Basic Life Support and Resuscitation-Related Knowledge, Situation, and Attitudes Questionnaire

Abstract

The Basic Life Support and Resuscitation-Related Knowledge, Situation, and Attitudes Questionnaire (Gradvohl et al., 2023) is a comprehensive psychometric assessment tool specifically constructed to evaluate the multidimensional preparedness of adolescents and school-aged children regarding cardiopulmonary resuscitation (CPR) and basic life support (BLS) execution in real-world crisis settings. Bystander CPR significantly elevates survival rates following out-of-hospital cardiac arrest (OHCA); however, bystander intervention rates among the lay public, including young bystanders, remain constrained by deficits in knowledge, operational apprehension, and ambiguous prosocial motivation. To rigorously evaluate educational interventions aimed at young populations, Gradvohl and colleagues developed an instrument comprising two overarching sections: Part I, which captures general individual baseline variables across sociodemographic parameters (3 items), adolescent health behaviors (10 items), and historical exposure to BLS instruction (1 item); and Part II, which operationalizes domain-specific resuscitation competency through cognitive knowledge (initially 36 items), real-world hypothetical situational decision-making (2 items), and prosocial bystander attitudes (8 items).

Psychometric evaluation was performed on a sample of primary and secondary school pupils in Hungary who participated in standardized resuscitation training initiatives. Psychometric scrutiny, including item difficulty analysis (p-values) and 10-day test-retest temporal stability evaluation, established refined discriminatory performance. Knowledge item difficulties assessed among BLS-naïve adolescents (n = 123) demonstrated acceptable discrimination indexes, with select items isolating core technical BLS metrics such as chest compression rates, compression depth, automated external defibrillator (AED) utility, and recognition of agonal respiration. Correlation analyses among situational and attitudinal items revealed robust intra-individual stability across time. This measurement tool equips clinical educators, school health coordinators, public health epidemiologists, and pediatric psychologists with a methodologically validated, developmentally targeted metric for quantifying resuscitation readiness, programmatic efficacy, and psychosocial barriers to emergency bystander intervention.

Keywords

Basic Life Support, Resuscitation, Out-of-Hospital Cardiac Arrest, Adolescent Health, Bystander Intervention, Cardiopulmonary Resuscitation, Health Knowledge, Prosocial Attitude, Pediatric Psychometrics, Emergency Preparedness

Authors

The questionnaire was developed and validated by an interdisciplinary team of researchers and clinical resuscitation specialists affiliated with Semmelweis University in Budapest, Hungary:

• Edina Gradvohl, Ph.D. — Faculty of Health Sciences, Semmelweis University, Budapest, Hungary. Correspondence: Semmelweis University, Faculty of Health Sciences, Vas street 18, Budapest, Hungary, H-1088. Email: [email protected]
• Ágnes J. Lukács, Ph.D. — Faculty of Health Sciences, Semmelweis University, Budapest, Hungary.
• Johanna Takács, Ph.D. — Faculty of Health Sciences, Semmelweis University, Budapest, Hungary (ORCID: 0000-0002-8709-8826).
• Gábor Fritúz, M.D., Ph.D. — Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary.
• András Falus, Ph.D., D.Sc. — Department of Genetics, Cell, and Immunobiology, Semmelweis University, Budapest, Hungary.
• Helga Judit Feith, Ph.D. — Faculty of Health Sciences, Semmelweis University, Budapest, Hungary (ORCID: 0000-0001-8855-5059).

Purpose

Out-of-hospital cardiac arrest represents one of the foremost leading causes of mortality globally. International resuscitation guidelines, such as those promulgated by the European Resuscitation Council (ERC) and the American Heart Association (AHA), have repeatedly affirmed that early bystander cardiopulmonary resuscitation and rapid deployment of an automated external defibrillator double or triple survival rates. Consequently, global public health initiatives, such as the World Health Organization-endorsed “KIDS SAVE LIVES” campaign, advocate for mandatory, systemic resuscitation training within primary and secondary school curricula. Educating school-aged youth creates a generation of empowered, lifelong lay responders who carry knowledge and readiness into domestic and civic environments.

Notwithstanding the proliferation of school-based CPR training paradigms, educational institutions and public health agencies historically lacked a standardized, methodologically rigorous psychometric instrument tailored to the developmental, cognitive, and psychosocial profiles of children and adolescents. Existing instruments frequently suffered from non-validated item banks, exclusive focus on rote factual recall, or total neglect of the emotional and situational determinants of bystander intervention. Gradvohl and colleagues (2023) developed the Basic Life Support and Resuscitation-Related Knowledge, Situation, and Attitudes Questionnaire to fill this critical measurement gap.

The primary clinical and pedagogical purpose of the instrument is to systematically assess the instructional efficacy of pediatric and adolescent BLS educational programs. Beyond documenting whether adolescents memorize theoretical facts (such as the numerical ratio of compressions to ventilations), the questionnaire evaluates whether students possess the affective readiness, self-efficacy, moral conviction, and operational confidence necessary to overcome the bystander effect when encountering a medical emergency. The scale fulfills several functional research and applied objectives:

• Pedagogical Program Evaluation: Serving as an objective pre-test and post-test measurement battery to quantify learning gains across diverse teaching methodologies, such as peer-led training, virtual reality simulation, or traditional instructor-led mannequin sessions.
• Identification of Cognitive Misconceptions: Pinpointing critical deficits in emergency symptom appraisal, such as the conflation of agonal gasps (abnormal snoring breathing) with adequate respiratory function, which frequently delays resuscitation initiation.
• Psychosocial Risk Screening: Gauging fear-driven barriers to action, including panic regarding disease transmission, somatic hesitation regarding causing musculoskeletal injury (e.g., fractured ribs), and social anxiety surrounding public intervention.
• Longitudinal Retention Tracking: Measuring the decay rate of knowledge, self-efficacy, and moral willingness over 3-, 6-, and 12-month post-training intervals to establish optimal refresher training schedules in secondary schools.

Psychological Construct

The questionnaire conceptualizes basic life support competence not merely as a mechanical skill set, but as an integrated sociocognitive construct comprising three core, interdependent psychological dimensions: cognitive-procedural knowledge, situational appraisal and willingness, and prosocial attitudes.

1. Cognitive and Procedural Knowledge

The cognitive knowledge domain examines the mental representations and declarative understanding of emergency protocols necessary to sustain cerebral and coronary perfusion. Rather than evaluating isolated trivia, this dimension focuses on action-oriented heuristics required during critical incidents. Key cognitive components include:

• Recognition of Cardiac Arrest: Distinguishing unresponsiveness accompanied by absent or abnormal breathing (specifically recognizing agonal breathing and irregular gasping) from non-arrest states such as acute stroke or simple syncope.
• Biomechanical Parameters: Accurate factual retention of compression mechanics, including optimal chest compression rates (100–120 compressions per minute) and physiological compression depth (5–6 cm in adults) necessary to generate adequate forward cardiac output.
• Technological Competence (AED Utility): Understanding the operational simplicity of automated external defibrillators, recognizing that modern devices provide clear voice and visual prompts that enable any layperson to safely deliver defibrillation without prior clinical credentials.
• Emergency Communication Protocols: Cognitive familiarity with emergency dispatch communication, identifying oneself to dispatchers, and following dispatcher-assisted CPR (telecommunicator CPR) directives.

2. Situational Appraisal and Behavioral Willingness

The situational domain captures behavioral intent across varying social environments. Research in social psychology shows that situational factors substantially moderate prosocial action. Specifically, bystanders exhibit different behavioral thresholds depending on the relational closeness of the victim. The instrument isolates two distinct ecological contexts:

• Familiar/Kinship Emergency Scenario: Behavioral willingness to initiate CPR when the victim is a family member or close relative in a private domestic setting. In these scenarios, emotional closeness heightens internal motivation, though affective panic may impede systematic execution.
• Unfamiliar/Stranger Public Scenario: Behavioral willingness to intervene when an unknown stranger collapses in a public street or public square. Here, public scrutiny, evaluation apprehension, and diffusion of responsibility represent formidable psychological hurdles.

3. Prosocial Bystander Attitudes and Affective Self-Efficacy

The attitudinal subscale assesses internal belief systems, moral obligations, and emotional apprehensions regarding emergency medical assistance. This domain addresses the affective and motivational determinants that translate cognitive knowledge into overt motor action:

• Civic Duty and Moral Obligation: Beliefs regarding whether basic life support should be compulsory within educational curricula, and whether society should legally or morally require citizens to provide assistance to individuals experiencing life-threatening distress.
• Affective Self-Efficacy: Subjective confidence in one’s capacity to correctly detect a cardiac arrest state under stress and successfully initiate resuscitation.
• Perceived Risk of Harm (Iatrogenic Apprehension): Inhibitory anxiety regarding causing physical harm or bodily injury (such as rib fractures or sternal separation) to the victim during vigorous chest compressions.
• Infection Anxiety and Barrier Concerns: Affective reluctance or hesitation to initiate interventions—particularly rescue breaths or mouth-to-mouth resuscitation—driven by fear of infectious disease transmission.
• Dispatcher Alliance: Receptivity and trust toward instructions provided by emergency medical services (EMS) dispatch personnel via telephone guidance during an ongoing resuscitation attempt.

Theoretical Framework

The conceptual architecture of the Basic Life Support and Resuscitation-Related Knowledge, Situation, and Attitudes Questionnaire is grounded in established models of social psychology, health behavior, and emergency intervention, primarily integrating the Bystander Intervention Model, the Theory of Planned Behavior, and Social Cognitive Theory.

The Bystander Intervention Model (Latané & Darley)

Bibb Latané and John Darley’s seminal (1970) five-step bystander intervention model provides the structural foundation for the situational and cognitive elements of the scale. According to this framework, an individual can only provide emergency aid if they navigate five successive sequential cognitive steps:

1. Notice that something is happening: The observer must attend to the sudden collapse of an individual in their sensory field.
2. Interpret the event as an emergency: The observer must recognize that the victim is in life-threatening cardiac arrest rather than intoxicated, sleeping, or experiencing a transient faint. Items in the knowledge domain assessing the identification of agonal breathing specifically measure this interpretive capacity.
3. Assume personal responsibility: The individual must overcome diffusion of responsibility. The attitudinal items measuring perceived moral duty and societal expectations gauge this sense of personal obligation.
4. Know appropriate form of assistance: The layperson must possess the procedural knowledge (compression depth, rates, AED execution) to intervene safely and effectively.
5. Implement the chosen intervention: The bystander must overcome inhibitory anxieties, such as the fear of causing musculoskeletal injury or contracting disease, to perform chest compressions.

The Theory of Planned Behavior (Ajzen)

Icek Ajzen’s Theory of Planned Behavior (TPB) posits that behavioral execution is directly governed by behavioral intention, which is jointly shaped by attitudes toward the behavior, subjective norms, and perceived behavioral control:

• Attitudes Toward the Behavior: Captured by items querying whether CPR training should be compulsory, whether helping is valuable, and whether bystander action is socially beneficial.
• Subjective Norms: Reflected in items probing societal expectations of children and laypersons to render aid to distressed individuals, including normative accountability.
• Perceived Behavioral Control: Operationalized through self-efficacy items assessing personal confidence in cardiac arrest identification, confidence in following EMS dispatcher telephone coaching, and low inhibitory fear regarding potential mechanical errors.

Social Cognitive Theory and Self-Efficacy (Bandura)

Albert Bandura’s Social Cognitive Theory underscores self-efficacy—the subjective belief in one’s capabilities to execute actions required to manage prospective situations—as the primary driver of goal-directed performance. In the context of pediatric resuscitation education, acquiring cognitive knowledge without self-efficacy yields behavioral paralysis during crises. By evaluating adolescents’ fear of doing harm and confidence in recognizing arrest, Gradvohl et al.’s questionnaire captures this self-regulatory dynamic.

Validity

The psychometric validation of the questionnaire was conducted by Gradvohl et al. (2023) across multiple Hungarian educational cohorts, evaluating content validity, item difficulty, and criterion-related validity.

Content and Face Validity

The initial instrument items were generated through an extensive literature review of international resuscitation guidelines (European Resuscitation Council, American Heart Association) and existing first-aid assessment paradigms. An expert panel comprising anesthesiologists, emergency medicine intensivists, health science pedagogues, and public health researchers reviewed the item pool to guarantee clinical accuracy, clarity of pediatric phrasing, and relevance to the target demographic.

Item Difficulty and Discrimination (Knowledge Subscale)

To eliminate response bias and ceiling effects associated with prior instructional exposure, item difficulty indices (p-values) were calculated using a baseline subsample of adolescents who had no previous exposure to basic life support training (n = 123). In psychometrics, an acceptable item difficulty index generally ranges from 0.20 to 0.80, indicating that items are neither excessively facile (yielding ceiling effects) nor overly difficult (yielding floor effects):

• Acceptable Range Items: Nine knowledge items demonstrated difficulty indices within the psychometrically desirable 0.20 to 0.80 window, reflecting clear discriminatory capacity among adolescents with varying degrees of baseline intuition.
• Out-of-Range Items: Fifteen items fell outside this optimal psychometric range: 14 items had difficulty values exceeding 0.80 (>80% of untrained adolescents answered correctly, indicating high intuitive obviousness or excessive cueing), and 1 item fell below 0.20 (<20% correct, indicating extreme clinical obscurity for school-aged youth).
• Refined Effective Items: Ultimately, eight knowledge items demonstrated optimal combined psychometric performance across item difficulty and test-retest stability, isolating core factual domains of bystander BLS.

Criterion and Relational Validity (Situation and Attitude Subscales)

Bivariate correlation analysis demonstrated meaningful construct-related validity among the situation and attitude variables:

• Situational Items: Repeated measurements confirmed a statistically significant, strong positive correlation between situational items (r > 0.70), demonstrating consistent behavioral intent across distinct emergency scenarios.
• Attitudinal Correlations: Six of the eight attitude items exhibited moderate, statistically significant positive Pearson product-moment correlation coefficients with prosocial intervention willingness. One attitude item demonstrated a strong positive correlation, while one item displayed a non-significant correlation, highlighting distinct attitudinal nuances between moral conviction and operational hesitation.

Reliability

The temporal stability of the questionnaire was evaluated via a test-retest methodology administered to adolescent cohorts with a 10-day inter-test interval. Test-retest reliability reflects the degree to which an instrument yields consistent scores across repeated administrations in the absence of an intervening educational manipulation.

Test-Retest Temporal Stability (Part II Knowledge Pool)

Across the initial 36 cognitive knowledge statements evaluated over the 10-day testing interval, stability coefficients varied across three performance strata:

• High Reliability: Ten items demonstrated strong test-retest stability coefficients exceeding r = 0.70, indicating robust, enduring conceptual retention over time.
• Moderate Reliability: Nine items exhibited moderate stability coefficients falling between r = 0.40 and r = 0.70.
• Low/Unacceptable Reliability: Eight items demonstrated stability coefficients below r = 0.40, indicating vulnerability to guessing, ambiguous phrasing, or unstable adolescent baseline beliefs.

By cross-referencing temporal stability coefficients (r > 0.40) with optimal item difficulty indexes (0.20 ≤ p ≤ 0.80), the researchers isolated an effective core set of psychometrically resilient knowledge questions suitable for pre- and post-intervention evaluations.

Factor Analysis

In the original validation study by Gradvohl et al. (2023), no formal factor analysis (exploratory factor analysis [EFA] or confirmatory factor analysis [CFA]) was indicated or performed on the overall instrument pool. The authors structured the questionnaire based on established pedagogical, clinical, and theoretical criteria aligned with European Resuscitation Council guidelines rather than empirical latent factor reduction.

The deliberate omission of latent factor modeling reflects the structural heterogeneity of the instrument’s component domains:

• Index vs. Scale Construction: The cognitive knowledge domain functions as a formative pedagogical criterion index rather than a reflective latent psychometric trait. In declarative clinical knowledge tests, individual knowledge elements (such as compression depth vs. AED operational knowledge) are not necessarily driven by a single common causal factor; a student may master phone dispatch communication without mastering the biomechanical depth of sternal compressions. Consequently, internal consistency metrics (such as Cronbach’s alpha) and factor loadings are less theoretically relevant than item difficulty, content representativeness, and test-retest stability.
• Situational-Attitudinal Differentiation: The situation items (2 items) and attitude items (8 items) represent distinct behavioral scenarios and cognitive-affective evaluations. While subsequent cross-cultural adaptations and larger multicenter trials may perform CFA to evaluate whether attitudes fall into latent dimensions (such as ‘Prosocial Civic Duty’ versus ‘Intervention Anxiety’), the original 2023 validation established the instrument’s utility through classical item analysis and bivariate test-retest correlation.

Instrument / Measurement Tool

• Instrument Name: Basic Life Support and Resuscitation-Related Knowledge, Situation, and Attitudes Questionnaire (BLS-SAQ)
• Authors: Edina Gradvohl, Ágnes J. Lukács, Johanna Takács, Gábor Fritúz, András Falus, and Helga Judit Feith (Semmelweis University)
• Publication Year: 2023
• Test Type: Original standardized inventory, educational evaluation questionnaire
• Target Population: Primary and secondary school students, children, and adolescents (school age: 6–12 years; adolescence: 13–17 years)
• Administration Format: Self-administered paper-and-pencil or digital interactive survey
• Language Available: English (developed and tested in Hungarian cohorts)
• Structural Organization:
  • Part I (General Information): 14 baseline background items:
    • Sociodemographic background: 3 items (e.g., age, biological sex, grade level)
    • Health behavior indices: 10 items (e.g., physical activity, health-related lifestyle habits)
    • Previous BLS training exposure: 1 item (prior participation in resuscitation instruction)
  • Part II (Basic Life Support Domains): 46 total original items:
    • Knowledge items: 36 declarative statements assessing core clinical BLS topics (with 8 core items demonstrating optimal psychometric properties)
    • Situation items: 2 real-world emergency scenarios measuring behavioral willingness
    • Attitude items: 8 statements capturing prosocial duty, intervention confidence, and affective anxieties
• Response Scale (Mandatory Standard Formulation): The instrument is comprised of the following domains: Part I (General information [socio-demographic, 3 items; health behavior, 10 items; and previous BLS training, 1 item]), Part II (BLS [knowledge, 36 items; situation, 2 items; and attitude, 8 items]).
• Scoring and Interpretation Procedures:
  • Knowledge Subscale: Scored dichotomously (1 = Correct, 0 = Incorrect). Summed to generate a composite objective BLS knowledge score.
  • Situation and Attitude Subscales: The questionnaire evaluates two main components: Situation/Willingness to act in emergency scenarios (Items 1-2) and Attitudes towards Basic Life Support (BLS) and resuscitation (Items 3-10). Scores on the 8 Likert items can be summed or averaged to assess positive attitude towards bystander resuscitation.
  • Reverse Scoring Rules: In accordance with standard psychometric evaluation of the attitude domain, items reflecting negative or inhibitory barriers (such as fear of causing injury, fear of disease transmission, or viewing personal matters as more urgent than assisting) must be reverse-coded prior to composite summation, so that higher cumulative scores consistently reflect greater prosocial readiness and lower psychological hesitation.

Permissions & Fee and Test Year

The Basic Life Support and Resuscitation-Related Knowledge, Situation, and Attitudes Questionnaire was published in 2023. In accordance with open-science practices and educational dissemination goals, the instrument is licensed under the Creative Commons Attribution 4.0 International License (CC BY 4.0).

• Commercial Use: Non-commercial research and educational applications permitted without fees.
• Usage Fee: None. Free access for academic, educational, and public health research.
• Permissions: Researchers, school boards, and health educators may reproduce, translate, and implement the questionnaire for non-commercial research, quality improvement, and instructional assessments, provided appropriate academic attribution is given to the original authors (Gradvohl et al., 2023) and the publication venue (Evaluation and Program Planning).

References

• Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2), 179–211. https://doi.org/10.1016/0749-5978(91)90020-T
• Bandura, A. (1997). Self-efficacy: The exercise of control. W. H. Freeman and Company.
• Böttiger, B. W., Semeraro, F., & Wnent, J. (2020). KIDS SAVE LIVES: School children education in resuscitation worldwide is feasible. Resuscitation, 156, 238–240. https://doi.org/10.1016/j.resuscitation.2020.08.121
• Gradvohl, E., Lukács, Á. J., Takács, J., Fritúz, G., Falus, A., & Feith, H. J. (2023). Development and validation of the questionnaire on resuscitation-related knowledge and attitude for adolescents. Evaluation and Program Planning, 100, 102338. https://doi.org/10.1016/j.evalprogplan.2023.102338
• Latané, B., & Darley, J. M. (1970). The unresponsive bystander: Why doesn’t he help? Appleton-Century-Crofts.
• Olasveengen, T. M., Semeraro, F., Ristagno, G., Castren, M., Handley, A., Kuzovlev, A., Monsieurs, K. G., Raffay, V., Smyth, M., Soar, J., Svavarsdottir, H., & Perkins, G. D. (2021). European Resuscitation Council Guidelines 2021: Basic Life Support. Resuscitation, 161, 98–114. https://doi.org/10.1016/j.resuscitation.2021.02.009
• Plant, N., & Taylor, K. (2013). How best to teach CPR to schoolchildren: A systematic review. Resuscitation, 84(4), 415–421. https://doi.org/10.1016/j.resuscitation.2012.12.008

Items of the Scale