It is well-established that increasing the willingness of laypeople to perform cardiopulmonary resuscitation (CPR) in Germany could improve survival rates among the approximately 55,000 patients who experience out-of-hospital cardiac arrest (OHCA) annually (Behrens et al., 2020; Christ et al., 2014; Schroeder et al., 2017; Zeymer et al., 2023). Currently, the 30-day survival rate in Germany, Europe’s largest economy, is only 10.4%. In contrast, Norway reported a survival rate of 14% in 2021, with 85% of OHCA patients receiving layperson CPR (Bjørshol et al., 2023), compared to 51% in Germany (Fischer, 2024). This 3.6% difference in survival rates corresponds to approximately 2,000 preventable deaths in Germany annually if layperson CPR rates were raised to the Norwegian level.
It is well-documented that CPR education in schools increases the proportion of the population equipped with resuscitation skills (Bohn et al., 2015). Alongside other factors, school-based CPR education serves as a vital strategy in combating sudden cardiac death, encouraging children to assist others, and fostering enjoyment in learning, with long-term societal benefits (Böttiger, 2015). Since 2014, this issue has been addressed through a recommendation from the Standing Conference of Ministers of Education and Cultural Affairs in Germany (Gröbel, 2014). However, German states have largely failed to implement CPR education on a widespread basis by 2022, limiting efforts to pilot studies and regional projects (Rücker et al., 2022).
As of 2023, only the federal states of Mecklenburg-Western Pomerania and Baden-Württemberg had achieved comprehensive implementation of school-based CPR education (two out of the 16 federal states). In Brandenburg, a pilot project aimed at implementing CPR education, starting at Grade 7, was launched. Of the initial 33 schools, only five fulfilled their commitment to participate in the project (Kehlert et al., 2024). While the project demonstrated that the education was worthwhile and students achieved the desired learning outcomes, the high dropout rate was a setback. The reasons remain unclear.
Although numerous studies explore CPR instruction in different age groups, by different instructors (Abelairas-Gómez et al., 2014; Bohn et al., 2012; Humbsch et al., 2023) the appropriate duration, and the structure of the lessons (Schroeder et al., 2017), only a few authors currently address the sustainable and long-term implementation of such training, as well as the necessary resources and obstacles that need to be overcome. Following the pilot project in Brandenburg, school staff were interviewed about the reasons for the high cancellation rate and potential issues in the process. In addition, the Ministries of Education and the Arts of all 16 federal states were consulted on the current status of implementation. The aim was to identify the underlying problems in the implementation of CPR training in the 16 federal states of Germany from the connections found and to derive potential solutions from these findings.
Methods
Study Setting and Design
This study is based on interviews with school staff and an inquiry conducted amongst the Ministries of Education from Germany’s 16 federal states as part of the “Herzensretter” study (English: Heart Saver) (Kehlert et al., 2024). The primary objective was to identify barriers and opportunities for the long-term curricular integration of CPR education at two levels. First, by conducting interviews with teachers from 28 schools that did not implement the project to understand challenges at the school level. Second, surveying the Ministries of Education to examine obstacles in adopting the recommendation of the KMK (Kultusministerkonferenz, English: Standing Conference of the Ministers of Education and Cultural Affairs) at the state level. Based on these findings, the study aims to derive potential solutions for more effective nationwide implementation.
Interview Study
First, all schools (n = 33) were contacted to determine whether they had conducted the pilot project (Figure 1). Schools were divided into two groups: those that had implemented the project (n = 5) and those that had not (n = 28). Teachers from the group that had not implemented the project were identified as potential participants and were contacted by the research team.
They were invited to participate in an interview about the project. Follow-up interviews were conducted with those that agreed to participate. The interviews were voluntary and were conducted with the designated contact teacher from each non-participating school. The interview questions were specifically developed for this study and pretested with a small group of teachers for clarity and completeness. They included both closed and open-ended questions:
Should the lessons be taught by the school’s teachers or external specialists?
In your opinion, will resuscitation lessons be taught in your school in the medium term?
How many teachers should teach resuscitation lessons?
How do you see the need to establish resuscitation lessons in schools? Answer on a five-point Likert scale: very useful, somewhat useful, neutral, somewhat not useful, not useful, don’t know (no rating).
What needs to be done to establish resuscitation lessons?
The questionnaire for the interviews, as well as the questions used to survey the ministries, were validated in consultation with school teachers, principals, and first aid instructors to ensure relevance to the study objectives.
Data Analysis
Responses were recorded and grouped semantically where possible, see Table 1. The semantic grouping of questions was carried out by analyzing their content-related similarity and meaning. Related questions are clustered together to form thematic groups. This process enables a structured categorization of the questions and helps identify key topics and recurring patterns within the dataset. Open-ended answers were analyzed qualitatively to identify recurring themes and patterns.
Table 1: Anonymized responses from schools that voluntarily participated in the interviews.
School (Number) | Should the lessons be taught by the school’s teachers or external specialists | In your opinion, will resuscitation lessons be taught in your school in the medium term? | How many teachers should teach resuscitation lessons? | How do you see the need to establish resuscitation lessons in schools? | What needs to be done to establish resuscitation lessons? |
---|---|---|---|---|---|
1 | School teachers; external trainers complicate the organization | Yes | Min. 2 | Very useful | More support from leadership, training, time |
2 | External experts preferred | Definitely in the 7th grade; later, there’s barely time due to few biology lessons | One—each biology/sports teacher teaches their own class during their regular lesson time | Very useful | Time, training, teaching materials |
3 | School teachers preferred over external experts | Yes | Min. 2 | Very useful | Time, teaching materials |
4 | School teachers preferred over external experts | Yes | Min. 2 | Very useful | Training |
5 | School teachers preferred over external experts | Yes | Min. 2 | Useful | Training |
6 | External experts preferred | Yes | Min. 2 | Useful | Training, better logistics (hygiene) |
7 | Prefer external experts, but also possible with teachers | Yes | Min. 2 | Useful | Training, better logistics (hygiene) |
8 | External experts preferred | Yes | Min. 2 | Useful | Training, better logistics (hygiene), teaching materials (own mannequins) |
9 | School teachers; external trainers not financially feasible | Yes | Min. 2 | Very useful | More time, teaching materials (own mannequins), better logistics (hygiene), training |
10 | School teachers preferred over external experts | Yes, first aid is already well established in our school (9th graders complete the full first aid certificate) | Min. 2 | No rating | More support from school leadership, more time, more teaching materials (videos, pictures, books) |
11 | Prefer external experts, but also possible with teachers | Yes | Min. 2 | Useful | Teaching materials (videos, pictures, books) |
12 | Prefer external experts, but also possible with teachers | Hopefully | Min. 2 | Useful | Time, training, teaching materials |
Ethical approval for the underlying “Herzensretter” study, which included follow-up interviews with teachers (conducted in this study), was granted by the ethics committee of Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum (Application Number EA2/041/20). Further ethical approval was not required for the survey of education ministries, because this present study is a follow-on study from the previous study, using publicly available data.
Statistical Analysis
Statistical analysis was applied selectively based on the nature of the data. For categorical variables where comparisons between groups were relevant, such as instructor preference (Question 1), we conducted statistical tests (e.g., chi-square test). For questions aimed at identifying general trends, such as the importance rating of resuscitation training (Question 4) or reported obstacles (Question 5), descriptive statistics were deemed sufficient, as the primary goal was to summarize the responses rather than test specific hypotheses.
Inquiry Among Ministries
A systematic inquiry was conducted among the education ministries of Germany’s 16 federal states to evaluate the status of CPR education implementation. The questions, set out in Table 2, were:
Table 2: Results of the survey sent to the education ministries of all 16 states.
*UE is a unit of time used in the German education system. It corresponds to a period of 45 minutes. 2UE = 90 minutes.
State | Is CPR Training Part of the Curriculum? | Is CPR Training Offered Statewide? | What is the starting grade for CPR training in your state? | What is the duration of CPR training in your state?* |
---|---|---|---|---|
Bavaria | Yes | Yes | 7th Grade | 2UE |
Hesse | No, but planned | No, but planned | 7th Grade | 2UE |
Saxony | No, but implicitly through first aid | No, but planned | 7th Grade | 2UE |
Lower Saxony | No, but possibly from 2026 | No | 7th Grade | N/A |
Hamburg | Yes, starting in primary school | Pilot projects | 7th Grade, in pilot projects from 2nd Grade | 2UE |
Berlin | No | No | N/A | N/A |
North Rhine-Westphalia | No | Pilot projects | 7th Grade | 2UE |
Baden-Württemberg | Yes | Yes | Primary school for first aid, 7th Grade for CPR | 2UE |
Mecklenburg-Western Pomerania | Yes | Pilot projects, but statewide implementation planned | 7th Grade | 4UE (2UE for first aid, 2UE for CPR) |
Brandenburg | No, but implicitly in health promotion | Pilot projects | 7th Grade, regionally from primary school | 2UE |
Thuringia | No | No | 7th Grade | 2UE |
Schleswig-Holstein | No | Yes, but not comprehensively | 7th Grade | 2UE |
Saarland | Yes, but only in theory | No, but planned | 7th Grade | 2UE |
Bremen | No | No | N/A | N/A |
Bavaria | Yes | Yes | 7th Grade | 2UE |
Hesse | No, but planned | No, but planned | 7th Grade | 2UE |
Saxony | No, but implicitly through first aid | No, but planned | 7th Grade | 2UE |
Lower Saxony | No, but possibly from 2026 | No | 7th Grade | N/A |
Is CPR training part of the curriculum?
Is CPR training offered statewide?
At what grade level do students in your federal state typically begin receiving CPR training in school?
Could you please indicate the duration of CPR training sessions provided in schools in your federal state?
Standardized emails containing a predefined questionnaire were sent to the education ministries of all 16 states. Follow-up reminders were sent to non-responding ministries at intervals of two and four weeks.
Responses were reviewed by the research team to ensure consistency and accuracy. Discrepancies or ambiguities were clarified directly with the respective ministries. The collected data were tabulated and comparatively analyzed to highlight differences between states, identifying patterns and challenges.
Results
Teachers from a total of twelve schools participated in the interviews, and their anonymized responses are summarized in Table 1. The interview results highlight different perspectives on implementing resuscitation lessons in schools. Regarding the preferred instructors, 50% (6/12) of schools favored their teachers, citing organizational challenges and financial constraints as the reasons for this. In contrast, 25% (3/12) of schools preferred external experts for their specialized knowledge, while 25% (3/12) remained neutral, stating that both options were possible. The chi-square test results in a chi-square statistic of 1.5 and a p-value of approximately 0.472. This indicates that there is no significant deviation from an equal distribution (p > 0.05), meaning the preference for own teachers, external experts, or neutrality does not significantly differ from what would be expected by chance.
The vast majority (91.7% or 11/12 of schools) believed that resuscitation lessons would be introduced in the 7th grade, with one school already integrating a full first aid certification program for ninth graders. Most schools agreed that at least two teachers should be responsible for teaching these lessons to ensure effective instruction. On a five-point Likert scale, 41.7% (5/12) of schools rated resuscitation lessons as “very useful,” while 50% (6/12) found them “useful.” One school did not provide a rating (8.3% or 1/12).
Several challenges were identified including the need for additional time (41.7% or 5/12 of schools), teacher training (75% or 9/12 of schools), better logistical arrangements such as hygiene considerations (33.3% or 4/12 of schools), and improved teaching materials (50% or 6/12 of schools). Some schools specifically mentioned the necessity of dedicated mannequins, videos, pictures, and books to enhance instruction. Additionally, 16.7% (2/12) of schools emphasized the importance of support from school leadership for successful implementation.
The responses to Question 5 (What needs to be done to establish resuscitation lessons?) were categorized into thematic groups and illustrated using a bar chart (Figure 2). The responses given thus represent the expectations of the teachers, which they see as prerequisites for sustainably integrating and implementing resuscitation training in the curriculum. A possible relationship between schools preferring their own teaching staff and those planning to implement the training was examined. However, we found that both those that preferred their own teaching staff and those who wanted external instructors all indicated that they planned to implement resuscitation training in the 7th grade, suggesting this preference did not influence the decision to introduce training.
Findings from the survey of Education Ministries
The results of the survey are provided in Table 2.
Out of Germany’s 16 federal states, six (37.5%) reported that resuscitation training is already firmly embedded within their school curricula. In five states (31.25%), integration is currently being planned, while the remaining five (31.25%) had not yet initiated any relevant measures.
When it comes to implementation, only two states (12.5%) have established resuscitation training on a statewide level. In contrast, six states (37.5%) offer such training regionally or through pilot projects, with the long-term goal of expanding coverage. However, half of the states (50%) reported having no comprehensive programs in place.
The majority of states (12 out of 16, or 75%) begin resuscitation training in the 7th grade. Two states (12.5%) have extended this instruction to primary schools, while another two (12.5%) did not provide any information on the grade level at which training begins.
Regarding the duration of training, 13 states (81.25%) follow a standard format of two teaching units. The remaining three states (18.75%) did not specify any details about the duration.
Statistical Test
Curriculum Integration vs. statewide Implementation: A chi-square test was conducted to examine the relationship between curriculum integration and nationwide implementation. The result (χ² = 5.4, p = 0.067) indicated no significant association (p > 0.05).
Discussion
The interview results indicate that structural and resource-related deficits present major challenges to implementing resuscitation training in schools. Schools that withdrew from the pilot project, despite initially agreeing to participate, cited insufficient training, a lack of teaching materials, and time constraints as key obstacles. Similarly, teachers emphasized that these limitations make effective instruction difficult. To manage organizational challenges, they suggested having at least two instructors per session to ensure smooth lesson delivery.
Encouragingly, the interviewed teachers demonstrated high motivation and recognized the value of resuscitation training. This was expected, as participating schools had volunteered for the pilot phase. The central issue during the pilot phase of the Herzensretter project was not a lack of acceptance among teachers but rather insufficient resources.
The COVID-19 pandemic exposed additional vulnerabilities in the concept. Originally planned for the 2019/2020 school year, the project was significantly disrupted by the pandemic, which led to school closures, teaching interruptions, and staff shortages. Deficiencies in physical infrastructure, such as inadequate ventilation systems, exacerbated the situation.
Funding for the pilot project was also insufficient to ensure sustainable implementation. Although the state provided initial resources including 40 resuscitation mannequins and training sessions for instructors, critical follow-up tasks, including maintenance and cleaning of the mannequins, were not addressed. The long pandemic-induced hiatus meant that trained instructors could not refresh their skills and missed resuscitation sessions have yet to be rescheduled. A lack of accompanying teaching materials and ongoing professional development further hindered sustainable implementation.
The survey of ministries highlighted that these challenges are not isolated. Among the 16 federal states, only six had formally integrated resuscitation training into their curricula, and just two had achieved statewide implementation. Where training is conducted, it generally adheres to the 2014 recommendations of the Standing Conference of the Ministers of Education and Cultural Affairs (KMK), (i.e., two teaching units starting in the 7th grade).
Statistical analysis underscored these findings. A chi-square test showed no significant correlation between curriculum integration and statewide implementation (p = 0.067). This indicates that curriculum integration alone is insufficient to ensure sustainable implementation.
In summary, despite strong support from teachers and the recognized importance of resuscitation training for public health, its implementation is hindered by structural challenges, insufficient funding, and organizational deficiencies. Sustainable adoption requires targeted investments in resources, comprehensive financing, and centralized coordination to support schools in overcoming these obstacles. Additionally, according to the statements made by the teachers in the interviews, standardized teaching materials could represent an improvement.
Limitations
The limitations of this study fall into several key areas that may influence the interpretation of the results. First, the study was based on a non-representative sample, as only schools that had voluntarily registered for the previous pilot project were included. This introduces potential bias, as these schools may have higher intrinsic motivation or better infrastructure compared to the average school. Furthermore, interview participation was voluntary, raising the possibility of non-response bias, as schools with limited resources or a critical stance toward the project may have opted out.
Second, the low response rate from schools and late and sparse responses from ministries poses challenges. Sixteen schools did not respond, and not all ministries provided complete answers. This incomplete data could mean that actual barriers and progress remain underreported.
Third, the validity of the interview questionnaire is another consideration. Although the questionnaire was piloted and developed in consultation with experts, it is unclear whether it fully captured all relevant aspects of resuscitation training in schools. Contextual factors such as regional differences in educational infrastructure or specific political frameworks may have been overlooked.
Finally, temporal and logistical constraints presented limitations. Data collection occurred within a restricted time frame, potentially overlooking significant developments, particularly those related to the long-term impacts of the COVID-19 pandemic. This pandemic not only disrupted school capacities but also shifted educational priorities, limiting the generalizability of the findings.
Conclusion
Resuscitation training saves lives. It can be effectively implemented by schoolteachers, medical students, physicians, paramedics, and first-aid instructors from aid organizations. Research has already identified the necessary components of these programs, including their frequency, content, and optimal teaching strategies to increase lay resuscitation rates.
Given this robust body of evidence, it is increasingly urgent to address the lack of progress in Germany over the past decade. Tackling the infrastructural issues involved in implementing first-aid training requires acknowledging the “elephant in the room”: it will incur costs. We need functional infrastructure, efficient resource allocation, and innovative approaches such as the use of online platforms to deliver CPR training and/or a combination of online and in-person instruction to enhance accessibility and effectiveness. Professional development opportunities and teaching materials are also needed, along with mechanisms for independently measuring implementation. All of this entails costs for both procurement and maintenance.
While the path is long, it is undoubtedly worthwhile. As of 2025, the situation remains largely unchanged, with only two federal states having achieved statewide implementation. It is no longer a question of whether resuscitation training is valuable but how it can be implemented. Embedding it in curricula alone is insufficient. Financial commitment and clear expectations regarding program structure, delivery methods, and resources are essential. After a decade, it is alarming that a greater level of implementation has not been achieved across Germany.
Competing Interests
Philipp Humbsch is a co-founder of the Pépinière Foundation, the Jan-Anton Mikulicz Radecki Foundation and the Pépinière Association, which are voluntary organizations that carry out first aid projects in primary schools in Germany and Poland.
Konrad Bohm is a co-founder of the Pépinière Foundation and the Pépinière Association, which are voluntary organizations that carry out first aid projects in primary schools in Germany.
Robert Gintrowicz received a student research grant by the Pépinière Foundation, Frankfurt (Oder), Germany. This research grant was partially funded by the Ministry of Science, Research and Culture of the federal State of Brandenburg, Germany. Beyond that he is a member of the Pépinière Association, which is a local voluntary organization that carries out first aid projects in primary schools in germany.
Izabela Jastrzebska is a co-founder of the Jan-Anton Mikulicz Radecki Foundation which is a voluntary organization that carry out first aid projects in primary schools in Poland and Germany.
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