Knowledge, Attitudes, and Practices of Cardiopulmonary Resuscitation in 110 Undergraduates in Radiological Sciences at Jazan University

Introduction

Cardiopulmonary resuscitation (CPR) is a critical component of Basic Life Support (BLS) and Advanced Life Support, and an essential life-saving skill for healthcare professionals both in emergency departments and outside of hospitals. Early detection of cardiac arrest and initiation of CPR has been shown to increase survival rates, improve neurological outcomes, and reduce mortality and morbidity [1–3]. While prompt defibrillation remains a key determinant of cardiac arrest in adults [4], effective CPR maintains blood flow to the brain until specialized tools, such as an automated external defibrillator, are available [5]. The delivery of high-quality CPR can greatly improve patient outcomes [1], and inadequate training can have tragic and legal consequences.

The absence of BLS training in undergraduate curricula, particularly CPR training, is a critical gap in higher education [6]. This gap poses significant risks to public health, overall community safety, and emergency response capabilities. Undergraduate programs can beneficially incorporate CPR training [7]. Integrating CPR instruction during clinical rotations provides hands-on experience, improving preparedness and patient outcomes. Research indicates that even short, targeted training sessions can equip students with the necessary knowledge and confidence. Clinical practice in the diagnostic radiography setting allows students to develop a professional identity, improve communication skills, apply classroom learning, and gain confidence and empathy in patient care [8,9].

Several studies have investigated CPR knowledge, attitudes, and practices among healthcare profession students in different countries, including Saudi Arabia [10–17]. However, there is a significant research gap regarding students of radiological sciences in Saudi Arabia. These students can face emergencies in clinical settings. For example, radiography students during their clinical rotation or internship year often work alone or in small teams in diagnostic rooms. As the first point of contact during a cardiac arrest, whether caused by underlying pathology or by an adverse reaction to contrast media, these students must initiate the chain of survival before a dedicated crash team arrives. Severe anaphylactoid reactions to iodinated contrast media occur in various cases and can rapidly progress to respiratory or cardiac arrest [18,19]. Undergraduate training ensures that entry-to-practice professionals are competent to manage these life-threatening emergencies immediately. Because radiographers may administer intravenous contrast agents and monitor unstable patients in high-acuity settings, CPR proficiency is not optional but an essential professional requirement for patient safety. This context raises questions about their preparedness and confidence in managing cardiac arrest. Therefore, this study aimed to evaluate the knowledge, attitudes, and practices of CPR among 110 undergraduates in radiological sciences at Jazan University between February 1 and May 25, 2022.

Material and Methods

ETHICS APPROVAL:

Ethics approval was obtained from the Jazan Research Ethics Committee (reference number: REC-43/10/226). The study adhered to the Declaration of Helsinki. Electronic informed consent was obtained from all participants. The questionnaire was completed on a voluntary basis. All participants provided consent on page 1 of the questionnaire, and their data were recorded anonymously.

STUDY DESIGN AND DATA COLLECTION:

This was a cross-sectional study conducted at the Diagnostic Radiography Department of Jazan University. This study used a convenience sampling approach with total population invitation. Regarding data collection, all eligible undergraduate students enrolled in the Diagnostic Radiography Department (levels 3–8, n=200) during the study period (February-May 2022) were invited to participate. Students who studied in levels 3 to 8 were included in the study, whereas students in the preparatory year, interns, transfers, and those who declined participation were excluded. Among the included participants, 11 students withdrew, and 9 transferred to another department; therefore, a total of 180 students met the inclusion criteria. Of these, 110 participated, yielding a response rate of 61.1%. To ensure broad and equitable coverage of the study population, the questionnaire was distributed electronically via student WhatsApp groups and official university email using Google Forms. Participation was voluntary, and electronic informed consent was obtained prior to students opening the survey. To minimize social desirability bias and preserve confidentiality, no personally identifiable information was gathered, and answers were recorded anonymously. Further reminders were sent to ensure consistent data collection and to maximize participation during the study period. Male and female radiography students volunteered to participate in the study. Moreover, to minimize the possibility of bias, the survey was distributed through the WhatsApp groups of Diagnostic Radiography Department students, which include most students at Jazan University, thereby ensuring representation across different age groups, sex, and academic levels.

SAMPLING AND SAMPLE SIZE CALCULATION:

Based on G*Power analysis version 3 (effect size=0.3, α=0.05, power=0.80), the minimum required sample was 132. Due to the 61.1% response rate, the final sample consisted of 110 participants, which is acknowledged as a limitation regarding generalizability.

STUDY QUESTIONNAIRE:

The survey questionnaire was designed to assess CPR knowledge, attitudes, and practice among undergraduate radiography students, addressing the study’s primary aim. A 4-part, self-administered questionnaire was used, with each section based on validated instruments from published studies [10,20]. The questionnaire underwent a formal content validity review by a multidisciplinary expert panel, including 3 associate professors in the field of radiological sciences and paramedicine sciences, each with a minimum of 4 years of experience. This review ensured that the questionnaire was tailored to our study demographics and was concise, clear, and focused in its purpose. The panel was provided with clear and detailed information about the purpose of the study, their roles in the review process, the measures in place to maintain confidentiality, and their right to participate voluntarily. In addition, a pilot study was conducted with 5 radiography students to evaluate the clarity of the questions and ensure the concepts were well understood. To avoid any potential bias, these students were not included in the final analysis. The reliability of the knowledge (α=0.73) and practice (α=0.71) sections was assessed using Cronbach’s alpha, with both sections demonstrating acceptable internal consistency for the study.

The questionnaire included 4 sections. The first section collected demographic information, including sex, age, and academic year level (semester), and included a yes/no question about prior CPR training. These items were essential for stratifying subsequent analyses and identifying independent predictors of knowledge, practice, and attitude outcomes, thereby aligning with the secondary objective of examining associated factors.

The second section assessed students’ theoretical knowledge of CPR (7 questions). The third section explored students’ attitudes toward CPR, and the final section assessed students’ CPR practices (7 questions). Knowledge and attitude questions were structured as yes/no or multiple-choice questions, while practice-based questions were structured as multiple-choice questions. A scoring system was used to assess the responses in the second and fourth sections.

The first (theoretical knowledge) section of the survey consisted of 7 multiple-choice items. An incorrect answer was assigned a score of 0, while a correct response was assigned a score of 1. The initial question asked whether respondents were aware of the emergency contact number for the Saudi Red Crescent, which serves as the primary ambulance service in the country. Participants were given the option to select either “yes” or “no” as their responses. The remaining 6 questions presented participants with 4 choices, from which they were required to choose the correct answer. In this section, the scores ranged from 0 to 7, reflecting the number of correct responses to the questions. Scores of 57% or higher (≥4 correct answers) indicated good knowledge, and scores below 57% (<4 correct answers) indicated poor knowledge. The attitudes section of the questionnaire contained 5 questions. This included 2 questions with yes or no answers, 2 questions with 4 multiple-choice answers, and 1 question with agree, disagree, and neutral options. As there were no optimal correct answers in this section, there was no cut point (specific score). The practice section consisted of 7 questions, each of which asked participants to select 1 correct answer from 4 potential options. Scores of 57% or higher (≥4 correct questions) were considered to reflect good practice, and scores of below 57% (<4 correct questions) reflected poor practice.

DATA ANALYSIS:

Data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 27. All completed questionnaires were coded according to a predefined coding framework to ensure consistency and accuracy. Descriptive statistics were used to summarize the data. Categorical variables were presented as frequencies and percentages to describe participants’ demographic characteristics, prior CPR training status, responses to theoretical knowledge items, attitudes, and responses to practice scenarios.

For the knowledge section, each correct response was awarded 1 point, yielding a possible total of 7. The overall knowledge score was calculated and converted to a percentage. Based on a predefined cut-off (≥4 correct answers out of 7, equivalent to ≥57%), participants were categorized as having “good” or “poor” knowledge. Similarly, for the practice section, responses to scenario-based questions were scored as correct or incorrect. A total practice score was computed and dichotomized using the same higher or lower than 57% cut-off to classify participants as having “good” or “poor” practice.

To identify factors independently associated with good CPR knowledge, multivariable logistic regression analysis was performed. The dependent variable was knowledge level (good vs poor). Independent variables entered into the model included sex (reference: female), age group (reference: <20 years), academic level (reference: level 3), and prior CPR training (reference: no). Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. A P value <0.05 was considered statistically significant. All statistical tests were 2-tailed. Conclusions regarding factors associated with CPR knowledge were based on the adjusted odds ratios and corresponding P values obtained from the multivariable logistic regression model.

Results

DEMOGRAPHICS:

A total of 110 students participated in the study: 55.5% were men and 44.5% were women. Most were aged 20 to 23 years. Approximately 65% had never taken a CPR course. Table 1 summarizes demographic characteristics.

RADIOLOGICAL STUDENTS’ THEORETICAL KNOWLEDGE OF CPR:

The theoretical knowledge of the participants regarding CPR was assessed using a 7-item scale. Based on a predefined proficiency cut-off of 57%, the overall mean knowledge score was 46.6%, indicating insufficient (low) knowledge among the participants, as shown in Figure 1. Table 2 details responses. While participants showed good knowledge regarding the emergency telephone number (80.9%) and the definition of BLS (58.2%), significant knowledge gaps were identified in technical CPR parameters. Specifically, only 22.7% of students correctly identified the proper chest compression depth, and only 30.9% were aware of the recommended compression rates. Consequently, the most participants failed to meet the threshold for good knowledge.

ATTITUDES OF RADIOLOGICAL STUDENTS TOWARD CPR:

Table 3 shows attitudes toward CPR: 71% of students believed CPR training should be mandatory, and 90% agreed it would help save lives. Nearly all (94%) wanted to learn CPR.

PRACTICES OF RADIOLOGY STUDENTS TOWARD CPR:

Only 28.7% of students demonstrated good practice, as seen in Figure 1. Table 4 shows that 80% of students did not identify safety as the first step, and 90% did not prioritize activating EMS. Only 54.5% reported they would perform abdominal thrusts for choking.

MULTIVARIABLE ANALYSIS OF KNOWLEDGE AND PRACTICE WITH ASSOCIATED FACTORS:

Multivariable logistic regression analysis was performed to assess factors associated with CPR knowledge and CPR practice, adjusting for sex, age group, academic level, and prior CPR training (Table 5). Among the predictors, prior CPR training was the only factor significantly associated with CPR knowledge. Students who had received CPR training were significantly more likely to demonstrate adequate knowledge than those who had not (OR=2.70, 95% CI: 1.16–6.30; P=0.021). Sex, age group, and academic level were not significantly associated with CPR knowledge (P>0.05 for all). In contrast, none of the examined variables showed a statistically significant association with CPR practice at the 0.05 level. These findings suggest that formal CPR training plays a key role in improving students’ CPR knowledge, whereas demographic and academic characteristics were not significant predictors of CPR knowledge or CPR practice in this sample.

Discussion

STRENGTHS AND LIMITATIONS:

This study provides a benchmark and a rationale for targeted curriculum reform, serving as a framework for similar evaluations in other allied healthcare disciplines. The findings can serve as a framework for future research in this area, guiding the development of interventions and educational programs to improve CPR competency among radiography students in Saudi Arabia and ensure they are prepared to respond in emergencies.

This study has several limitations. The single-center design and reliance on convenience sampling limit the generalizability of the findings to other institutions or regions. One major drawback of using a self-reported questionnaire to evaluate practice is that it gauges perceived competency rather than actual competency. Therefore, self-report and recall biases may have affected response accuracy. Future studies should incorporate objective skills assessments (eg, objective structured clinical examination stations). The final sample fell short of the calculated target (110 vs 132), which may have reduced the statistical power to detect significant associations in the practice domain. Future research should use multi-center designs to confirm these findings, conduct intervention studies comparing the efficacy of simulation vs traditional training in radiography students, and identify systemic and perceptual barriers to curriculum integration of CPR training. The study highlights the need for longer-term research to understand how well students retain their CPR knowledge and skills after structured training. One useful approach would be a longitudinal interventional study that follows participants over time, assessing them before training, immediately afterward, and then again at 3, 6, and 12 months. This would help determine how much knowledge and skill are retained, how quickly skills may decline, and whether participants remain behaviorally prepared to respond in real-life situations.

Following the same group of students over time could also provide valuable insight into how changes in the curriculum influence CPR competence. In addition, randomized controlled trials could compare different teaching approaches, such as blended learning or simulation-based training vs traditional lectures, to determine which methods are most effective in promoting lasting behavioral change. Including periodic refresher courses in these studies would further allow researchers to assess how reinforcement affects long-term competence and confidence.

Conclusions

CPR is a critical skill for all healthcare providers. This study reveals significant gaps in CPR knowledge and practice among radiography students at Jazan University, despite positive attitudes. Previous CPR training was significantly correlated with higher knowledge. We strongly recommend integrating mandatory, simulation-based CPR training into the radiography curriculum and establishing it as a graduation requirement. Moreover, CPR knowledge can be improved by other methods, such as refresher courses, workshops, and lectures. Addressing this gap is crucial for patient safety in diagnostic and interventional settings, aligning with the broader professional responsibility of all healthcare workers. Future research should identify barriers to training, assess skill proficiency, and evaluate the feasibility of a departmental CPR certification program.