Australasian Emergency Nursing Journal (2011) 14, 240245

available at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/aenj

LITERATURE REVIEW

Advanced life support training and assessment:

A literature review
Noelene Maree Williams, CNE, Grad Dip. Clinical Practice (Emergency
Nursing), Grad Cert. Clinical Education
The Tweed Hospital Emergency Department, Northern NSW Local Health District, Australia
Received 25 March 2011; received in revised form 6 July 2011; accepted 7 July 2011

KEYWORDS
Advanced Cardiac
Life Support;
Resuscitation;
Emergency Medicine;
Critical Care;
Nursing;
Learning

Summary Advanced Life Support (ALS) certication has become a mandatory requirement
for most critical care nurses in Australia. The purpose of this review is to critically evaluate
current literature in relation to ALS training and certication for critical care nurses. There
is some evidence in the literature that ALS training programs can improve patient outcome
following cardiac arrest. Teaching methods vary including simulation training, e-learning and
lecture based courses. Of continued concern is the consistent message that competence declines
rapidly following ALS courses. Whilst many critical care units require evidence of annual ALS
assessment there is little evidence that this translates into ongoing practical competence or
condence. Recommendations from regulatory bodies and ALS training literature reinforce that
frequent, relevant and practical learning activities may be more effective, however it is unclear
from the review if this occurs nor if critical care nurses remain condent in their skills as time
passes.
Crown Copyright 2011 Published by Elsevier Ltd on behalf of College of Emergency Nursing
Australasia Ltd. All rights reserved.

Introduction
Advanced Life Support (ALS) or Advanced Cardiac Life
Support (ACLS) certication has become a mandatory
requirement for most critical care nurses in Australia.1 The
intention of such certication has been to improve the

Correspondence address: 21 Boyd Street, Tweed Heads, NSW

2485, Australia. Tel.: +61 7 55992091; fax: +61 7 55991680;
mobile: +61 0411 244899.
E-mail addresses: noelenewilliams@gmail.com,
Noelene.williams@ncahs.health.nsw.gov.au

chances of survival for patients suffering in-hospital cardiac

arrest. The 2010 resuscitation council guidelines have made
signicant changes to ALS algorithms and recommendations,
and as such education will be an important component of a
smooth transition to the implementation of these changes.
The purpose of this review is to critically evaluate current
literature in relation to ALS training and certication for
critical care nurses.

Search strategy
The literature reviewed in this paper was identied using
the following databases; Nursing@OVID, Nursing Consult

1574-6267/$ see front matter. Crown Copyright 2011 Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia Ltd. All rights reserved.

doi:10.1016/j.aenj.2011.07.001

Advanced life support training and assessment

and British Nursing Index and Medline. Initially the key
word Resuscitation was used however the results of
the search were too broad for an advanced life support focus. The search was repeated using the terms
advanced life support; advanced cardiac life support;
ALS; and ACLS resulting in a more relevant selection.
Limiting criteria included articles published between 2005
and September 2010 in the English language. This initial search resulted in approximately 250 articles. The
abstracts were reviewed and approximately fty ve original research articles were retained that related to advanced
life support training or assessment of health care providers.
Approximately twenty articles that related only to basic
life support (BLS); immediate life support (ILS), specic
trauma life support or pre-hospital care were removed
from the selection. Additional articles of relevance were
chosen from their reference lists and Australian and international resuscitation council websites were explored for
position statements and regulatory requirements which
included the 2003 ILCOR advisory statement on education in resuscitation.2 Following the peer review process
and the 2010 release of updated resuscitation guidelines an additional four articles were included in this
review.
The European resuscitation council 2010 guidelines state
that the aim of educational interventions in resuscitation should be to ensure that learners acquire and
retain the skills and knowledge that will enable them
to act correctly in actual cardiac arrests and improve
patient outcomes.3 The International Liaison Committee
on Resuscitation (ILCOR) held a symposium on Education
in Resuscitation in 20012 and the 2010 release of resuscitation guidelines has seen no additional statements from
ILCOR relating to education on resuscitation. Their 2003
Advisory statement, although now dated, set a standard for
the international health care community in regard to resuscitation education. ILCOR recommendations in regard to
training health professionals in advanced skills included that
training should move away from large lecture based courses
to small group scenario based interactive teaching targeted at specic learning populations and the experiences
they might encounter in their practice. They also recommended that simulation should supplement the instructor
directed training.2 These recommendations are in line
with adult learning principles where learning should be
relevant and immediately applicable to practice.4 The
symposium recognised the importance of a move toward
multi-professional teamwork training. ILCOR advised that
certication of course participation was probably appropriate however the general recommendations were in
regard to learning.2 The release of the 2010 European
Resuscitation Council (ERC) Guidelines3 and the American
Heart Association (AHA) guidelines5 reinforced these recommendations for increased emphasis on teamwork and
leadership. There is an acknowledgement of the role of technology in resuscitation training in terms of self-instruction
and video/computer aids, although the importance of
combining this with hands-on practice is emphasised.3
Interestingly the AHA recommendations had more emphasis on assessment and re-training if required5 likely
based on the focus of literature over recent years on
assessment.

241
The Australian Resuscitation Council (ARC) in conjunction with the Australian College of Critical Care Nurses
(ACCCN) in 2008 developed the Australian Standards for
Resuscitation: Clinical Practice and Education. This document, endorsed by prominent Australian emergency health
professional organisations, also recommended that resuscitation training should be tailored to practice environments
and clinicians should update their skills on an annual basis.6
The focus of the education component was on upgrading
knowledge and skills and the issue of certication was not
delineated.7 Since the release of the 2010 ARC guidelines no
changes in recommendations for education in regard to ALS
have been made.

ACLS training and patient outcomes

Surviving cardiac arrest requires high-quality cardiopulmonary resuscitation, advanced life support
interventions and optimal post-cardiac arrest care.8
Changes to resuscitation guidelines internationally in
2010 outlined recommendations based on the evidence for
interventions to improve patient outcomes following cardiac
arrest.3,5,9 It is disappointing to nd that since the previous (2005) guidelines there is little evidence to demonstrate
that advanced life support education improves survival for
victims of in-hospital cardiac arrest. There are very few
papers in the literature over recent years that can demonstrate a correlation between educational interventions and
survival of patients who suffer in-hospital cardiac arrest.
Spearpoint, Gruber and Brett10 performed an audit over
six years in relation to cardiac arrest outcome and concurrent introduction of an immediate life support (ILS)
course. They discovered a relationship between ILS training and patient survival following in-hospital cardiac arrest.
Their ndings related mostly to rst responder interventions
rather than those commonly recognised as ALS interventions however the study is signicant in this review due
to the impact that an educational program was found to
have on patient outcome. Of more signicance, the study
by Moretti, Machado Cesar, Nusbacher, Kern, Timerman,
and Ramires11 also looked at patient outcomes following
in-hospital cardiac arrest. Moretti et al., identied a relationship between patient outcome and the involvement of
ACLS trained staff in their resuscitation. They found that
the presence of at least one ACLS trained staff member
reduced the time to a return of spontaneous circulation
and increased both short and long term patient survival.
Patients cared for by an ACLS trained clinician were 2.06
times more likely to be successfully resuscitated. The
improvements in survival were thought to be attributed
to earlier rst debrillation, advanced airway management
and adrenaline administration.11 Neither study differentiated between medical and nursing resuscitation providers
and as such may not specically relate to nurses however
the educational intervention again was the important factor.
A more specic study comparing traditional and simulation
based ACLS training for resident medical ofcers was performed by Wayne, Didwania, Feinglass, Fudala, Barsuk and
McGaghie12 in relation to leading the cardiac arrest team.
They found that the simulation group more closely adhered

242
to the recognised ACLS protocols although there was no difference in patient survival between the two groups and as
such it is unclear if the educational intervention was superior.
Gilligan et al.13 found no difference between emergency
nurses and doctors when assessed as team leaders using
a simulated cardiac arrest scenario. They also found that
nurses had a greater awareness of the potentially reversible
causes of cardiac arrest. Their conclusion that emergency
nurses could effectively lead a resuscitation event was
based on scenario assessments and further research would
be required to determine if this would translate to practice situations. However the study is relevant here due to
the specic emergency focus and the consideration of the
nurses role.

Advanced life support training practices

ALS certication has become a mandatory requirement for
many critical care clinicians. Most authors agree that Medical practitioners and Registered nurses working in critical
care areas, encompassing emergency departments, intensive care, coronary care and high dependency units where
patients are at risk of sudden life threatening emergencies due to airway, breathing and/or circulatory conditions
should become competent in the provision of advanced life
support.1,14,15 However there is very little Australian data
available about who is trained, how and when. Preston,
Currey and Eastwood1 went some way to address this gap
in their study focussed on Victorian practices of assessing ALS for nurses. Their study focussed on assessment of
ALS skills rather than education and described the assessment processes used by intensive care educators in Victoria.
They identied that scenario based assessment was widely
used and written theoretical tests used to a lesser degree
(60%). Most respondents reported that ALS competency was
assessed annually however this evidence is from intensive
care educators only and cannot be generalized to the rest
of the Australian nursing workforce without further study.
Additionally educators may have reported their ideal intention to annually reassess rather than what actually happens
in practice.
The results of Spearpoint, Gruber and Bretts ILS course
study reinforces that the ALS course should be restricted to
practitioners that are regularly involved in the management
of cardiac arrest patients and other professional groups
should be encouraged to attend a course more suited to their
needs such as an immediate life support course (ILS).10

Effectiveness of advanced life support training

methods
Whilst ALS competence is recognised as important, evidence of the effectiveness of training methods is varied.
Simulation training has become a popular method to provide for experiential learning and evaluation of critical
and reective thinking skills.16 Hoadley17 found that whilst
participants pre-course to post course ACLS knowledge
increased there was no signicant difference in participant
knowledge between low and high delity simulation. They
did, however concede that much of the learning for both

N.M. Williams
groups may have occurred in the debrieng session that
followed the simulations. Hoadleys study is important to
refocus our attention to the learning of knowledge and skills,
however is limited in generalisability to nurses due to the
sample described simply as health care providers. Miotto
et al. compared ACLS scenario performance in groups using
live actors rather than manikins in an attempt to improve the
delity of the experience for learners. They found no difference between the groups.18 These results are not surprising
given that the majority of patients requiring ACLS interventions are unconscious and interaction with the patient
requires assessing a pulse or breathing pattern which are
difcult to manipulate in a live actor. Rodgers, Seccurio
and Pauley19 also compared high and low delity simulation in ACLS courses however in contrast to the Hoadley
and Miotto et al. studies found a signicant difference in
assessed skills performance favouring the high delity group.
The researchers acknowledged that the use of high delity
simulation allowed the use of advanced debrieng tools following scenario practice.19 The comparison of this evidence
leads this author to wonder if the debrieng was the effective intervention as opposed to the delity of the manikin.
High delity simulators are expensive and most often
require additional and expert instructors to facilitate programs with their inclusion.16,20 Iglesias-Vazquez et al.20
compared cost effectiveness of high delity simulators and
conventional ALS manikins. They found that although candidates performed slightly better in terms of passes for ALS
courses high delity simulators were not as cost effective
as compared to conventional manikins. Again participant
knowledge improved after ALS courses including simulation
however the delity of the simulation was not found to be
the important factor.
e-Learning modules have emerged as a way of achieving training in situations where face to face training may
not be available, and is considered to be supported by adult
learning principles in that learners can participate in their
own time at their own pace.21 Perkins et al.22 found no
superiority in either cognitive or psychomotor skills when
participants used a pre-course ALS e-learning module. Gerard, Scalzo, Laffey, Sinks, Fendya, and Seratti,23 evaluated
a web based Paediatric ALS course and found that there
was little difference in cognitive and psychomotor performance when compared to the traditional face to face course
however, as was conceded by the researchers the retention of the knowledge gained was not assessed. Jensen
et al.21 did not nd that the ongoing use of e-learning
programs maintained ALS skills or knowledge. They also
found that the lack of social interaction that occurs with
the use of e-learning may negatively inuence its use and
benet.21 Adults are known to learn better when they are
motivated so barriers to motivation should be avoided or
overcome.4 The actual usage of the e-learning programs in
all these studies was self-reported or unknown, and hence
may not have led to valid results. These studies can add
information to educators when choosing options for training
programs however should not be considered as the complete
answer.
In line with ILCORs team work recommendations some
studies have emerged looking at both inter-professional
learning and team-work in resuscitation. Inter-professional
resuscitation education for medical and nursing students

Advanced life support training and assessment

has been rated highly by participants as a valuable learning experience in a study by Dagnone, McGraw, Pulling,
and Patteson.24 The Dagnone et al. study was one of few
who considered participants views of training and as such
is important to remove the possible educator bias from
the other literature reviewed. The study is limited in
generalisability to practicing clinicians as the educational
intervention was performed with a multidisciplinary undergraduate group. The performance outcomes of the groups
are not mentioned as this was not their focus, however,
Bradley, Cooper and Duncan25 compared inter-professional
learning (IPL) and uni-professional learning (UPL) again with
undergraduates and found no difference in team leadership
or resuscitation task performance. Bradley et al. agreed
with Dagnone et al. in the participants perceived benet
of IPL. No studies were identied that considered interprofessional training in practicing clinicians. Further study
may demonstrate a benet from multi-professional training
in the continuing education area of practicing clinicians.
Whilst the ERC3 and the AHA5 recommend evaluation of
ALS programs to ensure that the ALS providers acquire and
retain skills and knowledge that improve patient outcomes
there is no clear evidence to suggest that current education
initiatives are achieving these aims. More research needs
to be focussed on links between the structure and content
of our ALS programs and patient outcomes following cardiac
arrest. This may help guide educators toward more effective
programs.

Knowledge and skill degradation

Whilst evidence is present that ACLS education results in
immediate improvement in assessed ALS knowledge and
skills, evidence is also available to indicate that knowledge and skills decline rapidly following ALS courses.
Improvements in knowledge and skills competence was
demonstrated by variances between pre course and post
course tests by Hoadley.17 Smith, Gilcreast, & Pierce15 compared nurses abilities to retain knowledge and psychomotor
skills immediately and then three, six, nine and twelve
months following training in ALS to a specied standard.
Their ndings reinforced previous knowledge that ACLS skills
decline rapidly however the rate of decline was found to be
greater than previously thought with only 31% passing assessment after 3 months. They found that following this skills are
expected to decline in a linear fashion over time despite
some inconsistencies in their results. Their recommendation for more frequent refresher training is well supported
by their results. Jensen et al.26 found that clinical experience had a slight benet on knowledge and skills retention
in a study involving rst year medical staff who had clinical
experience compared to the newly graduated, supporting
the view that practice improves knowledge retention. This
should indicate to critical care educators and advanced life
support instructors that more needs to be done to improve
retention of these valuable skills. Sandroni, Gonnella, de
Waure, Cavallaro, La Torre, and Antonelli27 investigated
what factors would predict ALS course outcome and identied pre-course knowledge and prior BLS certication as
major predictors. This supports this authors view that

243
education more so than certication should be the focus of
improving advanced life support competence.

Competency assessment and certication

Nursing competence involves the acquisition of relevant
knowledge, the development of technical and psychomotor skills, time management and the ability to apply the
knowledge and skills appropriately in a given context.16,28
Competency assessment requires measurement of knowledge, skills and attitudes using established standards.28 It
is therefore important that ALS assessment methods be
standardised, valid and reliable. In this way certication
means the same for all clinicians who hold it. The literature
on ACLS/ALS competence shows many courses use similar
methods of assessment. ALS courses use outcome based performance criteria to measure candidate performance and
guide the examiner in assessing competence.29
Most research in the literature on assessment utilised
some form of written knowledge test such as a multiple
choice question (MCQ) paper or short answers to assess
theoretical knowledge, and skill station assessments are
commonly used to assess skills such as airway management
and debrillation.22,30 The majority of assessments also
utilised scenario testing which is considered to be more realistic in terms of cardiac arrest scenarios (CAS).22,30 Rodgers,
Bhanji & McKee31 investigated the correlation between
performance in a written cognitive knowledge evaluation
and practical performance of psychomotor skills in ACLS.
Their results demonstrated that whilst the written assessment indicated a sufcient knowledge base this did not
consistently translate into adequate skills performance.31
Given that competent skills performance is the goal of ALS
programs then these results promote concern about the
structure of such educational programs.
Perkins, Davies, Stallard, Bullock, Stevens, & Lockey29
evaluated a common form of assessment tool the Cardiac
Arrest Scenario test (CAS test) and found that even with
a specic assessment tool differences in examiner application of the tool could lead to variability in pass/fail results.
In order to standardise assessment there should be minimal variance between assessors and strategies to achieve
this includes well designed checklists listing acceptable and
unacceptable responses to improve test reliability.29 Perkins
et al. also identied that the training centre attended
inuenced the outcome for participants suggesting that variability in education method may be a factor.
A number of studies in the United Kingdom (UK) and
Europe on ALS competence utilized standardised tests from
the European Resuscitation Council (ERC). The ERC guidelines provide a recognised standard26,29,30 and this may be
why a greater volume of research into ALS training has been
performed in Europe and the UK. A consistent approach
in Australia could not be found due to the lack of available studies however the Victorian study1 did demonstrate
similarities between assessment practices of intensive care
educators. The ARC provides ALS course regulations which
include standardised tests for ARC accredited courses32 however due to the lack of local literature it seems possible that
the standards may not be widely utilised in Australia.

244

Discussion
Anecdotal evidence is supported by some current authors
who suggest that frequent and ongoing ALS competency
assessments, rather than specic learning activities, are
being used to maintain and determine retention of ALS
knowledge and skills.1 There is however little evidence to
suggest that annual competency assessments are an effective means of ensuring this occurs. Anxiety is common prior
and during performance examinations28 and anxiety may
hinder learning. Additionally the time spent assessing individual participants is lengthy28 and when multiple assessors
are used to improve reliability33 in assessments valuable
learning time may be lost.
This author agrees with Preston, Currey and Eastwood1
who concluded that opportunities for learning and revising
information about resuscitation should be the primary focus
to prevent knowledge decay and enhance performance and
that courses that focus only on certication may actually
inhibit learning. Smith et al.15 recommended more frequent
refresher training which would allow more time for hands on
practice. Kidd & Kendall34 examined the use of experiential
learning and recommended that training be conducted in
small groups to facilitate effective learning. These recommendations are in congruence with adult learning principles
and ILCORs recommendations.
The joint ARC and ACCCN statement on resuscitation
standards recommend that staff should undergo regular
resuscitation education to a level appropriate for their
clinical responsibilities6 and it is noted that recommendations for education in this document focus on education
rather than assessment. The decline in ALS skills and knowledge are noted to occur within 312 months following
a course however the recommended timeframe between
ALS courses varies. The ARC courses themselves provide
certication as an ALS Provider for four years32 despite evidence that skills and knowledge decline at a much greater
rate. There emerges a discrepancy between what is recommended in the literature in terms of ALS training and what
occurs in practice both in evidence and anecdotally. The
Preston et al. Victorian study utilising telephone interviews
of Intensive Care Unit educators found that 95% reported
using annual assessments also recommended by ACCCN.14
Obtaining information from critical care nurses at the coal
face about ALS education and certication may have yielded
different results.

Conclusion and recommendations

Some evidence is available that advanced life support interventions can improve outcome for patients suffering in
hospital cardiac arrest. The literature examined in this
paper suggests that appropriate educational interventions
can improve ALS competence for critical care nurses. Whilst
many critical care units require evidence of annual ALS
assessment there is little evidence that this translates into
ongoing practical competence or condence. Recommendations from regulatory bodies and ALS training literature
reinforce that frequent, relevant and practical learning
activities may be more effective.

N.M. Williams
It is not possible to determine from this literature how
frequently critical care nurses attend training programs,
how frequently they utilise ALS skills, nor how condent critical care nurses feel in their use of ALS skills as time passes
from their accreditation programs. It is also not possible
to determine if the stated aims of resuscitation education
of acquiring and retaining adequate skills and knowledge in
resuscitation are actually being achieved. As such these gaps
emerge as recommendations for future study.

Provenance and Conict of Interest

No conicts of interest have been identied in this paper.
This paper was not commissioned.

Funding
The preparation of this paper was self-funded by the author.

Acknowledgements
None declared.

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