Regional School-Based CPR Training With a Low-Cost Manikin: A Community Nursing Approach
Cardiopulmonary resuscitation, commonly known as CPR, is one of the most important emergency skills the public can learn. When a person has a sudden cardiac arrest, every minute without action reduces the chance of survival. Immediate bystander CPR can help keep blood and oxygen flowing to the brain and vital organs until emergency services arrive. Because of this, many public health programs now focus on teaching CPR in schools, where children can learn early and share what they learn with their families.
This study examined whether a regional, nurse-led school CPR program could be carried out effectively using low-cost, hand-made manikins and whether students would “multiply” the training at home by teaching family members or close contacts. The work was conducted in Murcia, Spain, between June and August 2025, in public and publicly funded private schools.
Why School CPR Training Matters
School-based CPR education has several advantages. First, it reaches large numbers of children in a structured setting. Second, children often remember practical skills well, especially when training includes hands-on practice. Third, students can act as “health messengers” in their households, spreading lifesaving knowledge beyond the classroom. This home-based multiplier effect is especially valuable in communities where many adults may never have received formal CPR training.
The program in this study was led by community school nurses, one nurse for each health area, supported by standardized preparation. Nurses delivered a basic life support session lasting about 60 minutes to intact classes of students aged 10 to 12 years. The training covered key actions in basic life support, including recognizing cardiac arrest, activating emergency help, performing chest compressions, and requesting or using an automated external defibrillator, often called an AED.
How the Program Was Delivered
A central feature of the program was the use of a low-cost, hand-made manikin. This approach is practical for schools and public health services because it reduces equipment costs while still allowing students to practice the physical steps of CPR. After the classroom session, students were invited to build a similar low-cost manikin at home and teach CPR to a family member or close contact.
To document this home teaching activity, students submitted WhatsApp videos. This method made the project easier to scale because it used a familiar, widely accessible communication platform. It also allowed investigators to review actual performance rather than relying only on self-report. Two independent CPR experts, who were not involved in the training itself, scored eligible videos using an 11-item checklist. Each item contributed to a total score ranging from 0 to 11. Any disagreements between the reviewers were resolved by consensus.
Study Design and Outcomes
This was a prospective observational study, meaning the researchers followed participants forward in time and observed what happened after the school training was delivered. The primary outcomes were the reach of the school program and the multiplying effect at home. School reach reflected how many students participated in the training, while the multiplying effect was measured as the number of home trainees per participating student. Secondary outcomes included the CPR performance scores derived from the video reviews.
This design is useful for public health implementation research because it helps answer a practical question: can a low-cost training program be carried out at scale, and does it lead to meaningful real-world learning outside the classroom?
Key Findings
In total, the nurses trained 1,047 students. That is a substantial number for a regional school-based initiative and shows that the program was feasible across multiple health areas. The home activity was completed by 472 of the 1,047 students, which equals 45.1% of participants. In other words, nearly half of the students continued the learning activity at home.
Those 472 students trained 1,136 family members or close contacts. This produced a multiplying effect of 2.41 home trainees per participating student. For public health, this is an important result because it demonstrates that one school lesson can extend into the community and generate additional educational reach without major extra cost.
Of the 1,136 videos submitted, 489 were analyzable, corresponding to 43.0% of submissions. The analyzable videos showed that trainees achieved a mean total performance score of 7.8 out of 11. This suggests generally adequate performance of the basic life support steps assessed, although there was room for improvement.
Performance was stronger for recognizing arrest and activating help, as well as for chest compressions, than for AED-related actions such as requesting the device or using it in a simulated way. This pattern is not surprising. In many CPR training programs, chest compressions are easier for learners to grasp and practice, while AED use may feel more complex or less familiar. It also reflects an important training need: emphasizing AED awareness and confidence, since early defibrillation is a critical part of the chain of survival in certain cardiac arrests.
What the Results Mean
The findings suggest that a community-nurse-delivered CPR program in schools can be both feasible and impactful. Feasible here means it can be organized, taught, and completed across a regional school network using practical resources. Impactful means it does more than teach the students in the classroom; it reaches families at home and supports wider community preparedness.
The low-cost manikin model is especially relevant for schools and health systems with limited budgets. Many CPR training programs depend on commercially produced manikins, which can be expensive and difficult to provide at scale. A handmade model, if properly designed, can make it easier to deliver repeated instruction to large groups.
The study also highlights the important role of nurses in school health promotion. Community school nurses are trusted professionals who can teach lifesaving skills in a way that is age-appropriate, engaging, and practical. Their involvement may improve program acceptance and help integrate CPR education into routine school health activities.
Strengths and Limitations
This study has several strengths. It was conducted in real schools, involved a large number of students, and assessed not only classroom participation but also home-based spillover effects. It also used independent expert review of video submissions, which is more objective than asking families whether they practiced CPR.
However, there are limitations. Not all students completed the at-home activity, and not all submitted videos were analyzable. This could reflect differences in motivation, family availability, recording quality, or other practical barriers. In addition, video-based assessment captures performance during a simulated exercise, which may not fully reflect how someone would act in a real emergency. The study also did not measure long-term retention of CPR skills, actual emergency response behavior, or patient outcomes such as survival after cardiac arrest.
Another important consideration is that while AED actions scored lower, the exact reasons for this are not fully clear from the abstract. Possible explanations include limited prior exposure to AEDs, uncertainty about how to use them, or the fact that AEDs are less commonly available in daily life than the concept of chest compressions. Future training may need more hands-on practice and repeated reinforcement of AED steps.
Public Health Implications
Despite these limitations, the study offers an encouraging model for public health practice. School CPR education can serve as a community intervention, not just a classroom lesson. When students teach others at home, they help expand awareness of cardiac arrest response to parents, grandparents, siblings, and other close contacts. This may be particularly important in households where adults have never received formal first aid or CPR instruction.
Programs like this could be adapted to other regions, especially where resources are limited and school nurses are available to support health education. The combination of standardized nurse-led teaching, low-cost practice tools, and digital submission through a widely used messaging platform is practical and scalable.
More broadly, the study supports the idea that public health interventions can be designed to create “secondary learners” at home. That multiplier effect may be one of the most efficient ways to improve community readiness for sudden cardiac arrest.
Conclusion
A regional school-based CPR program led by community nurses and delivered with a low-cost manikin was feasible in Murcia, Spain, and reached more than 1,000 students. Nearly half of the students completed the home activity, training more than 1,100 family members or close contacts. Performance on video review was generally adequate for key basic life support steps, but AED-related actions were weaker. Overall, the study shows that school CPR education can generate a meaningful home-training multiplier and strengthen community preparedness for cardiac emergencies.
For schools, health authorities, and public health planners, this is a promising model: simple, low-cost, scalable, and capable of extending lifesaving knowledge far beyond the classroom.
