Increasing Bystander CPR Confidence and Knowledge

Neal Madhani, MD, instructs students on proper CPR and AED use during the hands-on simulation part of the AHA Heartsaver course.
Neal Madhani, MD, instructs students on proper CPR and AED use during the hands-on simulation part of the AHA Heartsaver course.(Photo/Matthew Lombardi, DO)

The Effects of a Standardized CPR Education on High School Students


Introduction: Cardiac arrest is a major cause of death in the United States. Its survival rate can be improved with better bystander CPR performance. The current study aims to assess whether a formalized CPR education for high school students will increase their confidence and knowledge of this life saving procedure.

Methods: A formalized four-hour CPR class (AHA Heartsaver CPR/AED and 1st Aid) was administered to a group of high school students. A pre- and post-course assessment was administered and results were analyzed. The post course test results were compared to a similar cohort of high school students with a similar education already present in their high school curriculum.

Results: For both our questions concerning confidence in performing CPR as well as knowledge of CPR, students scored statistically higher on the post course test compared to the pre course test showing they gained both confidence and knowledge from taking the course. Similarly, the results from the post course analysis were statistically equivalent or superior to the responses given by the cohort of students with a CPR education already in place.

Conclusion: Our four hour standardized CPR course significantly increased student confidence and knowledge for performing CPR and first aid skills bringing them to a level on par with students who receive a formal CPR education as part of their high school education.



Sudden death from cardiac arrest is a leading cause of mortality in the United States. As of 2016, the overall survival rate of out of hospital cardiac arrest is 10% and an 8% survival rate with good neurologic outcome.1 Early CPR administration for a cardiac arrest patient is the only way to continue blood flow throughout the human body and bridge them to life saving measures performed by advanced level providers. For every one minute of CPR withheld, the patient’s chances of survival decrease by 10%.2

According to the American Heart Association, approximately 350,000 out of hospital cardiac arrest occur each year. Although cardiac arrest is a dire medical condition with a mortality rate of over 90%, when bystander CPR is performed the mortality rate decreases to 55%. Unfortunately, only 45% of patients with out of hospital cardiac arrest will have bystander CPR performed.1 If it is evident that bystander CPR is crucial to patient survival then why are the rates of bystander CPR so low? Studies suggest that the main reason is lack of CPR training.3 Perhaps the reason that AEDs are used in only 8% of cardiac arrests in public settings is because 64% of Americans have never even seen an AED.4

Currently, the state of Rhode Island mandates that high school students receive CPR training; at many schools, however, this training is not standardized or taught by certified instructors. At some schools, for instance, it is acceptable to have a one-hour class taught by a physical education teacher who demonstrates only mechanical chest compressions on a soccer ball. With a curriculum so lacking for high school students, who will grow to be the majority of these able bodied bystanders, it is no wonder why the rate of bystander CPR in the state of Rhode Island is well below the national average at 22%, according to the Rhode Island Department of Health.5 One would have to wonder if these students were taught a more standardized curriculum by a certified instructor, would they be more apt to perform lifesaving bystander CPR and AED use.

The current study aims to discover the impact of a four hour standardized and certified instructor taught CPR class on high school student’s comfortability and knowledge of lifesaving CPR and first aid procedures. We compared students responses to both subjective confidence in performing CPR as well as objective knowledge of CPR with an assessment both before the administration of our class and immediately afterwards. We also compared students who took our CPR course with students of similar demographics who have CPR training as part of their high school curriculum. Our hope is that by improving CPR education, we will enable more bystanders to perform these lifesaving tasks if ever in the situation.


For this study, forty-six volunteers from Bishop Hendricken High School (BHHS) in Warwick, Rhode Island, were enrolled in a series of CPR courses. The students were all in their sophomore and junior years of high school. They all voluntarily enrolled in this after-school course for the fee of $15. All students had already fulfilled their state mandated CPR training which included a one hour instruction focusing on chest compressions taught by a physical education teacher at the school. No student was excluded in participating in the class.

The CPR class was taught as a formalized American Heart Association (AHA) Heartsaver First Aid and CPR/AED course by an instructor certified as an AHA Basic Life Support instructor (BLS). The course duration was four hours and focused on adult and pediatric CPR/AED use. The course also included instruction on choking as well as various first aid topics such as hemorrhage control, opiate overdose, stroke management, anaphylaxis and diabetic emergencies. The class utilized both video tutorials as well as hands on training with resuscitation manikins, training AEDs, and other training equipment such as epi-pens, naloxone kits and tourniquets.

Each student was administered the same assessment both before and after the course. The assessment consisted of a total of 14 questions. Five of the questions were confidence based on a scale of one to four to determine the learner’s confidence in performing certain tasks. The remainder of the questions were designed to directly assess knowledge of certain CPR and lifesaving concepts. See Figure 1 for a copy of the assessment which was administered.

Figure 1.

CPR and First Aid Assessment

1.) On a scale of 1 to 4, how confident would you be right now to provide CPR and operate an AED on an adult who is unresponsive with no pulse?

4 – extremely confident

3 – confident

2 – somewhat confident

1 – not confident

2.) On a scale of 1 to 4, how confident would you be right now to provide CPR and operate an AED on a child/infant who is unresponsive with no pulse?

4 – extremely confident

3 – confident

2 – somewhat confident

1 – not confident

3.) On a scale of 1 to 4, how confident would you be right now to help an adult who is choking?

4 – extremely confident

3 – confident

2 – somewhat confident

1 – not confident

4.) On a scale of 1 to 4, how confident would you be right now to help an infant who is choking?

4 – extremely confident

3 – confident

2 – somewhat confident

1 – not confident

5.) On a scale of 1 to 4, how much training have you received thus far in your high school career regarding CPR, AED use, and basic First Aid.

4 – too much

3 – the right amount 2 – not enough

1 – severely lacking

6.) What does the acronym ‘CPR’ stand for?

7.) What does the acronym ‘AED’ stand for?

8.) Name one location in your school where you can find an ‘AED’.

9.) When performing CPR on a person with no pulse, how many chest compressions should be given in one minute? (provide a number)

10.) What is the name of the device which can slow down or stop external bleeding from a person?

11.) A person can’t smile properly, has slurred speech, and can’t raise their right arm. You should call 911 because this person may be having a XXXXXXX?

12.) What is the name of the medication diabetic patients inject to lower their blood sugar?

13.) Name the medication that is injected into a body to treat a severe allergic reaction (ie anaphylaxis).

14.) Name the medication that is used to reverse an opiate drug overdose (ie. heroine, oxycodone, etc).

As a second part of this study, we administered this same test to a group of 78 sophomore and junior high school students at Cranston West High School (CWHS) in Cranston, Rhode Island. These students have a weekly class which includes CPR and first aid training as part of their high school curriculum. This class is taught by nurses and EMTs who are AHA BLS instructor certified. We directly compared answers from this cohort to the answers of the post course assessment given to the group of students at BHHS.

For each question, the pre-test and post-test results values were analyzed. For questions assessing skill confidence which utilized a one to four rating scale (with one being the lowest confidence and four being the highest confidence) the mean confidence was calculated along with the standard error of the mean. For questions assessing general knowledge, the number of students with the correct answer was recorded. These questions were not marked incorrect for grammatical errors. The same calculations were made for all student responses to the same test given to this separate student population at CWHS. We compared the pre-test and post-test mean scores for the five confidence based questions using a two sample t-test analysis. Similarly, we compared the proportion of correct to incorrect responses on the nine knowledge based questions for the pre-test and post-test group using a chi squared analysis. We then compared the means of the confidence based questions for the post-test BHHS students to the corresponding means of the CWHS students via a two sample t-test. And similarly, we compared the post-test BHHS cohort to the CWHS cohort in their knowledge question responses using a chi squared analysis.


Table 1 shows the pre-test and post-test mean and standard error values for the five questions on CPR confidence given to students taking our course at BHHS. It also shows the t-value of the two sample t- test comparing pre-test and post-test means along with the p-value associated with the given t-value.

Graph 1 is a bar graph which depicts changes in the mean from pre-test to post-test.

Table 2 shows the percentage of students at BHHS answering each general knowledge question correctly for the pre-test group as well as the post-test group. It also shows the chi squared value along with the p-value for the chi squared analysis comparing the percentage of correct answers to each question post-test as compared to pre-test.

Table 3 shows the mean and standard error values for the five questions on CPR confidence for both the post-test group which took our course at BHHS, as well as the group of students from CWHS which did not take our course.

Graph 3 depicts the differences in these means of the two groups.

Table 4 depicts the percentage of correct answers on the nine knowledge based questions for the post- test BHHS group as compared to the CWHS group as well as the chi-squared value and p-value comparing the two groups on each question.

Graph 4 shows the differences in correct answer percentage between the two groups.


The first part of the current study aims to show the effectiveness of a standardized CPR course taught by a certified instructor in terms of student confidence in performing CPR and knowledge of performing CPR and first aid. As is shown in Table 1, the five questions assessing confidence level all had a statistically significant increase in level of confidence from the pre-course assessment to the post- course assessment. Specifically, on the question of confidence in performing CPR and operating an AED on an adult, average confidence went from 1.71 (between not confident and somewhat confident) pre-course to 3.43 (between confident and extremely confident) after the course. And likewise, for the same question asked about performing CPR and using an AED on the pediatric population, confidence went from 1.4 to 3.11. This clearly shows while confidence was lacking prior to the course, simply providing a four hour course boosted confidence on our assessment scale. Similar statistically significant increases were seen in questions #3 and #4 assessing confidence in helping adult and pediatric choking victims. On the question of whether the level of CPR training that these students had received during high school, the pre-test group had an average of 1.64 which was between severely lacking and not enough whereas the post-test group had an average of 2.98 which correlates to “the right amount” of CPR training received in high school. The result of these five questions clearly shows an increase in confidence level from helping victims in need after taking this course.

Similar effects were seen in the general knowledge based questions. In seven of the nine questions, there was a statistically significant increase in post-test correct answers as opposed to the pre-test. Questions #6 and #7 assessed the most basic knowledge of what CPR and AED are by simply asking what these two acronyms represented. It is hard to imagine that people can perform a task when they don’t even know what the letters representing the task stand for. Before the course, only 9.5% and 19% of students knew what the acronyms “CPR” and “AED” stood for, respectively. After the class, 70% and 72% of students could answer those questions correctly respectively. We believe it is of vital importance to know that when performing CPR that you are performing cardiac and pulmonary resuscitation so as to perform this life saving technique effectively.

Question #9 assessed the specific knowledge of correct rate of compressions recommended to be given in CPR according to the AHA. It has been shown in studies that not performing CPR within a rate of 100-120 beats per minute is ineffective at maintaining cerebral perfusion pressure and results in worse neurologic outcomes.6 The results clearly point to a robust, statistically significant improvement in knowledge for this specific question with only 9.5% of students obtaining the correct rate on the pre-test assessment and 65% of students on the post-test assessment. This shows that had these students performed CPR prior to this class, the majority would have done so at a compression rate that doesn’t optimize cerebral perfusion pressure whereas after the class the majority would be aware of the correct rate of compressions and therefore perform more effective CPR.

Questions #10 – #14 assessed knowledge regarding general first aid recognition and management for situations including hemorrhage control, acute stroke, diabetic emergency, anaphylaxis and opioid overdose. For most of these questions there was again a statistically significant increase in correct responses after the class as opposed to before the class. The only question that didn’t have a statistically significant increase in correct answers was question #12 which assessed the knowledge that insulin is the main medication involved in hypoglycemic diabetic emergencies. For this question, we did see an increase in the proportion of correct answers post-course.

However, likely due to the ubiquitous nature of diabetes in our culture, 85% of students responded correctly on the pre-course assessment making it nearly impossible to obtain a statistically significant increase. With today’s epidemic of violent mass casualty events including school shootings and alarmingly high prevalence of opioid use and deaths among young people, it was particularly encouraging to see extremely significant increases in the correct answers dealing with these issues. Prior to our class only 30% of respondents could name that a tourniquet is the mainstay treatment method of hemorrhage control, whereas 74% could do so after the class. Likewise, prior to the course only 12% could identify Narcan (naloxone) as the antidote for opioid overdose, whereas after the course 76% could do so. Not assessed on our test, but taught on our course, were the proper uses of these first aid modalities; in order to save lives first and foremost you need to identify the correct treatment modality and then be able to properly implement its use. Our data has shown that our classes have at the very least significantly increased the rate at which the students can identify the modality. A limitation of our study is that we did not assess how effectively the students were able to use this modality which is an area that would require further study.

In the second part of our study, we compared the post-course assessment of the BHHS students to the cohort of students from CWHS who already receive formalized CPR education as part of their high school curriculum. On the questions assessing confidence in performing CPR and helping choking victims, there was a statistically significant higher rating for all questions among BHHS students as compared the CWHS students. This is an important finding as it shows that after taking our course, we were able to instill not just as much confidence but more confidence compared to students who receive CPR and first aid education as part of their high school curriculum. A confounder to this finding is the fact that the BHHS students took this survey immediately after taking our class, which likely boosted confidence as they had just learned this information. Regardless, a major hurdle to bystanders performing CPR is confidence and we were able to show that in a one-session course we were able to raise confidence to an even greater level as compared to those receiving regular CPR education as part of their high school curriculum. On question #5, which assesses student perception of how much CPR education they have received thus far in their high school career, the students taking our class perceived having on average essentially the same amount of training which was the “right amount” as those who have been receiving CPR and first aid education on a nearly weekly basis for a more prolonged time period. This shows that even just a four-hour course gave the perception that these students received a comprehensive education regarding CPR and basic first aid.

The results when comparing the BHHS and CWHS students for the knowledge based questions were mixed. For knowing what the acronym of “CPR” and “AED” stood for, there was a statistically significant higher proportion of correct answers among the CWHS students which may reflect that their more extensive education has allowed them to be more familiar with these terms (Questions #6 and

#7). Importantly, the BHHS students were statistically more likely to know where an AED was in their school and the correct rate of compressions during CPR (Questions #8 and #9). For the questions #9 –

#14 assessing first aid knowledge, four of the five questions had no statistical difference between the two groups; the only question with a statistically significant difference in correct answer rate was question #11 which was knowledge identifying a stroke where there was a slightly statistically significant increase in proportion of correct answers for the CWHS group. Taken all together, on the basis of knowledge there was overall not much of a difference between the group of students who took the four house course versus the students who receive an extensive CPR and first aid curriculum.

In summary, the two parts of our study each indicate the effectiveness of a formal CPR course taught by a certified instructor. In the first part of our study comparing answers pre- and post-course for the BHHS students, ratings of confidence and percentage of correct answers regarding knowledge increased across the board. One limitation to these findings is that the investigators of this study both instructed the course and wrote the questions of the pre- and post-course assessment. This made it possible that the course was taught specifically to the test, artificially increasing the post course correct responses and levels of confidence. However the questions asked were assessing basic knowledge and

principles which should be included in any proper CPR and first aid course. The second half of our study compared the post course students to students who received a CPR and first aid education as part of their high school curriculum. Overall these results affirmed our notion that a standardized CPR course from a certified instructor improved the students’ knowledge of CPR related information. A fact that there were very few statistically significant differences in knowledge based answers shows that after our class the knowledge level of the BHHS students was similar to that of the CWHS students who received the extensive curriculum.

Again, a limiting factor is the fact that the CWHS students did not take our course but did take our test and may not have been taught to the test as the other BHHS students may have been. Another limitation is the fact that the BHHS students took the test immediately after the course when the knowledge was fresh in their minds. This study was only conducted at two high-schools in Rhode Island. Without further inclusion of students from other parts of the country, it is hard to generalize the findings to all students. Also, while the CPR class was offered to the general population of all students at this school on a voluntary basis, there was a cost of $15, which could add to sample bias. A final limitation of our study we did not directly assess procedural skills. Further studies need to be done directly assessing students performing CPR to make the assertion that an increase in confidence and knowledge leads to higher quality CPR.


The numbers from previous research on CPR practices prove that bystanders performing CPR saves lives. Our study has shown that a more formalized education in CPR improves both confidence and knowledge in performing lifesaving tasks and should be considered when devising programs to improve bystander CPR performance.


  1. Go A, et al. Heart Disease and Stroke Statistics – 2013 Update: A Report From the American Heart Association. Circulation. December 12, 2012.
  2. Larsen MP, Eisenberg MS, Cummins RO, Hallstrom AP. Predicting survival from out-of-hospital cardiac arrest: a graphic model. Ann AmergMed. 1993;22:1652-1658.
  3. Sasson C, Meischke H, Abella BS, et al. Increasing cardiopulmonary resuscitation provision in communities with low bystander cardiopulmonary resuscitation rates: a science advisory from the American Heart Association for healthcare providers, policymakers, public health departments, and community leaders. Circulation 2013; 127:1342.
  4. The PARADE/Research!America Health Poll. Charlton Research Company, 2005.
  6. Lurie, Keith G. et al. “The Physiology of Cardiopulmonary Resuscitation.” Society for Critical Care Anesthesiologists. Volume 122. March 2016.


  • Dr. Seth Lampert is currently an emergency medicine resident at Kent Hospital in Warwick, Rhode Island. He graduated medical school from Tufts University School of Medicine in Boston, Massachusetts in 2017.

  • Dr. Matthew Lombardi is currently an emergency medicine resident physician at Kent Hospital in Warwick, RI, and formerly an undersea medical officer in the U.S. Navy. He graduated medical school from the University of New England College of Osteopathic Medicine in 2013. He is an Advanced Trauma Life Support Instructor through the American College of Surgeons and an American Heart Association Instructor of Basic Life Support, Advanced Cardiac Life Support, and Pediatric Life Support.

  • Dr. Madhani is a board-certified residency trained emergency physician who is the acting ultrasound director for the emergency medicine residency based out of Kent Hospital in Warwick, Rhode Island. Dr. Madhani obtained a bachelor of science degree in biomedical engineering from the University of Texas at Austin prior to obtaining his medical degree from Baylor College of Medicine in Houston. He then went on to complete residency training in emergency medicine at the University of Pittsburgh in Pittsburgh, Pennsylvania. He subsequently completed a fellowship in emergency ultrasound at the University of Texas at Houston in the Texas Medical Center.

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