Application effect of Miller’s pyramid teaching method based on HeartCode BLS in basic life support training for nursing students

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Online and blended learning sustain instructional continuity and improve theoretical knowledge.

“Online and blended learning sustain instructional continuity and improve theoretical knowledge (10, 11)”

• cites [10] Lactona, 2021, Efficacy and knowledge of conducting CPR through online learning during the COVID-19 pandemic: literature review., J Public Health Res sourceSupported
• cites [11] Tobase, 2017, The effects of an online basic life support course on undergraduate nursing students’ learning., Int J Med Educ sourcePartly supported

  The Results (page unavailable) report significantly higher written-test scores after the online BLS course, supporting improved theoretical knowledge in undergraduate nursing students. The Conclusions say the course could be used for continuing education, but the paper does not establish that online or blended learning sustains instructional continuity, and it does not study blended learning. (LLM, conf=0.87)

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing).

The study adopted the Kirkpatrick Four-Level Evaluation Model as its overall assessment framework.

“This study adopts the classic Kirkpatrick Four-Level Evaluation Model (18, 19) as its overall assessment framework.”

• cites [18] Kim, 2024, Development and evaluation of nursing clinical practice education using m-learning., Healthcare sourceSupported
• cites [19] Shin, 2024, Effects of governmental support on clinical nurse educators in South Korea: a repeated cross-sectional study., Int Nurs Rev sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing).

Extended reality provides immersive environments supporting psychomotor skill acquisition.

“extended reality provides immersive environments supporting psychomotor skill acquisition (13, 14)”

• cites [13] Bodur, 2025, Evaluating the effectiveness of virtual reality simulation in CPR training for nursing students: a randomized controlled trial., Nurse Educ Pract sourceNot checked — no full text of the source
• cites [14] Fijačko, 2025, Extended reality technologies in adult basic life support education: a scoping review., Resusc Plus sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing).

Real-time feedback confers a distinct advantage for on-the-spot correction of technique compared with post-hoc video debriefing in BLS training.

“Ghaderi et al. compared real-time feedback with post-hoc video debriefing in BLS training and found that, although both modalities were effective, real-time feedback conferred a distinct advantage for on-the-spot correction of technique (29).”

• cites [29] Ghaderi, 2023, Comparison of real-time feedback and debriefing by video recording on basic life support skill in nursing students., BMC Med Educ sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing).

Smartphone-based serious games offer novel means for autonomous knowledge consolidation.

“smartphone-based serious games offer novel means for autonomous knowledge consolidation (15)”

• cites [15] Fijačko, 2024, Effects of a serious smartphone game on nursing students’ theoretical knowledge and practical skills in adult basic life support: randomized wait list-controlled trial., JMIR Serious Games sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The combined application of spacing and testing effects significantly improved 3-month retention of both basic and advanced life support skills, whereas learners receiving a single simulation session exhibited substantial skill decay.

“Soares et al. demonstrated that the combined application of spacing and testing effects significantly improved 3-month retention of both basic and advanced life support skills, whereas learners receiving a single simulation session exhibited substantial skill decay (5).”

• cites [5] Soares, 2025, The importance of combined use of spacing and testing effects for complex skills training: a quasi-experimental study., Med Teach sourcePartly supported

  The Results (page unavailable) report that the combined intervention maintained BLS skills after three months, while the single-session control group showed BLS skill decay. They do not support the same claim for ALS skills: performance did not differ significantly between groups or across the three time points, and neither group showed significant ALS skill decay. (LLM, conf=0.92)

  Experimental — accuracy not yet measured

May combine two claims.

Before training, the two groups did not differ significantly in educational background, gender, age, or baseline BLS-related theoretical and skill scores (all P > 0.05).

“Before training, the two groups of nursing students were compared across educational background, gender, age, and baseline BLS-related theoretical and skill scores. No statistically significant differences were identified in any of these variables (all P > 0.05), confirming that the two groups were well-matched at baseline and that subsequent between-group comparisons were methodologically sound (”

May combine two claims.

The enrolled students comprised 19 from technical secondary schools, 166 from junior colleges, and 44 undergraduates, and this distribution did not differ significantly between groups.

“The enrolled students represented the typical composition of clinical-intern nursing students, comprising 19 from technical secondary schools, 166 from junior colleges, and 44 undergraduates; these categories denote the students’ pre-service nursing qualification level, and their distribution did not differ significantly between the two groups (Table 2).”

May combine two claims.

At 3 months, the observation group significantly outperformed the control group in all three competency dimensions (emergency judgment and decision-making, emergency operation and execution, team communication and collaboration) and in the total composite score (all P < 0.001).

“The observation group significantly outperformed the control group in all three competency dimensions, emergency judgment and decision-making, emergency operation and execution, and team communication and collaboration, as well as in the total composite score (all P < 0.001).”

May combine two claims.

The observation group achieved significantly higher compliance rates across all four key CPR quality metrics-compression depth, compression rate, chest recoil, and bag-valve-mask ventilation-compared with the control group (all P < 0.001).

“Post-training assessment of CPR quality indicators revealed that the observation group achieved significantly higher compliance rates across all four key metrics—compression depth, compression rate, chest recoil, and bag-valve-mask ventilation—compared with the control group (all P < 0.001).”

• AssumptionRests on an assumption: The Anne QCPR real-time feedback system provides valid and accurate measurements of CPR quality indicators.

May combine two claims.

The effect sizes for the 3-month simulation scores ranged from 0.314 to 0.381, indicating moderate-to-large effects.

“The effect sizes (r) ranged from 0.314 to 0.381, indicating moderate-to-large effects and meaningful intergroup differences.”

May combine two claims.

Statistically significant group-by-time interaction effects were observed for theoretical knowledge, CPR performance, and defibrillation scores (all P < 0.001).

“In all three domains, statistically significant interaction effects were observed (all P < 0.001)”

May combine two claims.

The generalized eta-squared values for CPR (0.252) and defibrillation (0.292) indicated large effect sizes, exceeding the medium effect for theoretical knowledge (0.092).

“Notably, the generalized eta-squared (Ges) values for CPR (0.252) and defibrillation (0.292) indicated large effect sizes, substantially exceeding the medium effect observed for theoretical knowledge (0.092).”

May combine two claims.

The HeartCode BLS model confers demonstrable advantages in knowledge acquisition, psychomotor skill development, sustained integrative clinical competence, and a more positive learning experience.

“Collectively, these findings indicate that the HeartCode BLS model confers demonstrable advantages not only in knowledge acquisition and psychomotor skill development but also in fostering sustained integrative clinical competence and a more positive learning experience.”

May combine two claims.

The HeartCode model not only accelerates short-term skill acquisition but also improves mid-term skill retention.

“indicating that the HeartCode model not only accelerates short-term skill acquisition but also improves mid-term skill retention.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The skill gains observed in the present study closely parallel the mechanisms of real-time feedback.

“The skill gains observed in the present study closely parallel these mechanisms.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

All training was delivered by eight AHA-certified BLS instructors, two of whom were dedicated solely to outcome assessment and did not participate in teaching.

“All training was delivered by eight American Heart Association (AHA)-certified BLS instructors, two of whom were dedicated solely to outcome assessment and did not participate in teaching.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

BLS proficiency is a core clinical competency and a cornerstone of professional identity formation for nursing students.

“For nursing students, BLS proficiency is both a core clinical competency and a cornerstone of professional identity formation (2)”

• cites [2] Cruess, 2016, Amending miller’s pyramid to include professional identity formation., Acad Med sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

How Miller's pyramid can be operationalized within integrated instructional systems such as HeartCode BLS to systematically enhance nursing students' multilevel competence remains insufficiently examined.

“However, how this framework can be operationalized within integrated instructional systems such as HeartCode BLS, which combines online theoretical learning, simulation practice, and automated feedback, to systematically enhance nursing students’ multilevel competence remains insufficiently examined.”

Classified as probably not a substantial claim. May combine two claims.

All simulations were conducted on the same high-fidelity manikin; each simulation was limited to 10 min and followed by a 15-min structured debriefing; instructor prompts were fully scripted and identical facilitation language was used for all student teams.

“All simulations were conducted on the same high-fidelity manikin; each simulation was strictly limited to 10 min and was followed by a 15-min structured debriefing. Instructor prompts were fully scripted, and identical facilitation language was used for all student teams.”

Probably not a substantial claim: may not pass S4 (based). May combine two claims.

The HeartCode platform achieves a uniformly standardized training experience through digital delivery, ensuring that each learner receives equivalent knowledge exposition and skill demonstrations while its feedback mechanisms remain unaffected by inter-instructor variability, thereby securing comparability of training outcomes.

“The HeartCode platform, by contrast, achieves a uniformly standardized training experience through digital delivery, ensuring that each learner receives equivalent knowledge exposition and skill demonstrations while its feedback mechanisms remain unaffected by inter-instructor variability, thereby securing comparability of training outcomes.”

May combine two claims.

The model is practical and scalable for undergraduate nursing programs and for the orientation of newly recruited nurses.

“These observations suggest that the model is practical and scalable for undergraduate nursing programs and for the orientation of newly recruited nurses”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing). May combine two claims.

The model is particularly well-suited to large-scale deployment, for instance, as a substitute for conventional group-based instruction in nursing schools or in the orientation of newly hired nurses, where it can meaningfully alleviate faculty workload and enhance training efficiency.

“The model is particularly well-suited to large-scale deployment, for instance, as a substitute for conventional group-based instruction in nursing schools or in the orientation of newly hired nurses, where it can meaningfully alleviate faculty workload and enhance training efficiency.”

Classified as probably not a substantial claim. May combine two claims.

The same instructor team taught both groups, and instructors were not informed of the study's primary hypothesis regarding the superiority of the new model.

“The same instructor team taught both groups, so as to minimize instructor-related bias, and the instructors were not informed of the study’s primary hypothesis regarding the superiority of the new model.”

Classified as probably not a substantial claim. May combine two claims.

Random allocation sequence was generated by an independent research assistant using a computer random-number generator, and allocation concealment was ensured using sequentially numbered, opaque, sealed envelopes opened in strict enrolment order after baseline data collection.

“The random allocation sequence was generated by an independent research assistant using a computer random-number generator, and allocation concealment was ensured using sequentially numbered, opaque, sealed envelopes that were opened in strict enrolment order by an on-site assistant only after baseline data collection had been completed.”

May combine two claims.

Existing studies have largely assessed single methods in isolation, providing inadequate evidence on whether a theoretically grounded, integrated model can concurrently and durably improve theoretical performance, skill execution, and long-term clinical application.

“Existing studies have largely assessed single methods in isolation, providing inadequate evidence on whether a theoretically grounded, integrated model can concurrently and durably improve theoretical performance, skill execution, and long-term clinical application”

Classified as probably not a substantial claim.

The effectiveness of HeartCode requires corroboration in multicenter settings.

“the effectiveness of HeartCode requires corroboration in multicenter settings.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Ten Cate and colleagues have argued for the addition of a fifth, apex tier termed "Trusted," which represents educators' confidence in trainees to independently assume clinical responsibility.

“Ten Cate and colleagues have argued for the addition of a fifth, apex tier termed “Trusted,” which represents educators’ confidence in trainees to independently assume clinical responsibility (7).”

• cites [7] Cate, 2021, Entrustment decision making: extending miller’s pyramid., Acad Med sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

The study planned to enroll at least 110 nursing students per group to ensure statistical power.

“To ensure statistical power, the study planned to enroll at least 110 nursing students per group.”

Classified as probably not a substantial claim.

Before the study, all instructors completed a standardized 4-h calibration session covering the study protocol, Miller's pyramid framework, HeartCode BLS platform operation, and structured debriefing.

“Before the study, all instructors completed a standardized 4-h calibration session covering the study protocol, the Miller’s pyramid framework, operation of the HeartCode BLS platform, and structured debriefing, in order to ensure instructional consistency.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The observation group's reliance on the HeartCode platform implies that technical disruptions, such as network outages or device-calibration issues, could potentially interfere with the training process; no such incidents were reported in the present study.

“Moreover, the observation group’s reliance on the HeartCode platform implies that technical disruptions, such as network outages or device-calibration issues, could potentially interfere with the training process; although no such incidents were reported in the present study”

May combine two claims.

The study employed a single-center design, and the sample was drawn exclusively from one nursing institution, which may constrain the external generalizability of the findings.

“First, the study employed a single-center design, and the sample was drawn exclusively from one nursing institution, which may constrain the external generalizability of the findings.”

Classified as probably not a substantial claim. May combine two claims.

The sustained advantage observed in the present study may derive from two complementary mechanisms: repeated engagement with key skill modules fostering more durable motor memory, and holistic training integrating knowledge, skills, and clinical decision-making promoting deeper understanding and more reliable memory retrieval.

“The sustained advantage observed in the present study may derive from two complementary mechanisms: first, the HeartCode platform enables repeated engagement with key skill modules throughout the training period, thereby fostering more durable motor memory; second, the model deliberately integrates knowledge, skills, and clinical decision-making within unified scenarios, and such holistic training”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The study was not blinded, such that assessors' awareness of group allocation may have introduced measurement bias; concurrently, students exposed to a novel instructional format may have manifested a Hawthorne effect, with heightened engagement and performance.

“Additionally, the study was not blinded, such that assessors’ awareness of group allocation may have introduced measurement bias; concurrently, students exposed to a novel instructional format may have manifested a Hawthorne effect, with heightened engagement and performance.”

Probably not a substantial claim: may not pass S2 (checkable).

This model may represent a practical and scalable strategy for modernizing undergraduate nursing emergency training.

“This model may represent a practical and scalable strategy for modernizing undergraduate nursing emergency training.”

May combine two claims.

Baseline characteristics and pre-training BLS-related theoretical and skill scores did not differ significantly between groups (P > 0.05).

“Comparisons of baseline characteristics between the two nursing student groups, including educational background, gender, age, and pre-training BLS-related theoretical and skill scores, revealed no statistically significant differences (P > 0.05), confirming comparability.”

May combine two claims.

The structured, technology-enhanced instructional model exerted a particularly pronounced influence on psychomotor skill development, where greater room for improvement existed compared to cognitive knowledge acquisition.

“This pattern suggests that the structured, technology-enhanced instructional model exerted a particularly pronounced influence on psychomotor skill development, where greater room for improvement existed compared to cognitive knowledge acquisition (Table 4).”

May combine two claims.

The Miller's-pyramid-based HeartCode BLS model exhibits clear advantages in standardization, reproducibility, and cost-effectiveness.

“From the perspectives of clinical relevance and implementation, the Miller’s-pyramid-based HeartCode BLS model exhibits clear advantages in standardization, reproducibility, and cost-effectiveness.”

• AssumptionRests on an assumption: Traditional BLS instruction depends heavily on instructor expertise and on-site equipment, rendering educational quality and outcomes vulnerable to variability in faculty proficiency and facility resources.

May combine two claims.

All skill evaluations were conducted in a simulated environment, and learners' actual performance in authentic clinical settings was not assessed.

“Third, all skill evaluations were conducted in a simulated environment, and learners’ actual performance in authentic clinical settings was not assessed.”

Probably not a substantial claim: may not pass S3 (load-bearing).

High-fidelity simulation enhances student confidence in performing BLS.

“high-fidelity simulation enhances student confidence in performing BLS (12)”

• cites [12] Rushton, 2024, Basic life support training: Is student confidence enhanced by advanced levels of simulation?, Br J Nurs sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

For the 3-month high-fidelity simulation, the team was the unit of analysis (23 teams per group).

“For the 3-month high-fidelity simulation, which assessed integrated team performance, the team was the unit of analysis (23 teams per group).”

May combine two claims.

The Miller's Pyramid-based model not only enhanced individual skill proficiency but also effectively cultivated higher-order clinical competencies such as situational decision-making, adaptive resource allocation, and collaborative leadership within team-based emergency scenarios.

“These findings indicate that the Miller’s Pyramid-based model not only enhanced individual skill proficiency but also effectively cultivated higher-order clinical competencies such as situational decision-making, adaptive resource allocation, and collaborative leadership within team-based emergency scenarios (Figures 4A–D and Table 8).”

May combine two claims.

A Miller's Pyramid-based HeartCode BLS teaching model was associated with significantly improved immediate learning outcomes, CPR quality, learner satisfaction, and mid-term integrated clinical performance among nursing students.

“A Miller’s Pyramid-based HeartCode BLS teaching model was associated with significantly improved immediate learning outcomes, CPR quality, learner satisfaction, and mid-term integrated clinical performance among nursing students.”

• AssumptionRests on an assumption: The total instructional time difference of up to 90 min between groups does not materially confound the between-group comparison.
• AssumptionRests on an assumption: The Anne QCPR real-time feedback system provides valid and accurate measurements of CPR quality indicators.

Probably not a substantial claim: may not pass S3 (load-bearing).

Entrustment-based decision-making has been advanced as the operational core of does, reflecting supervisors' judgment of the independence with which a learner can perform a given task.

“entrustment-based decision-making has been advanced as the operational core of does, reflecting supervisors’ judgment of the independence with which a learner can perform a given task (7)”

• cites [7] Cate, 2021, Entrustment decision making: extending miller’s pyramid., Acad Med sourceNot checked — no full text of the source

May combine two claims.

The observation group's lower compression interruption times reflect superior compression continuity and overall procedural fluency under the new teaching model.

“reflecting superior compression continuity and overall procedural fluency under the new teaching model”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

Although the HeartCode model does not explicitly prescribe a spaced schedule, its modular architecture and repeatable access effectively permit learners to calibrate review cadence to their own mastery, thereby promoting memory consolidation.

“Although the HeartCode model does not explicitly prescribe a spaced schedule, its modular architecture and repeatable access effectively permit learners to calibrate review cadence to their own mastery, thereby promoting memory consolidation.”

May combine two claims.

The actual dropout rate was 3%, below the projected value, indicating sufficient statistical power.

“The actual dropout rate was 3% (below the projected value), indicating sufficient statistical power for this study.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The total instructional time differed by no more than 90 min between groups (observation 810 min; control 720 min).

“The total instructional time differed by no more than 90 min between groups (observation group, 810 min; control group, 720 min).”

May combine two claims.

The HeartCode BLS platform scaffolds self-paced acquisition of core BLS knowledge through interactive digital modules and scenario-based application exercises, thereby strengthening the "Knows" and "Knows How" tiers.

“The HeartCode BLS platform scaffolds self-paced acquisition of core BLS knowledge through interactive digital modules, reinforced by scenario-based application exercises, thereby effectively strengthening the “Knows” and “Knows How” tiers.”

Probably not a substantial claim: may not pass S2 (checkable).

The effect of such a model on learner satisfaction warrants further investigation.

“its effect on learner satisfaction likewise warrants further investigation.”

Classified as probably not a substantial claim.

Miller's pyramid stratifies clinical competence into four ascending levels: knows, knows how, shows how, and does.

“Miller’s pyramid, widely adopted in medical education, stratifies clinical competence into four ascending levels: knows, knows how, shows how, and does (7)”

• cites [7] Cate, 2021, Entrustment decision making: extending miller’s pyramid., Acad Med sourceNot checked — no full text of the source

May combine two claims.

The knowledge gains reported in the current study are consistent with, and appear more pronounced than, those of earlier work, a discrepancy plausibly attributable to the embedded immediate-assessment and targeted-feedback mechanisms within the HeartCode platform.

“The knowledge gains reported in the current study are consistent with, and appear more pronounced than, those of earlier work, a discrepancy plausibly attributable to the embedded immediate-assessment and targeted-feedback mechanisms within the HeartCode platform”

Probably not a substantial claim: may not pass S3 (load-bearing).

The satisfaction questionnaire demonstrated good internal consistency, with a Cronbach's alpha coefficient of 0.838.

“In the present study, the questionnaire demonstrated good internal consistency, with a Cronbach’s alpha coefficient of 0.838.”

Classified as probably not a substantial claim.

The HeartCode BLS model aligns closely with Miller's pyramid framework, spanning the hierarchical continuum from "Knows" to "Does," and ultimately to the "Trusted" level.

“By coherently integrating digitally delivered self-paced learning with high-fidelity simulation feedback, the model aligns closely with Miller’s pyramid framework, spanning the hierarchical continuum from “Knows” to “Does,” and ultimately to the “Trusted” level”

Probably not a substantial claim: may not pass S3 (load-bearing).

Internalization of professional values into professional identity (is) has been proposed as a higher aspiration than does alone.

“internalization of professional values into professional identity (is) has been proposed as a higher aspiration than does alone (2)”

• cites [2] Cruess, 2016, Amending miller’s pyramid to include professional identity formation., Acad Med sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

The trial was registered on the National Medical Research Registration and Filing Information System (registration number MR3325078976; 17 November 2025).

“This trial was registered on the National Medical Research Registration and Filing Information System (registration number MR3325078976; 17 November 2025).”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

HeartCode's modular architecture provides educational administrators with flexibility to configure hybrid (online-offline) content, and supports extension in line with contemporary interprofessional education trends.

“HeartCode’s modular architecture provides educational administrators with flexibility to configure hybrid (online-offline) content, and supports extension in line with contemporary interprofessional education trends.”