The Mini Anne CPR & AED kit instructs 
the user in a ‘practice-while watching’ format with the aid of a 30 minute instructional DVD, and a 
personal, inflatable manikin with an integrated adult/child compression clicker1. The first year 
medical students from Bern University Hospital use this manikin in their obligatory BLS course 
integrated in their first aid training. After a short introduction to the course they train CPR skills for 
30 minutes with the Mini-Anne supervised by the instructor. After the training the course continues 
with four different scenarios. The duration of the first aid course is three hours.  
In the “2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Care Science 
with Treatment Recommendations”(1) it was stated that there was a knowledge gap regarding the 
skill performance in actual resuscitations of students receiving self-instruction courses when 
compared with those receiving traditional courses (1). To expand our knowledge we wish to 
investigate whether there is a difference in the BLS skills in first year medical students directly after 
training and four months later, when randomly assigned to self-learning versus instructor-led training 
courses. Our 0-hypothesis is that the students in the self-learning group will not be inferior to the 
students in the instructor-led group.  
 
2. AIM OF STUDY  
The aim of this study is to investigate whether self-learning versus instructor-led learning results in 
the same BLS skills in first year medical students directly after training and four months later.  
 
                                                          
1 http://www.laerdal.com/gb/MiniAnne#/Info 

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3. HYPOTHESIS 
Our 0-hypothesis is that the students in the self-learning group will demonstrate the same BLS skills 
as students in the instructor-led group. The alternative hypothesis is that there will be a difference in 
the BLS skills demonstrated by the self-learning group compared to the instructor-led group. 
 
4. OBJECTIVES AND OUTCOMES 
4.1. Objectives 
The objective of this study is to compare the BLS skills measured by the percentage of correct 
compressions achieved directly after BLS skills training in a self-learning group compared to an 
instructor-led group using the printed report from the LSR and the score on the standardized ERC 
BLS/AED provider assessment record(13) (fig.2). Another objective is to investigate the degree of 
competence loss after four months. 
4.2 Outcomes 
Our primary outcome will be the percentage of correct compressions obtained from the printed 
report from the LSR. With this parameter we will compare the two groups directly after the first 
teaching session. 
 
Our secondary outcomes are: 
 
The subcomponents of the printed report from the LSR (ventilation volume, number of 
ventilations per minute, overall ventilation volume, number of ventilations, percentage of 
correct ventilations, number of ventilations with too much volume, number of ventilations 
with too little volume, number of ventilations that were too fast, the relation between 
ventilations and compressions, compression depth, number of compressions per minute, 
compression frequency, total number of compressions, percentage of correct compressions, 
number of compressions that were too deep, number of compressions that were too 
shallow, incorrect hand position, and incorrect decompression). 
 
The score on the BLS/AED provider assessment record(13) (fig.2). 
 
Degree of loss of competence after four months for all the primary and secondary 
outcomes.  
 
Influences of gender and prior BLS training will also be investigated, as well as the decay of 
competences. 

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5. PROJECT DESIGN 
5.1. Type of research and general project design  
This is a randomized controlled trial investigating whether self-learning versus instructor-led learning 
results in the same BLS skills in first year medical students directly after training and four months 
later. 
 
5.2. Procedures 
When participants attend the “Erweiterte Erste Hilfe für Studierende der Humanmedizin” they will 
receive a short introduction about the study. We will invite all first year students to participate in the 
study. As the study is voluntarily, participants will need to sign a written informed consent. After that 
we will randomize the students to either group A or Group B (see figure 1). Group A will train their 
technical CPR-skills with supervision by a tutor (either general practitioner or medical student, all 
trained in CPR teaching) and group B will train without supervision. The participants in group B will 
not be allowed to communicate with each other during the training. The training will take about 40 
minutes for each group. Directly after the training each group will be tested and the printed report 
form from the LSR will be obtained for each participant. In the test the students will perform CPR in a 
simulated scenario as a first responder. The scenario is: “A male person has collapsed in the hall of 
the university and you cross by. No other persons are present at the moment.” The participant 
should start CPR as learned in the training. During the CPR a departmental research fellow will 
observe the study participants and record BLS/AED actions on a scoring sheet. 
To avoid struggle with the equipment, each student will be given two minutes to familiarize 
themselves with the testing manikin and the equipment (an AED). We will record three cycles of two 
minutes CPR (with five times 30:2 compression : ventilation intervals, as recommended by the 
current international resuscitation guidelines) (14). During the three cycles an AED will be delivered 
and the study participant has to apply the AED and deliver a shock – after that the study terminates. 
After the BLS/AED competence testing, both groups will continue the rest of their first aid course 
together and the first part of the study ends. Four months later we will repeated the same scenario 
over the same time interval and record the same parameters. At the end of the second testing, a 
short feedback will be provided on the BLS/AED competence and further practice will be provided to 
the students to improve their CPR competence. From this point forward no further data will be 
collected  

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6. METHODS OF MINIMISING BIAS 
6.1. Randomization 
We will use a computerized randomization list (www.randomization.com) using block randomization 
of 10 to assure proper distribution during each group of students. 
6.2. Blinding 
There will be no blinding in this study because the participants will realize the difference in the 
teaching method.  
 
7. PROJECT POPULATION 
7.1. Participants 
All first year medical students at the University of Bern participating in the course “Erweiterte Erste 
Hilfe für Studierende der Humanmedizin”. 
 
7.2. Inclusion criteria 
Figure 1: Procedure 

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First year medical students at the University of Bern participating in the course “Erweiterte Erste 
Hilfe für Studierende der Humanmedizin” with written informed consent. 
 
7.3. Exclusion criteria 
Students with professional BLS-experience, unable to perform BLS, or missing informed consent will 
be excluded. 
 
7.4. Criteria for withdrawal  
The participants can withdraw their consent and leave the study at any time.  
 
8. PROJECT ASSESSMENT  
8.1. Assessment of primary outcome 
Our primary outcome will be the percentage of correct compressions obtained from the printed 
report from the LSR.    
8.2. Assessment of secondary outcomes 
The secondary outcomes are: 
 
The subcomponents of the printed report from the LSR.  
 
The score on the BLS/AED provider assessment record. 
 
Degree of loss of competence after four months for all the primary and secondary 
parameters.  
 
The printed report from the LSR consists of ventilation volume, number of ventilations per minute, 
overall ventilation volume, number of ventilations, percentage of correct ventilations, number of 
ventilations with too much volume, number of ventilations with too little volume, number of 
ventilations that were too fast, the relation between ventilations and compressions, compression 
depth, number of compressions per minute, compression frequency, total number of compressions, 
percentage of correct compressions, number of compressions that were too deep, number of 
compressions that were too shallow, incorrect hand position, and incorrect decompression. We will 
record these parameters over the entire testing period.  We will look at each parameter individually. 
 
To assess the score on the BLS/AED provider assessment record(13) (fig. 2) during the simulated 
scenario a departmental research fellow will observe the study participants and record BLS/AED 
actions on a scoring sheet. Actions recorded are: Check response, assess breathing, call emergency 
services, chest compressions, rescue breaths, compression : ventilation ratio, activate AED, attach 

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pads, stand clear, deliver shock, follow AED instructions, and CPR. Time to first chest compression 
and time to first shock will also be measured. 
 
 
By doing the same test four months later, we can measure the loss of competence by comparing the 
percentage of correct compressions and the subcomponents of the printed report, and compare the 
score on the BLS/AED provider assessment record. 
 
8.3. Assessment of other study variables 
By recording demographic data as age, gender, height and weight, CPR experience (CPR course 
attendance, real live CPR experience) we will be able to investigate the influence of prior training, 
gender etc. on competences and decay of competences.  
 
At the end of each course we will ask the participants how competent they feel on a visual analogue 
scale from 0 (totally incompetent, have no clue what to do) to 100 (totally competent, cannot be 
done better). The departmental research fellow will also rate the participant on the same scale.  
Figure 2: Procedure 

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9. STATISTICAL METHODOLOGY 
9.1. Determination of Sample Size 
Based on a pilot study with 14 participants we calculated a median of 84% correct compressions. The 
interquartile range was 47% to 93%. We have discussed in the study group that a 20% decrease in 
percentage of correct compressions would have a clinically impact. Therefore, using a two-sample 
proportion test with a significance level α of 0.05 and an effect size of 20% (from 64% to 84%) we 
calculate that it requires 150 subjects to reach a power of 80%. To compensate for drop-outs, we aim 
to include 200 participants in the study.  
9.2. Planned analysis 
All data will be summarized for each individual and a summary of all study participants will be 
computed. Data will be presented as mean (SD) or %. 
Parametric data will be compared by a Students-t test, non-parametric by Mann-Whitney-U test. A p 
< 0.05 is considered as statistically significant.   
 
9.3. Data management  
The data will be stored in LabKey.  
Participants will be coded to assure confidentiality of the personal data.  
 
10. TIMELINE 
The BLS course “Erweiterte Erste Hilfe für Studierende der Humanmedizin” takes place in March and 
April 2017. A manuscript will be ready for submission in winter 2017.  
Registration of the study in an international trail register is planned (train.gov). 
 
11. ETHICS 
The study has been approved by the Kantonale Ethikkommission Bern with registrationsnumber: 
Req-2016-00071. 
If students can accomplish the same BLS skills and maintain these skills over time, when training BLS 
by themselves compared to training led by an instructor, there is a foundation for more self-training. 
When no instructor is needed, the training can take place when it fits the student best; the student 
only needs a computer and a simple manikin, like the Mini-Anne. Retraining can take place more 
often because a course does not have to be planned, and salary for the instructor is saved. BLS skills 

10 
 
can be more widespread in the community; lay persons can practice without an advanced manikin or 
an instructor, leading to an increased chance that people who have a cardiac arrest outside the 
hospitals receive proper BLS.  
Participation in the study is voluntary, and if one chooses not to participate, he/she receives 
instructor-led training. It has been shown that skills acquired in a self-learning station combining 
video-instruction with training using voice feedback were not inferior to instructor-led training (11), 
so we do not consider it a risk for the participants of the self-learning group that they do not take 
part in the instructor-led group. A study has  shown that students taking part in a computer-based 
learning BLS course performed 60 chest compressions, 12 ventilations and 3 cycles of CPR with a 
significantly higher accuracy rate than students in an instructor-led group (10), so the participants in 
the self-learning group can potentially benefit from participating in the study.  
There is an excellent risk-benefit ratio in this study. The results from the test will be kept anonymous 
and it will not have an effect on the students grades. The information gained in this study is 
generalizable knowledge that can be used in health care systems all over the world. BLS skill training 
could potentially be more accessible to people in the community and cardiac arrest victims will have 
a better chance of survival, if more people in the community are able to perform BLS.      
12. PUBLICATION 
The plan is to submit the resulting manuscript to the peer reviewed journal: Resuscitation, Elsevier. 
 
 
 

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