Clinical simulation for nursing competence development in cardiopulmonary resuscitation: systematic review

Objective: to identify the effectiveness of clinical simulation for competence development regarding cardiopulmonary resuscitation in comparison with different teaching and learning strategies used in the education of nursing students. Method: systematic review, performed on the databases PubMed®/MEDLINE®, LILACS, Scopus, CINAHL and Web of Science. The Rayyan QCRI application was used to select the studies, in addition to the instruments for assessing the methodological quality of Joanna Briggs Institute and the Medical Education Research Study Quality Instrument. Results: a total of 887 studies were identified, and five we included in the final sample. The included studies had good methodological quality by the assessment instruments. All of them had statistically significant results to develop competence through clinical simulation, when compared to other methods. Conclusion: clinical simulation proved to be effective for the development of clinical competence in cardiopulmonary resuscitation of nursing students.


Introduction
Adopting new teaching and learning strategies in nursing is very important for excellence in the development of students' knowledge, skills and attitudes (1)(2) . Thus, clinical simulation, configured as a pedagogical mechanism for teaching and learning in health, which imitates real clinical care, has gained space in nursing education, characterized as an experiential, interactive, collaborative and learnercentered strategy (3) .
Specifically regarding teaching and learning of cardiopulmonary resuscitation (CPR) for nursing, strategies frequently adopted by educators are still guided by traditional approaches, such as lectures supported by PowerPoint ® presentations and laboratory skills training guided by an instructor (4)(5) .
This classic pattern of CPR training has shown ineffective results for care quality, such as a decrease in the cognitive and psychomotor skills of individuals 1 month after the completion of the courses (6)(7) . However, it is not yet clear whether new teaching and learning strategies, such as clinical simulation, are more effective in developing the competence of nursing students to attend CPR (4,8) .
The evaluation of the development of clinical competence, defined as the application of skills in all domains of practice, articulating knowledge, skills and attitudes in different clinical contexts (7,9) , is considered a complex and difficult to handle topic. Its use in the teaching of CPR to nursing students was verified in studies whose outcomes were varied and not always conclusive regarding its effectiveness (10)(11)(12) .
This study aimed to identify the effectiveness of clinical simulation for competence development regarding CPR in comparison with different teaching and learning strategies used in the education of nursing students.

Method
This is a systematic literature review, prepared in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) strategy (13) , from July to October 2019.
To comply with this systematic review, seven steps (7) elaboration of a critical summary, synthesizing the information made available by the articles included in the review, and presentation of conclusion, informing the evidence on the effects of the intervention (14) .
The research question was defined through the Patient -Intervention -Comparison-Outcomes (PICO) strategy (15) with the following elements: the acronym P referred to undergraduate nursing students; I, clinical simulation; C, different teaching and learning strategies; and O, the development of clinical competence for CPR.
Thus, the following guiding question was structured: What is the effectiveness of clinical simulation in comparison with different teaching and learning strategies for competence development regarding CPR in nursing students?
The following databases were defined as data According to the database, specific descriptors and search strategies were used. In PubMed ® and Scopus, the descriptors found in Medical Subjects Headings (MESH) "Students, Nursing", "Simulation Training", "Teaching", "Clinical Competence" and "Cardiopulmonary Resuscitation" were used, and the search strategies were P versus I − ("Students, Nursing" OR "Pupil Nurses" OR "Student, Nursing" OR "Nurses, Pupil" OR "Nurse, Pupil" OR "Pupil Nurse" OR "Nursing Student" OR "Nursing Students") AND ("Training, Simulation" OR "Interactive Learning" OR "Learning, Interactive") -and I versus C versus O − ("Training, Simulation" OR "Interactive Learning" OR "Learning, Interactive") AND (Teaching OR "Training Techniques" OR "Technique, Training" OR "Techniques, Training" OR "Training Technique" OR "Training Technics" OR "Technic, Training" OR "Technics, Training" OR "Training Technic" OR "Pedagogy" OR "Pedagogies" OR "Teaching Methods" OR "Method, Teaching" OR "Methods, Teaching" OR "Teaching Method" OR "Academic Training" OR "Training, Academic" OR "Training Activities" OR "Activities, Training" OR "Training Activity" OR "Techniques, Educational" OR "Technics, Educational" OR "Educational Technics" OR "Educational Technic" OR Resuscitation" OR "Cardio Pulmonary Resuscitation" OR "Resuscitation, Cardio-Pulmonary" OR "Code Blue" OR "Mouth-to-Mouth Resuscitation" OR "Mouth to Mouth Resuscitation" OR "Mouth-to-Mouth Resuscitations" OR "Resuscitation, Mouth-to-Mouth" OR "Resuscitations, Mouth-to-Mouth" OR "Basic Cardiac Life Support" OR "Life Support, Basic Cardiac").
Rayyan QCRI helps authors of systematic reviews to carry out their work quickly, easily and pleasantly, allowing the export of studies from a certain database for the program and the exposure of titles and abstracts, with the blindness of the auxiliary researcher, which guarantees reliability in the selection of information, accuracy and methodological precision (16) .
The 12 studies that showed divergence were sent to a third researcher, specialized in the theme, responsible for making the decision to include or exclude, and then a critical analysis of the articles was carried out. After we observed the incipience of selected studies, the references of the included articles were analyzed, without resulting in new additions to the final sample.
In data collection, the criteria from a validated instrument (17) were used, addressing title, authors, year of publication, origin of the study, language, journal, objectives, methodological design, results and conclusion. The Evidence Level (18) was also classified and the selection and inclusion of studies was demonstrated following the recommendations of the Preferred Reporting Items for Systematic Review and Meta-Analyzes-PRISMA (13) .
The methodological evaluation of the selected studies was carried out according to the critical evaluation instruments from Joanna Briggs Institute (19) and Medical Education Research Study Quality Instrument (MERSQI) (20) . We opted to use both to obtain a broad scenario of evaluation of the articles methodological quality, since Rev. Latino-Am. Enfermagem 2020;28:e3391. the adopted instruments have different perspectives and evaluation criteria.
The instrument referring to Joanna Briggs Institute has a total of nine items of methodological evaluation aimed at quasi-experimental studies and 13 for experimental ones and considers whether they are present, absent, and whether there is clarity or not (19) .
MERSQI consists of a total of six domains, composed of criteria that assess the methodological quality of the  (20) . Studies with scores ≤10 are considered low quality ones; from >10 to <15, moderate quality; and ≥15, high quality (21) .

Results
The selection and inclusion of the studies in this research is shown in Figure 1, following the recommendations of the Preferred Reporting Items for Systematic Review and Meta-Analyzes-PRISMA (13). Figure 2 shows the critical evaluation of the methodological quality of quasi-experimental studies, according to the evaluation instrument from Joanna Briggs Institute (19) . Figure 3 shows the critical evaluation of the methodological quality of experimental studies, according to Joanna Briggs Institute evaluation instrument (19) .
The quasi-experimental studies included in this review met most of the quality assessment requirements indicated by the instrument of Joanna Briggs Institute, being considered of good quality. Only the criterion that addresses the use of multiple measurements of results in pre-and post-intervention/exposure over time has not been met in two studies (23)(24) .
As for experimental studies, despite the fact that most criteria indicated for quality assessment have been met, there was a significant methodological weakness regarding the blinding of the researcher, participants, those responsible for providing treatment and results evaluators regarding the allocation of treatment.
MERSQI was also used to assess the methodological quality of the studies included in the sample, shown in     Rev. Latino-Am. Enfermagem 2020;28:e3391. of the assessment instruments highlighted by these manuscripts.
The articles included in the review are summarized in Figure 5. All of them were international publications. The authors identified that clinical simulation was an effective teaching and learning strategy to develop clinical competence in nursing students for cardiopulmonary resuscitation, when compared to other teaching mechanisms.

Discussion
A total of three quasi-experimental studies (22)(23)(24) and two experimental (25)(26) were included in the sample of this review. Although all authors have pointed to clinical simulation as an effective strategy to develop clinical competence for cardiopulmonary resuscitation in nursing students, the scarcity of identified studies demonstrates the need for further scientific exploration in this area (9) .
A randomized experimental study carried out with a total of 31 Chinese nurses, that compared the effectiveness of simulation to develop nursing competence with traditional teaching strategies corroborates this statements, highlighting statistically significant results for the increase of cognitive and psychomotor skills (p=0.001), a reduction in stress levels (p=0.011) and increased confidence (p=0.026) (27) .
MERSQI, another instrument used in this study, is described as reliable because it provides accuracy in identifying the methodological quality of the articles (37) .
This assessment instrument identified a moderate level pedagogical interventions in nursing be carried out in a single center (38) .
On the other hand, the validation of instruments is a criterion of fundamental methodological quality, as it confers the reliability of the intended findings. The lack of clarification on this issue, in the studies that comprised the sample of this review, may compromise the reliability of the statistical conclusions of researches and justify its moderate methodological quality (39) .
This study had two main limitations: the incipience