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LAYPERSON EDUCATION IN BASIC LIFE SUPPORT: IMPACT OF SHORT

COURSES ON EARLY DETECTION OF CARDIOPULMONARY ARREST

AND EMERGENCY RESPONSE

Alexander da Silva Borges1

Marco Antonio Plautz Chocron2

Abstract: Out-of-hospital cardiopulmonary arrest (OCA) is a high-mortality event, and survival

critically depends on the immediate intervention of bystanders. The participation of the lay population

in basic life support (BLS) actions is therefore essential to increase survival rates. This study will

investigate the educational impact of short BLS courses, taught by nurses, academic institutions,

and re departments, on the training of laypeople. The research will adopt a mixed-methods design,

integrating a quantitative assessment of knowledge and skills (pre- and post-training) with a qualitative

analysis of the psychosocial factors that modulate the willingness to intervene. Variables such as

early recognition of CPA, appropriate activation of emergency services, quality of chest compressions

(depth, frequency, chest recoil), and correct use of an automated external debrillator (AED) will

be examined. The study will also consider factors such as self-condence, anxiety, perceived

barriers, and motivation. Expected outcomes include validating short courses as an effective tool

1 Specialist nurse in intensive care, seeking opportunities and challenges in the area of pre-hos-

pital nursing, contributing to the development of the profession and promoting quality and safety in

urgent and emergency care through the dissemination of knowledge in this area.

2 Master’s degree in Health and Technology in the Hospital Environment from the Federal Uni-

versity of the State of Rio de Janeiro - UNIRIO (2015). Specialist in Urgency and Emergency Care,

Specialist in Occupational Nursing. Bachelor’s degree in Nursing from Estácio de Sá University (2010).

Sub-Lieutenant Fireghter - RIO DE JANEIRO MILITARY FIRE DEPARTMENT (2002). Specialist

in First Aid (2011); Specialist in Technical Approach to Suicide Attempts (2023), Specialist in Canine

Training, all from CBMERJ. Works on the cardiopulmonary resuscitation project through Realistic

Simulation, developed by UNIRIO (2017). Member of the Teaching, Research and Extension Group

in Health in Emergencies and Disasters - GEPESED / UFRJ (2019). She has experience in the areas of

Nursing, pre-hospital care, education of laypeople and healthcare professionals in emergencies, and

studies for re evacuation in hospitals.

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Introduction

Out-of-hospital cardiac arrest (OHCA) is one of the most signicant public health challenges

worldwide, accounting for a substantial portion of cardiovascular mortality. Epidemiological data

from the United States and other industrialized nations indicate hundreds of thousands of occurrences

annually, with survival rates that, despite advances in emergency medicine, remain alarmingly low,

frequently below 12% (Rao & Kern, 2018).

The vast majority of these deaths occur suddenly, outside of a hospital setting, where survival

is a race against time.

The American Heart Association (AHA) and the International Liaison Committee on

Resuscitation (ILCOR) have consolidated the approach to this emergency in the concept of the “Chain

of Survival.” This chain illustrates a sequence of interdependent and time-sensitive actions that, if

initiated promptly, maximize the chance of a favorable neurological outcome. The initial links—

immediate recognition of cardiac arrest and activation of emergency services, followed by high-

quality cardiopulmonary resuscitation (CPR) and rapid debrillation—are primarily the responsibility

of bystanders present at the scene (American Heart Association, 2025). In fact, the literature is

unequivocal: CPR initiated by a bystander can double or even triple the victim’s chances of survival

(Rao & Kern, 2018).

However, the gap between the ideal and reality is vast. Intervention rates by the general

public are insufcient, a multifactorial phenomenon attributed to lack of knowledge, fear of causing

for increasing public condence and competence, expanding community response to emergencies,

and strengthening health education policies aimed at reducing cardiac arrest mortality, aligned with

international resuscitation guidelines.

Keywords: Basic Life Support, Cardiopulmonary Arrest, Health Education, Laypersons,

Cardiopulmonary Resuscitation, Community Intervention.

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harm, psychological barriers such as anxiety and lack of condence, and social concerns such as fear

of litigation or reluctance to intervene with strangers (Uny et al., 2022). To overcome these barriers,

community interventions, particularly Basic Life Support (BLS) education, emerge as the most

promising strategy. A recent meta-analysis demonstrated that such interventions are associated with

a signicant increase in bystander CPR rates (Odds Ratio of 2.26) and overall survival (OR of 1.59)

(Simmons et al., 2023).

In this context, short courses focused on practical and simplied training are proposed as a

scalable and cost-effective approach to disseminate these vital skills (Al Jadidi & Al Jufaili, 2023). This

article proposes an in-depth study to investigate the impact of these courses on the ability of laypeople

to execute the initial links in the survival chain, analyzing not only the acquisition and retention of

skills, but also the psychosocial factors that determine the crucial transition from knowledge to action.

Literature Review

Epidemiology and Outcomes of Out-of-Hospital Cardiac Arrest

Out-of-hospital cardiac arrest is a common and devastating event. Large-scale epidemiological

studies, such as those by Chugh et al. (2008) and Zheng et al. (2001), estimated the annual incidence of

sudden cardiac death in the US to be between 180,000 and 450,000 cases (Chugh et al., 2008; Zheng

et al., 2001). In the UK, the numbers are equally signicant, with approximately 60,000 occurrences

annually (Hawkes et al., 2017). Survival rates vary drastically between different regions, ranging

from less than 2% to more than 25%, a variation largely explained by differences in the organization

of emergency systems and, fundamentally, in community engagement (Hawkes et al., 2017).

More recent studies conrm this variability, with 30-day survival rates ranging from 10.6%

to 22.1% in a 10-year analysis in Austria (Schwaiger et al., 2025).

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Basic Life Support Education Strategies and Skills Retention

The teaching methodology in Basic Life Support (BLS) has evolved signicantly. Hands-on

training is universally recognized as superior to purely theoretical instruction. The introduction of

simulation, especially with high-delity mannequins that provide real-time feedback on the quality

of compressions (depth, frequency, and chest recoil), has been shown to improve skill acquisition

(Herrero-Izquierdo et al., 2025; Faghihi et al., 2024). Sahu and Lata (2010) highlight that simulation

allows practice in a safe environment, replicating crisis scenarios and improving team performance

(Sahu & Lata, 2010).

The delivery format has also diversied, with the emergence of blended learning models,

which combine online modules with in-person practical sessions. This approach proves to be no

less effective than traditional training and offers greater exibility and scalability (Lim et al., 2022).

However, a persistent challenge is the rapid deterioration of CPR skills after training. Studies such

as that of Aqel et al. (2014) show a signicant loss of knowledge and skills within the rst 3 to 6

months, underscoring the critical need for periodic retraining programs to maintain competence (Aqel

& Ahmad, 2014). Short and frequent refresher courses have proven effective in combating this decline

(Al Jadidi & Al Jufaili, 2023).

Psychosocial Factors and Barriers to Intervention

A layperson’s decision to intervene in an emergency is a complex psychological process.

Self-condence is one of the strongest predictors of willingness to perform CPR (Jaskiewicz et al.,

2022). Fear of causing further harm, uncertainty in the diagnosis of cardiac arrest, and situational

anxiety are prominent psychological barriers. Additionally, social factors, such as fear of litigation,

perceived risk to personal safety (especially in certain urban contexts), and reluctance to have physical

contact with a stranger, also inhibit action (Uny et al., 2022).

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Studies in socioeconomically disadvantaged communities reveal that, although the

willingness to learn CPR is not lower, the condence to act is often lower, and barriers such as

lack of community cohesion and fear of violence are more acute (Uny et al., 2022). The “Intention-

Focused” paradigm, proposed by Panchal et al. and explored by Jaskiewicz et al. (2022), emphasizes

that training programs should go beyond technique, explicitly addressing these psychological barriers

to increase the likelihood of intervention (Jaskiewicz et al., 2022).

Public Policies and Community Implementation

Recognizing the importance of mass training, many governments have implemented public

health policies to promote BLS education. The most widespread strategy is legislation that makes

CPR training mandatory for high school graduation. In the US, more than 40 states have already

adopted such laws (CPR in Schools Legislation Map, 2025). This approach has the potential to train

millions of young people each year, creating a generation of potential rst responders. Studies on the

implementation of these laws, such as that of Vetter et al. (2022), highlight the importance of providing

adequate resources to schools, especially in low-income communities, to ensure the effectiveness of

the training (Vetter et al., 2022).

Targeted community programs, such as those described by Ebunlomo et al. (2021), which

offer free, bilingual training in high-risk neighborhoods, have also proven viable and effective

(Ebunlomo et al., 2021).

Methodology

To robustly and holistically investigate the impact of BLS courses, a mixed-methods research

design with a longitudinal component will be adopted.

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Study Design and Population

The study will follow a quasi-experimental pre-post-test design with an intervention group.

The sample will consist of lay adult participants (>18 years old), without formal BLS training in the

last ve years, recruited from diverse community settings (businesses, neighborhood associations,

community centers) to ensure socioeconomic and demographic representativeness.1.

Educational Intervention

The intervention will consist of a 4-hour BLS (Basic Life Support) course, structured based

on the 2025 AHA/ILCOR (American Heart Association, 2025) guidelines. The course will be taught

by certied instructors and divided into:

• Theoretical Module (1 hour): Covering the pathophysiology of cardiac arrest, the chain

of survival, and the steps of basic life support (BLS).

• Practical Module (3 hours): Intensive training in small groups using high-delity CPR

mannequins with real-time audiovisual feedback. Simulated scenarios will include

recognizing cardiac arrest, activating emergency services, performing high-quality chest

compressions, and applying a training AED.

Data Collection and Analysis

Assessments will take place at three points in time: T0 (baseline, before the course), T1

(immediately after the course), and T2 (six months after the course).

1 is project was submitted to the Research Ethics Committee of the Faculty of Human and

Social Sciences at the University of Brasília.

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Table 1. Instruments for statistical data collection and analysis.

Domain Evaluated Instrument / Metric C o l l e c t i o n

Moments

Statistical Analysis

Theoretical Knowledge Validated questionnaire (20

multiple-choice questions)

T0, T1, T2 Repeated measures

A NOVA

Practical Skills Simulated scenario with high-

delity mannequin.

T0, T1, T2 Paired t-tests /

Wilcoxon

Quality Metrics Average depth, frequency,

compression fraction, time to

impact

T1, T2 Analysis of variance

Self-condence 5-point Likert scale (self-assessment

of condence)

T0, T1, T2 Repeated measures

A NOVA

Psychosocial Factors Semi-structured interviews and

focus groups

T2 Thematic content

analysis

Qualitative Analysis:Interviews and focus groups in T2 will explore in depth participants’

perceptions of barriers and facilitators to action, the usefulness of the training, and their residual

condence, seeking to understand the “why” behind the quantitative data.

Expected Results

Based on the reviewed literature, it is anticipated that the study will conrm and quantify

several hypotheses:

Signicant Improvement in Knowledge and Skills

A sharp and statistically signicant increase (p < 0.05) is expected in knowledge scores

and practical skills performance from T0 to T1. The quality of compressions, measured objectively,

should reach the standards recommended by the guidelines in the immediate post-course assessment.

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Increased Self-Condence and Willingness to Act

A substantial increase in reported self-condence levels is projected for each step of BLS

between T0 and T1. Qualitative analysis should corroborate this nding, with participants expressing

greater readiness to intervene after practical training demystied the procedure and reduced

performance anxiety.

Partial Decline, but Functional Retention of Skills

At the six-month assessment (T2), a statistically signicant decline in skills is expected

compared to T1, consistent with the literature on retention (Aqel & Ahmad, 2014). However, scores at

T2 are expected to remain signicantly higher than at baseline (T0), indicating that participants retain

a level of functional competence that would still be benecial in a real emergency.

Identication of Residual Barriers

Qualitative analysis will likely reveal that, even after training, some psychological (e.g., fear

of a negative outcome, panic) and social (e.g., concern about the scene, presence of multiple spectators)

barriers persist as concerns, informing areas for focus in future training programs.

Discussion

The expected results of this study have the potential to generate important implications for

public health practice and policy. By validating the effectiveness of a short-duration, high-intensity

training model, the study will provide an evidence-based argument for its widespread adoption by

companies, schools, and community organizations. The demonstration that such an intervention not

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only teaches technique but also boosts self-condence reinforces the need to focus on practical and

simulation components in course design.

Data on skill decline over six months will contribute to the formulation of evidence-based

recommendations on the ideal frequency for refresher courses. Instead of a single model, reinforcement

“dosing” strategies, such as short videos or brief practical sessions, could be considered to maintain

community readiness.

Furthermore, in-depth exploration of residual psychosocial barriers can lead to innovations

in the training curriculum. For example, including discussions on stress management in emergencies

or simulating socially complex scenarios (e.g., a victim in a crowded public place) can better prepare

laypersons for real-world challenges.

Conclusion

Training laypersons in Basic Life Support is a cornerstone of the strategy to combat the high

mortality rate of out-of-hospital cardiac arrest. This study aims to provide a rigorous and multifaceted

evaluation of the effectiveness of short-duration courses, a promising intervention model due to its

scalability and feasibility.

By measuring not only “what” laypeople learn, but “if” and “why” they feel prepared to act,

the research seeks to generate actionable insights to optimize training programs, inform public policy,

and ultimately strengthen the chain of survival. The ultimate goal is to transform passive bystanders

into active rst responders, increasing the chances that every citizen can one day save a life.

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