Hospital nurses’ CPR knowledge falls short, global systematic review finds

When a patient’s heart stops in a hospital ward, the first person to notice is often a nurse. That nurse must recognize the arrest, activate the emergency response system, and begin cardiopulmonary resuscitation within seconds, because every minute without effective chest compressions sharply reduces the odds of survival with intact brain function. A new systematic review published in BMC Nursing by Aintzane Beti-Abad of Biobizkaia Health Research Institute and colleagues now offers the most comprehensive international picture to date of how well hospital nurses actually know the adult CPR guidelines they are expected to follow, and the overall verdict is sobering: knowledge across 25 studies and 4,653 nurses in 17 countries was frequently reported as poor, insufficient, moderate, or average.

The review, registered in PROSPERO under CRD420261351580 and reported according to the PRISMA 2020 statement, set out to synthesize evidence on hospital nurses’ objectively assessed knowledge of adult CPR in the context of in-hospital cardiac arrest. The team searched eight major bibliographic databases, including PubMed, Embase, Scopus, Web of Science, CINAHL, LILACS Plus, PsycINFO and the Cochrane Central Register of Controlled Trials, on March 15, 2026, capturing studies published from January 1, 2010 onward with no language restrictions. Two reviewers independently carried out study selection, data extraction, and methodological quality assessment, a double-checking architecture that reduces the risk of subjective bias creeping into any single stage of the synthesis.

Methodologically, the review focused on observational studies, and every one of the 25 included investigations used a cross-sectional design, meaning each study measured nurses’ knowledge at a single point in time rather than tracking how it evolved. The researchers appraised methodological quality with the Joanna Briggs Institute Critical Appraisal Checklist for studies reporting prevalence data, a standardized instrument that probes issues such as the appropriateness of the sampling frame, the validity of the statistical methods, and the adequacy of response rates. Supplementary material published alongside the article details the complete search strategies, the characteristics of all included studies, the JBI appraisal results, and the full PRISMA checklist, giving other researchers the raw material needed to reproduce or extend the synthesis.

One of the review’s most striking findings concerns the sheer heterogeneity of the assessment instruments themselves. Knowledge tests ranged from as few as 7 items to as many as 32, and they covered different domains: some probed general CPR, others basic life support, others advanced life support, and still others combined several of these areas. Reporting of instrument validity and reliability, the psychometric properties that determine whether a test actually measures what it claims to measure consistently across occasions, was inconsistent across the evidence base. In practical terms, this means two studies reporting apparently similar knowledge scores may have been measuring quite different constructs with quite different degrees of precision.

The problem extends to how adequate knowledge was defined. Competency thresholds, the percentage of correct responses a nurse needed to be classified as knowledgeable, ranged from approximately 50 percent to more than 85 percent, while several studies used relative or study-specific classifications rather than fixed cutoffs. A nurse judged competent in one country under a 50 percent criterion would fail outright in another applying an 85 percent bar. This variability precluded quantitative pooling, the statistical synthesis of results across studies that meta-analysis makes possible, and forced the authors to synthesize their findings narratively, which in turn limited direct comparison across the evidence base.

Despite these measurement caveats, the qualitative pattern that emerges is consistent. Hospital nurses’ knowledge of adult CPR was frequently incomplete or intermediate across the international evidence. The review cannot tell us precisely what proportion of nurses worldwide would pass a standardized exam, because no standardized exam exists across these studies, but it does show that wherever researchers looked, with whatever instrument they chose, substantial knowledge gaps appeared. The authors point to the physiological logic behind why this matters: in-hospital cardiac arrest outcomes depend on timely, guideline-based care, and guidelines from bodies such as the American Heart Association and the European Resuscitation Council are periodically updated, most notably in the sequence of interventions, which shifted from the airway-breathing-compressions model to the chest-compressions-first approach as evidence accumulated on the primacy of circulation.

Guideline evolution creates a specific vulnerability for knowledge decay. A nurse trained thoroughly under one version of the guidelines may retain accurate knowledge of an outdated sequence while lacking awareness of current recommendations. Knowledge also erodes with time since last training, a phenomenon well documented in resuscitation research, and skills fade faster than facts. The review’s findings therefore support the authors’ call for regular training and periodic assessment rather than one-time certification, a model in which knowledge is treated as a perishable clinical asset that must be refreshed and verified, not assumed to persist indefinitely after an initial course.

The review’s most actionable recommendation is the development of standardized, validated, role-sensitive instruments to identify knowledge gaps and guide targeted education. Role-sensitive here means tests calibrated to what nurses in specific hospital settings actually need to know, since a ward nurse who must recognize an arrest and start basic life support faces different knowledge demands than a critical care nurse expected to participate in advanced life support. Validated instruments with documented psychometric properties would also allow hospitals to benchmark performance over time and across departments, converting the current fog of incomparable study-specific scores into actionable quality data.

For hospital administrators and resuscitation committees, the review functions as a warning about the limits of self-assurance. Institutions often assume that nurses who completed a CPR course in the recent past possess current knowledge, yet the international evidence synthesized here suggests that assumption is frequently wrong. The findings argue for embedding periodic objective knowledge assessment into routine professional development, pairing written assessment with the practical skills drills that resuscitation training already includes, and treating knowledge gaps identified by validated tests as triggers for targeted education rather than as failures of individual nurses.

The review also exposes a research infrastructure problem that the scientific community will need to solve before the next generation of studies can be pooled. Until researchers converge on validated instruments and defensible competency thresholds, each new cross-sectional survey will add an incomparable data point to an already fragmented evidence base. The authors of this synthesis have done the field a service by documenting that fragmentation in detail, and their conclusion, that hospital nurses’ CPR knowledge is frequently incomplete or intermediate, should be read simultaneously as a clinical concern and as a methodological challenge: the knowledge gaps are real, but so is the measurement problem, and fixing the latter is a prerequisite for precisely quantifying and closing the former.

Subject of Research: Hospital nurses’ knowledge of adult cardiopulmonary resuscitation: a systematic review

Article Title: Hospital nurses’ knowledge of adult cardiopulmonary resuscitation: a systematic review

Article References: Beti-Abad, A., Hernando-Gorgojo, L., De-Ríos-Briz, N., Blanco-Blanco, J., Holland, B., & Tíscar-González, V. (2026). Hospital nurses’ knowledge of adult cardiopulmonary resuscitation: a systematic review. BMC Nursing. https://doi.org/10.1186/s12912-026-05483-1

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05483-1

Keywords: Hospital, nurses, knowledge, adult, cardiopulmonary, resuscitation, systematic, review, scientific research