Simulation-Based CPR Education for Student Nurses: A Narrative Review of Effects on Knowledge, Skills, and Confidence

Abstract

Background

Simulation-based education has become an important teaching strategy in nursing education, particularly for high-risk and time-sensitive procedures such as cardiopulmonary resuscitation (CPR). This review aimed to synthesize the available evidence on the effects of simulation-based education on CPR knowledge, skill retention and confidence among nursing students.

Methods

A narrative review of the literature was conducted using studies identified through Google Scholar and PubMed. Peer-reviewed studies published between 2016 and 2026 were considered. Studies addressing simulation-based CPR education among nursing students and reporting outcomes related to CPR knowledge, skills, or confidence were included. A total of 42 studies were included in the review.

Results

The current research shows that there are usually associations between simulation-based education and improved levels of CPR knowledge, skills retention, and self-confidence when compared to traditional forms of education. Yet, different simulation designs, facilitators’ experience, evaluation techniques, and available resources may impact the results. Information about retention and transferring learning to clinical settings is rather scarce.

Conclusion

Simulation-based education may be a useful approach for supporting the development of CPR knowledge, skills, and confidence among nursing students. Further longitudinal studies using standardized assessment methods, particularly in low- and middle income countries, are needed to strengthen the evidence and inform the implementation of simulation-based CPR education.

Introduction

The evaluation of simulation in healthcare has progressed from basic models used to teach procedural skills to advanced, interactive approaches that develop both technical and non-technical competencies. Simulation provides nursing students with safe and standardized opportunities to practice clinical procedures, critical thinking, decision decision-making, teamwork, and clinical reasoning without compromising patient safety. Modern simulation includes high-fidelity mannequins, virtual reality, standardized patients, role-play, and clinical scenarios that recreate real-life healthcare situations.^1–3

Worldwide, simulation-based education has become an important component of nursing education because it addresses some limitations of traditional clinical teaching, including limited opportunities for students to practice procedures and concerns related to patient safety. It allows nursing students to repeatedly practice clinical skills and manage simulated situations in a controlled environment. Simulation has also been associated with improvements in clinical skills, communication, teamwork, and clinical decision-making.^2,3

In developing countries, however, the implementation of simulation-based education may be hindered by limited funding, inadequate infrastructure, limited access to simulation equipment, and a shortage of trained educators. Despite these challenges, opportunities for strengthening simulation-based education exist through international collaboration, context-appropriate innovations, faculty development, and institutional or government support.⁴

Simulation-based education provides nursing with opportunities to develop clinical skills and self-efficacy in a safe learning environment. Virtual simulation provides clinical learning experiences that support nursing students in applying knowledge and developing confidence. These approaches supports practical learning and are relevant to papering nursing students for CPR education.^5,6

Cardiopulmonary resuscitation (CPR) is an important competency for nursing students because they may be required to recognize cardiac arrest and initiate immediate resuscitation measures. Effective CPR requires adequate knowledge of resuscitation principles, correct performance of practical skills, and confidence to respond appropriately during an emergency.⁷ Traditional approaches to CPR education, particularly lecture-based teaching, may provide theoretical knowledge but offer limited opportunities for repeated hands-on practice and the development of practical skills. Simulation-based education can complement conventional teaching by providing nursing students with opportunities to translate theoretical knowledge into practical skills. Simulation-based BLS-CPR education resulted in greater improvement in CPR knowledge and skills than conventional teaching.⁸

In addition to limitations in teaching approaches, opportunities for practical and clinical exposure to resuscitation may be limited because cardiac arrest events cannot be predicted or guaranteed during routine clinical placements. Evidence from Uganda highlights gaps in BLS education and the need for more practical approaches. In a study conducted among undergraduate medical students across eight Ugandan universities, found that only 42.7% of participants had received formal BLS training and 29.3% demonstrated good BLS knowledge. The authors recommended practical approaches such as clinical exposure and field experience to strengthen BLS education these findings provide relevant local evidence supporting the need for educational approaches that provide structured opportunities for students to practice resuscitation skills.⁹

Simulation-based teaching provides nursing students with opportunities to practice CPR in realistic and controlled situations, receive feedback, and repeat procedures without risk to patients thereby supporting the development of CPR knowledge, skills, and confidence.^7,8 Despite the growing use of simulation in nursing education, evidence regarding its effectiveness in CPR training among nursing students remains dispersed across studies using different simulation approaches and outcome measures. Therefore, there is a need to synthesize the available evidence on how simulation teaching affects CPR knowledge, skills, and confidence among student nurses. This review aims to examine the impact of simulation teaching on CPR knowledge, skills, and confidence among student nurses.

Methods

A narrative literature review was conducted to synthesize evidence on the effects of simulation based teaching on cardiopulmonary resuscitation (CPR) knowledge, skills, and confidence among nursing students. A literature search was conducted using PubMed and Google Scholar to identify relevant literature on simulation-based CPR education. Studies published between 2016 and 2026 were considered. The search used combination of the terms simulation-based teaching, simulation-based education, simulation, cardiopulmonary resuscitation (CPR), nursing students, CPR knowledge, CPR skills, skill retention, and confidence, using the Boolean operators AND and OR where appropriate.

Inclusion and Exclusion Criteria

Studies were eligible if they

• (i)Were published in English between 2016–2026;
• (ii)Evaluated a simulation-based intervention for CPR, basic life support, or closely related resuscitation skills;
• (iii)Involved nursing students or, where directly relevant to CPR skill acquisition and retention, comparable pre-licensure health-professions students or early-career nurses; and
• (iv)Reported outcomes relating to knowledge, confidence, or skill retention.

Studies were excluded if they focused primarily on non-resuscitation procedures, such as surgical or dental simulation; involved only qualified specialist practitioners without a student or novice component; or were editorials, commentaries, conference abstracts without primary data, or studies unrelated to simulation-based CPR education.

Study Selection and Data Synthesis

Records identified through the database searches were screened for relevance based on their titles and abstracts. Potentially relevant articles were then assessed against the predefined inclusion and exclusion criteria, and studies meeting the eligibility criteria were included in the narrative synthesis. The final number of studies included in the review was 39.

Because this was a narrative rather than a systematic review, no formal quality-appraisal instrument or meta-analytic pooling was undertaken. Instead, the findings were critically compared and synthesized thematically according to major outcomes, including CPR knowledge acquisition, skill retention, and learner confidence. Differences in simulation modality, study design, sample size, follow-up duration, and outcome measures were considered when interpreting the evidence.

Literature Review

Conceptual Review

Simulation-based learning (SBL) has become an essential instructional method in nursing education, allowing students to refine and master clinical skills in a safe setting. This educational approach utilizes manikins, role-playing, and virtual reality to mimic real-world patient care scenarios, enabling nursing students to develop both technical and interpersonal skills. SBL is particularly beneficial for preparing students for critical, high-pressure procedures such as cardiopulmonary resuscitation (CPR), but it is also applicable to other complex tasks like intravenous therapy, wound care, and patient assessment.^10,11

Importance of CPR Education

Cardiopulmonary resuscitation (CPR) education is an essential component of nursing and healthcare education because it equips healthcare professionals with the knowledge, practical skills, and confidence needed to recognize and respond effectively to cardiac arrest. Cardiac arrest is a time-critical emergency in which every minute without CPR decreases the chance of survival. Therefore, student nurses must be competent in performing high-quality CPR before entering clinical practice to improve patient outcomes. The American Heart Association (AHA) emphasizes that regular CPR education and hands-on practice are necessary to ensure that learners maintain competence in delivering high-quality chest compressions, providing effective ventilation, and using an automated external defibrillator (AED) appropriately during resuscitation. For student nurses, acquiring these competencies during pre-service education is essential for preparing them to respond effectively to cardiac arrest in clinical settings.¹²

The European resuscitation council (ERC) further recommends that CPR education should be continuous rather than one-time event the guidelines highlights that regular refresher training, simulation-based learning, feedback, and debriefing improve knowledge retention, psychomotor skills, teamwork, and confidence, enabling student nurses to develop and maintain the competence required to perform high-quality CPR during real cardiac arrest situations.¹³

The importance of CPR education is reinforced by the high mortality associated with cardiac arrest. A systematic review and meta-analysis that included more than 141 studies and over 1.8 million patients reported that the global survival to hospital discharge following out-of-hospital cardiac arrest was only 8.8%, indicating that more than 91% of patients did not survive. These findings highlight the urgent need to improve CPR knowledge and performance through effective education and training.¹⁴ Since early, high-quality CPR is one of the strongest predictors of survival, ensuring that student nurses are adequately trained before graduation is critical for preparing a competent nursing workforce and reducing preventable deaths.¹²

It is even more imperative to train on CPR in Africa because of the poor survival rates following out-of-hospital cardiac arrest in the region. Several countries in Africa have poor survival rates for the reasons mentioned earlier, including insufficient emergency care services, late recognition of cardiac arrest, poor bystander CPR rate, and poor CPR training in health care providers and the general population. This reinforces the importance of developing CPR education as an essential part of nursing curricula to ensure that graduates are equipped with the necessary knowledge, skills, and confidence to offer resuscitation.¹⁵

Types of Simulation

Virtual Simulation

Virtual simulation is a computer-based learning method that replicates real clinical situations, allowing nursing students to interact with virtual patients in safe and realistic healthcare environments. It enhances the application of theoretical knowledge while eliminating risks to real patients. Studies have shown that virtual simulation improves students’ clinical reasoning, decision-making, psychomotor skills, critical thinking, confidence, engagement, and satisfaction with teaching.¹⁶

Virtual reality (VR) has emerged as a revolutionary tool in nursing education, providing realistic and interactive learning experiences that enhance both theoretical knowledge and practical skills. It enables nursing students to engage in complex clinical scenarios within a safe and simulated environment, helping bridge the gap between theory and clinical practice.¹⁷

The integration of VR into nursing education has been shown to improve the acquisition of essential nursing competencies, including leadership, communication, diversity awareness, and critical thinking.^16,17

A meta-analysis of 12 studies involving 821 nursing students found that virtual reality significantly improved nursing students’ knowledge (SMD = 0.58, P <0.001). However, no significant improvements were observed in clinical skills, learning satisfaction, confidence, or performance time compared with traditional teaching methods. Furthermore, virtual simulation helps address challenges associated with traditional clinical placements, such as limited clinical training sites and patient safety concerns. By providing standardized learning experiences, virtual reality ensures that students are exposed to essential clinical situations, thereby promoting equitable learning opportunities.¹⁷

Standardized Patient (SP) Simulation

Standardized patient (SP) simulation involves trained actors portraying patients in realistic clinical scenarios, allowing nursing students to practice communication, clinical decision-making, and technical skills in a safe and controlled environment. This method particularly strengthens interpersonal communication, professional behaviour, self-confidence, and student satisfaction by providing authentic human interactions.¹⁸

A study likened the effects of infection control education by using SP compared to peer role-play. They demonstrated that education based on SP yielded significantly better performance in infection control procedures, along with greater student engagement and knowledge retention levels.¹⁹

For successful SP simulation, it is essential that best practice guidelines are adhered to the underlying principles for the development of successful healthcare simulations include formal scenario design, clear learning objectives, and the use of debriefing to promote reflection and learning. Successful simulation design ensures students not only have realistic clinical encounters but also develop crucial thinking and decision-making abilities through a guided process.²⁰

All of these investigations reflect the immense value of standardized patient (SP) simulation in nursing education. Investigations consistently demonstrate that SP simulations significantly enhance major clinical skills, including communication, clinical decision-making, and technical proficiency. For example, the literature quotes improved self-esteem and communication between the students who utilized SP simulations¹⁸ as well as in their performance in emergency scenarios like infection control.¹⁹ Additionally, adherence to best practices in SP design renders these simulations educationally effective in attaining learning objectives and building critical thinking.²⁰

Hybrid Simulation

Hybrid simulation is a newer approach that combines different modalities of simulation in order to enhance learning outcomes in healthcare education. Hybrid simulation merges features such as standardized patients, high-fidelity mannequins, and virtual reality to achieve realistic and interactive learning experiences. By leveraging the advantages of multiple simulation methods, hybrid simulation offers an integrated training environment that bridges the theory-practice divide.²¹

The use of hybrid simulation in nursing training has also been shown to improve students’ clinical decision-making, teamwork, and hands-on skills. A systematic literature review highlighted the versatility of hybrid medical simulation, with an emphasis on its ability to engage learners in complex clinical scenarios and provide them with immediate feedback and assessment. This approach enables students to develop both technical competencies and essential soft skills such as communication, leadership, and teamwork.²¹

A hybrid team-based Advanced Cardiopulmonary Life Support (ACLS) simulation program among clinical nurses demonstrated that hybrid simulation training improved nurses’ confidence, skill retention, and team coordination. These findings suggest that hybrid simulation is an effective educational approach for preparing healthcare professionals to manage high-stress clinical situations. To maximize the benefits of hybrid simulation, instructors should design scenarios based on learning outcomes, integrate different simulation modalities, and emphasize scenario realism, effective debriefing, and the use of digital learning tools. Additionally, hybrid simulation should be tailored to learners’ needs to promote the development of both technical skills and critical thinking abilities.²²

While all three simulation types are intended to help nursing students become competent in clinical skills, they vary in approach and learning outcomes. Virtual simulation is the use of technologies whereby the learners engage in simulated activities involving computer-generated patients or situations that enable them to perform and make decisions based on critical thinking in the virtual environment.^16,17 The other technique, standardized patient (SP) simulation, utilizes trained individuals who play the role of real patients in order to give realistic face-to-face encounter, mainly for the development of communication and patient assessment skills.^18,19 On the other hand, hybrid simulation utilizes two or more types of simulations; for instance, the combination of standardized patients and task trainer or high-fidelity manikins.^20–22

Effect of Simulation-Based Teaching

Effect of Simulation-Based Teaching on Nursing Students’ Knowledge

Several studies have demonstrated that simulation-based teaching significantly improves nursing students’ knowledge of cardiopulmonary resuscitation (CPR), although the magnitude of improvement varies according to the simulation modality and study characteristics. Overall, the available evidence suggests that simulation provides a more active learning environment than traditional teaching by enhancing learners’ understanding, retention, and application of CPR knowledge.^7,8,23,24

Evidence from studies with varying sample sizes consistently supports the effectiveness of simulation-based education in improving CPR knowledge. A quasi-experimental study involving 240 nursing students reported that participants who received simulation-based BLS-CPR education achieved significantly higher knowledge scores than those who received conventional lecture-based instruction (p < 0.001), indicating that simulation is an effective teaching strategy for improving CPR knowledge.⁸ Similarly, an interventional study involving 49 nursing students found significant improvements in CPR knowledge immediately after high-fidelity simulation, with knowledge retained during follow-up assessments.²³

Both studies have indicated the positive impact of simulation training on CPR knowledge; however, the larger sample size made statistical significance more obvious in one of the studies due to more statistical power. Nonetheless, the results of the study conducted on a smaller sample need to be interpreted taking into account the small sample size. Still, both studies have proved that simulation training can enhance CPR knowledge of nursing students.^8,23

Differences in simulation modality have also been shown to influence educational outcomes. A quasi-experimental study involving 75 nursing students demonstrated that combining a flipped classroom approach with simulation significantly improved CPR knowledge by allowing students to review theoretical content before participating in simulation sessions.⁷ In comparison, a randomized controlled trial involving 73 nursing students evaluated mannequin-based simulation against virtual simulation and found that both instructional methods significantly improved students’ knowledge after the intervention.²⁴ However, unlike the flipped classroom approach that integrated preparatory learning with simulation, the comparison between mannequin-based and virtual simulation showed no statistically significant difference in knowledge outcomes between the two simulation modalities, suggesting that the learning gains were attributable to simulation itself rather than the specific type of simulation used.²⁴ This finding indicates that institutions with limited financial resources may achieve similar improvements in students’ knowledge using less expensive simulation approaches without compromising learning outcomes.

In general, the reviewed studies consistently demonstrate that simulation-based teaching improves nursing students’ knowledge of CPR across different educational settings. While studies with larger sample sizes provide stronger and more generalizable evidence, smaller studies have reported similar positive findings. Furthermore, comparisons of different simulation modalities suggest that the active learning experience provided by simulation is more important than the specific simulation technology employed. These findings support the integration of simulation-based teaching into nursing education as an effective strategy for improving students’ knowledge while allowing institutions to select simulation methods that best suit their available resources.^7,8,23,24

Effect of Simulation-Based Teaching on Skill Retention

Retention of cardiopulmonary resuscitation (CPR) skills is essential for ensuring that nursing Students can perform effective resuscitation when required in clinical practice. Simulation-based teaching has been widely adopted as a strategy to reinforce psychomotor skills through repeated practice in a safe learning environment. However, the extent to which these skills are retained varies according to the duration of follow-up and the outcomes used to asses CPR performance. The reviewed evidence suggests that simulation not only improves the immediate acquisition of CPR skills but also enhances long-term skills retention when supported by regular practice and refresh training.^7,8,24–26

The duration used to assess skill retention differed considerably among the reviewed studies. A quasi-experimental study involving nursing students reported significant improvements in CPR practical skills immediately after simulation-based BLS-CPR training, demonstrating the effectiveness of simulation in promoting immediate skill acquisition; however, the absence of long-term follow-up limited the ability to determine whether these skills were retained over time.⁸ Furthermore, another study assessed participants at three and six months after simulation training and found that students maintained high levels of CPR competence when periodic simulation practice using the Resuscitation Quality Improvement (RQI) programme was provided, suggesting that repeated simulation sessions contribute to sustained skill retention.²⁵ Likewise, a study examining the acquisition and retention of CPR skills according to training frequency evaluated participants at both three and six months and demonstrated that learners who received more frequent simulation-based retraining retained their CPR skills better than those who underwent less frequent practice.²⁷ Collectively, these findings indicate that studies with longer follow-up periods provide stronger evidence of true skill retention than studies that assess only immediate post-training performance, emphasizing the importance of periodic simulation-based refresher training for sustaining CPR competence over time.^25–27

In addition to that, there was also some diversity in terms of the criteria used for measuring the skill retention. For example, one study used an evaluation of practical CPR skills and CPR-related knowledge altogether. This way, a comprehensive assessment of learning outcomes was conducted right after the simulation session.⁸ On the contrary, another study measured chest compression, ventilation, and CPR skills as a whole, thus giving a more detailed evaluation of the clinical performance.²⁵ There was one more study that examined such objective indicators of chest compression quality as compression depth, compression rate, and chest recoil. Thus, the psychomotor skills were evaluated in detail.²⁶ Finally, the study of CPR skills acquisition and retention measured CPR skills along with compression and ventilation skills and evaluated the effects of varying training frequency on them.²⁷

Although all four studies demonstrated that simulation-based teaching improves CPR skill retention, direct comparisons should be interpreted cautiously because they evaluated different components of CPR competence. While some studies measured overall CPR performance, others focused on specific technical skills such as chest compression quality, ventilation performance, or psychomotor competence, making direct comparison of outcomes challenging.^8,25–27

Effect of Simulation-Based Teaching on Nursing Students’ Confidence

Simulation-based teaching has been widely recognized as an effective educational strategy for improving nursing students’ confidence by providing realistic clinical experience in a safe learning environment. Most studies have reported that simulation-based learning enhances nursing students’ confidence in performing clinical tasks, although the strength of evidence varies according to research design and methodological quality.^7,28,29

A randomized controlled trial provided relatively strong evidence because randomization reduced selection bias and enhanced the internal validity of the findings regarding the effect of high-fidelity simulation on nursing students’ confidence.²⁹ Another study strengthened the evidence by using intervention and control groups while assessing multiple outcomes, including self-confidence, knowledge, skills, and satisfaction among nursing students following simulation-based CPR education.⁷ In contrast, a mixed-methods study combined quantitative findings with qualitative experiences, providing a broader understanding of nursing students’ confidence and perceptions following simulation-based education.²⁸ Similarly, a study involving a relatively larger sample of undergraduate nursing students improved the representativeness of the findings and provided additional evidence regarding the effect of simulation-based laboratory training on confidence and clinical learning outcomes.³⁰

While there were many benefits associated with the reviewed research, some limitations were identified. Research carried out in single institutions with small sample sizes may have low generalizability of the results to other nursing student populations.^7,28 Although the use of a randomized control design provides robust results, a small sample size in one study limited the study’s statistical power to detect any differences in the confidence levels of nursing students.²⁹ Also, a non-randomized design may introduce selection bias even when the sample size is large.³⁰

The findings were generally positive, although some inconsistencies were identified. Three studies reported significant improvements in nursing students’ confidence following simulation-based teaching.^7,28,29 In contrast, one study found that although simulation-based laboratory training significantly improved nursing students’ clinical skills and satisfaction, it did not produce a statistically significant improvement in self-confidence compared with the control group.³⁰ This inconsistency suggests that the effect of simulation-based teaching on nursing students’ confidence may be influenced by factors such as simulation design, study methodology, sample characteristics, and the instruments used to measure confidence.

Implications for Nursing Education in Low- and Middle-Income Countries (LMICs)

Simulation-based education has important implications for strengthening nursing education in low- and middle-income countries (LMICs), where nursing schools often face challenges such as limited clinical placement opportunities, shortages of trained faculty, inadequate teaching resources, and increasing student enrolment. Evidence indicates that simulation provides a safe and standardized learning environment in which nursing students can develop clinical knowledge, psychomotor skills, critical thinking, and decision-making abilities without compromising patient safety. The reviewed studies suggest that simulation-based education is both feasible and effective in low- and middle-income countries (LMICs) despite resource constraints.^31,32 Low-cost simulation approaches have been shown to improve learning outcomes when integrated into nursing curricula and supported by appropriate faculty training, demonstrating that resource limitations should not prevent the implementation of simulation-based education.³¹ In addition, simulation-based education has been found to enhance nursing students’ clinical competence, confidence, communication, teamwork, and critical thinking, particularly when implemented as a structured component of the curriculum rather than as a supplementary teaching strategy.¹⁶ Although both studies support the integration of simulation into nursing education, they differ in their emphasis. One study focused primarily on the feasibility of implementing simulation in resource-limited settings, whereas the other highlighted its broader educational benefits for improving nursing students’ learning outcomes and professional development.^31,32

These findings indicate that nursing institutions in LIMCs should prioritize simulation-based education through curriculum integration, faculty development, and investment in context-appropriate simulation resources, such strategies are consistent with global recommendations that emphasize competency-based education, strengthening the nursing workforce, and improving the quality of healthcare delivery. Integrating simulation into undergraduate nursing programs has the potential to improve graduates’ readiness for clinical practice, enhance patient safety, and contribute to achieving universal health coverage.³³

Research Gaps

One significant gap in the literature is the limited evidence on the long-term effects of simulation-based education on clinical decision-making and the retention and transfer of skills to clinical practice. Most studies focus on short-term post-training assessments, with limited attention to whether simulation-acquired skills are maintained and effectively applied in real clinical situations over time.^34,35 There is also limited evidence on how simulation-based education prepares healthcare professionals for high-stakes clinical situations in which rapid and accurate decision-making is required. In addition, factors such as cognitive overload, stress, and adaptability may influence the retention and transfer of simulation-acquired skills during unpredictable emergencies.^34,36 Further research is needed to determine whether skills developed in simulated environments can be effectively transferred to actual clinical practice.³⁴

Another gap concerns the limited comparison between simulation-based education and actual patient interaction during clinical placements. Although simulation provides controlled and standardized learning experiences, simulated environments may not fully reflect the complexity and variability of real patient care.¹⁷ Therefore, further research is needed to examine how simulation can bridge the gap between theoretical knowledge and practical clinical proficiency, particularly in high-acuity situations.³⁷

The literature also lacks standardized approaches for assessing the long-term retention of simulation-acquired skills. Studies have used different follow-up periods and reinforcement strategies, and there is no clear consensus regarding the optimal frequency of refresher training or the most effective approaches for maintaining competence.³⁸ Longitudinal studies are therefore needed to examine different reinforcement strategies, including refresher training, blended learning, and clinical exposure, and to assess their effectiveness over extended periods.¹⁷

Finally, comparative studies examining simulation-based learning and traditional clinical education are needed to provide further evidence on how simulation can contribute to preparing healthcare professionals for real-world practice.³⁷ Table 1 describes the summary of the key evidence for the reviewed studies.

Table 1.

Summary of Key Evidence

Author (Year)	Country	Sample Size	Simulation Modality	Follow-Up Duration	Key Findings
El Ougli et al (2024)24	Morocco	49 nursing students	High-fidelity manikin (adult in-hospital CPR)	30 days	Significantly higher immediate theory scores than control (16.41 vs 13.15/20); knowledge and technical/non-technical skills retained above control at 30 days.
Bdiri Gabbouj et al (2025)8	Tunisia	240 (130 intervention/110 control)	Manikin-based BLS-CPR simulation	Immediate post-test	Higher post-test knowledge (30-item) and skills (13-step checklist) scores in simulation group (p < 0.001).
Oermann et al (2024)39	USA	238 nursing students (6 universities)	RQI manikin with real-time audiovisual feedback (low-dose, high-frequency)	Baseline, 3 and 6 months	Compression and ventilation competence maintained or improved to 6 months with 3-monthly feedback practice; no skill loss.
Silva et al (2025)27	Brazil	43 senior medical students	Feedback-equipped CPR simulator	3 and 6 months	Overall performance 60% to 95% (p < 0.001); depth-adequate 13% to 71%, rate-adequate 69% to 89%; gains retained equally at 3 and 6 months.
Huang et al (2026)26	China	148 novice nurses	High-fidelity deliberate-practice simulation (single vs +3-month booster)	6 months	Deliberate practice improved proficiency, but a 3-month booster did not significantly enhance 6-month retention vs single session (knowledge P = 0.344; skill P = 0.400).
Nasiri et al (2025)7	Iran	75 (38 FCBS/37 control)	Flipped Classroom-Based Simulation (FCBS) vs standard SBE	Immediate post-test	FCBS group had significantly higher CPR knowledge, skills, self-confidence, and satisfaction (P = 0.001).
Mitchell et al (2020)36	Australia	146 acute-care staff (83% nurses)	Simulation-based education (aggression management; proof-of-concept)	3 to 6 months	Confidence increased post-training; 66% (N = 44) sustained confidence at 3 to 6 months; self-report only, no objective competence measure.
McMains et al (2023)40	USA	Small event cohorts (~17 to 22 per module)	Emergency-medicine simulation-based curriculum	Up to ~90 days	Higher retention of theoretical knowledge and practical skills than traditional didactic instruction; underpowered by small samples.
Abbasi et al (2024)24	Iran	73 nursing students	Manikin-based simulation vs virtual training	1 month	Both methods improved CPR knowledge, attitude, and performance (p < 0.001); simulation group performed better on practical CPR at 1 month.

Conclusion

This review highlights a growing body of evidence supporting the use of simulation-based teaching in cardiopulmonary resuscitation (CPR) education among nursing students. Across different simulation modalities, including virtual simulation, standardized patient simulation, high-fidelity manikins, and hybrid approaches, studies have reported improvements in CPR knowledge, skill retention, and learner confidence compared with conventional teaching approaches. However, the magnitude and consistency of these findings vary according to the simulation modality, study design, assessment methods, facilitator expertise, and available resources.

Simulation-based education provides a safe, controlled, and learner-centered environment in which nursing students can practice high-risk and time-sensitive procedures such as CPR without placing patients at risk. Its interactive and hands-on nature may support knowledge acquisition, clinical reasoning, and confidence in responding to emergency situations. Structured debriefing and facilitator-guided reflection may further support learning by enabling students to review their performance and identify areas for improvement. Nevertheless, improvements demonstrated in simulated environments should not be interpreted as direct evidence of improved clinical performance or patient outcomes.

Simulation-based teaching appears to be a promising educational approach for supporting CPR knowledge, skill retention, and confidence among nursing students. However, evidence regarding the sustained transfer of these gains to actual clinical practice and their effect on patient outcomes remains limited. Further longitudinal and context-specific research using standardized assessment methods and longer follow-up periods is needed, particularly in low- and middle-income countries, to strengthen the evidence base and guide effective implementation of simulation-based CPR education.

Disclosure

The authors report no conflicts of interest in this work.