When a patient’s heart stops, the first clinician to arrive at the bedside is usually a nurse. That reality makes the quality of a nurse’s cardiopulmonary resuscitation training one of the most consequential variables in hospital medicine, and a new study from Saudi Arabia suggests it is far from uniform. Researchers reporting in BMC Nursing found that both CPR knowledge and nurses’ confidence in their own resuscitation abilities differ dramatically depending on where they work, with critical care nurses at the top of the range and outpatient clinic nurses at the bottom.

The study, conducted across healthcare facilities in Saudi Arabia’s Eastern Province, surveyed 227 nurses working in four distinct clinical environments: critical care units, inpatient wards, outpatient clinics, and primary healthcare centres. The researchers combined a twenty-item knowledge test with a ten-item self-efficacy questionnaire adapted from an instrument first developed by Roh and colleagues, which showed strong internal consistency in this sample. Alongside the survey, they carried out twenty-two semi-structured interviews to probe the lived experiences behind the numbers, analysing the transcripts using a well-established thematic framework.

The statistical picture that emerged was consistent in direction but modest in magnitude. Knowledge and self-efficacy moved together: nurses who scored higher on the CPR knowledge test also reported greater confidence in their resuscitation abilities, a correlation that was highly statistically significant. Yet knowledge accounted for only about one-tenth of the variation in self-efficacy, meaning that the vast majority of what shapes a nurse’s confidence lies outside the boundaries of what a written test can capture. This finding alone carries an important implication for training programmes, because it suggests that simply teaching more facts about resuscitation algorithms will not, by itself, produce nurses who feel ready to lead or participate in a resuscitation attempt.

The differences between settings were striking on both measures. Critical care nurses recorded the highest self-efficacy scores, while their counterparts in outpatient clinics scored lowest, and the gap between these groups was substantial relative to the spread of scores within each group. Knowledge scores also varied by setting, though the differences were somewhat less pronounced. The researchers used analysis of variance with post-hoc comparisons to confirm that these were not chance findings, and the effect sizes they reported indicate that setting explains a meaningful, if partial, share of the variability in both outcomes.

One methodological caveat deserves attention. The researchers estimated how much of the variation in outcomes could be attributed to the clustering of nurses within settings, a quantity known as the intraclass correlation coefficient. Their point estimate was low, but because only four setting categories were available for this calculation, the confidence interval around the estimate was extremely wide. The authors themselves describe this figure as exploratory, and readers should treat it as a rough indication rather than a precise measurement. What it does suggest is that individual characteristics, such as prior experience, personal confidence, and recent exposure to real resuscitation events, likely matter more than the setting label itself.

The qualitative interviews added depth that the numbers alone could not provide. Six themes emerged from the analysis. The most prominent was that direct clinical exposure to real resuscitation events was the primary driver of self-efficacy: nurses who had recently participated in or witnessed an actual cardiac arrest response reported markedly greater confidence than those whose experience was limited to classroom scenarios. This aligns with a broader body of psychological research on self-efficacy, which holds that mastery experiences, meaning successful direct performance of a task, are among the most powerful influences on a person’s belief in their own capability.

The second theme concerned fear of error and the dynamics of the resuscitation team. Nurses described how anxiety about making a mistake, particularly in front of senior colleagues or physicians, could undermine their willingness to act even when they possessed the relevant knowledge. Team hierarchy, communication patterns, and the perceived consequences of speaking up all shaped whether a nurse felt able to contribute during an actual emergency. These findings echo long-standing observations in resuscitation research about the role of psychological safety in team performance during high-stakes events.

A third theme revealed a disconnect between how training is delivered and what it is meant to achieve. Many participants described pursuing CPR certification as a box-ticking exercise, a requirement to be completed rather than a genuine opportunity to build competency. This perception, the authors suggest, may explain why knowledge scores did not translate more strongly into confidence: if training is experienced as a formality, its content may not be deeply integrated into clinical practice or self-belief.

The fourth theme identified institutional support and structured debriefing as the factors that separated high-performing settings from low-performing ones. Units where resuscitation events were routinely followed by a reflective discussion of what went well and what could be improved tended to produce nurses with stronger self-efficacy. Debriefing after real events is well recognised in the resuscitation literature as a mechanism for consolidating learning, reducing emotional distress, and improving future team performance, and this study suggests its benefits extend to nurses’ confidence as well as their skills.

The fifth theme touched on psychological and emotional determinants, including the emotional weight of participating in resuscitation attempts, the fear of patient harm, and the lingering effects of difficult experiences. The sixth theme reinforced the idea that context matters: the same nurse may feel and perform differently depending on the environment in which they work, the resources available, and the frequency with which emergencies arise.

Taken together, the findings point toward a reframing of how resuscitation preparedness is understood and cultivated. The authors conclude that differences across settings cannot be explained by knowledge deficits alone, and that psychological and organisational factors contribute substantially. Their recommendations focus on two practical interventions: simulation-based training tailored to the needs of outpatient and primary care environments, where real resuscitation events are rare and experience accumulates slowly, and the establishment of routine debriefing practices after actual resuscitation events. Both recommendations are consistent with international resuscitation council guidance, which has increasingly emphasised the value of realistic rehearsal and structured reflection alongside traditional knowledge transmission.

For outpatient clinics and primary healthcare centres, the challenge is particularly acute. Nurses in these settings may go months or years without encountering a cardiac arrest, yet when one occurs they are often the first responders, and the outcome may depend on their readiness in those first critical minutes before advanced support arrives. Infrequent real-world exposure means that simulation becomes not a supplement but a substitute, the only reliable way to maintain the familiarity and confidence that critical care nurses develop through daily practice. The study’s finding that outpatient nurses scored lowest on both knowledge and self-efficacy suggests that current training provision in these settings is not closing that gap.

The study also carries implications for how healthcare organisations measure preparedness. Because the researchers explicitly note that clinical performance was not measured, only knowledge and perceived confidence, the findings should be read as a portrait of preparedness rather than a direct assessment of resuscitation quality. Nevertheless, the strong association between the two constructs, and the clear setting-level differences, provide administrators with a practical signal: where self-efficacy is low, it is worth investigating whether the underlying causes are educational, psychological, or organisational, since each calls for a different remedy.

The research was conducted in the Eastern Province of Saudi Arabia, a region with a well-developed healthcare infrastructure that includes tertiary cardiac facilities, general hospitals, and an extensive network of primary healthcare centres. The authors report that the study received no external funding and that it was approved by three separate institutional review boards covering all participating sites, with the study conducted in accordance with the Declaration of Helsinki. The reporting follows established guidelines for cross-sectional studies and for the qualitative component, and the mixed-methods design adheres to recognised criteria for studies of this type.

As with any cross-sectional design, the study captures a single moment in time and cannot establish whether low self-efficacy causes poorer resuscitation performance, whether infrequent exposure erodes confidence, or whether both are shaped by some third factor such as organisational culture. The authors are careful to frame their conclusions in these terms. What the study does establish is that preparedness, as measured by knowledge and confidence, is unevenly distributed across the healthcare system, and that the unevenness follows a pattern closely tied to clinical exposure and institutional support. For health systems seeking to improve survival from cardiac arrest, the message is that investment in simulation and debriefing, particularly in settings where real emergencies are rare, may yield returns that classroom instruction alone cannot deliver.

Subject of Research: CPR knowledge and resuscitation self-efficacy among nurses across different healthcare settings in Saudi Arabia

Article Title: CPR knowledge and resuscitation self-efficacy among nurses across diverse healthcare settings in Saudi Arabia: a mixed-methods cross-sectional study

Article References: Almualem, J., Alabdulbaqi, D., Alzain, F., Bazboz, M., Zahran, A., Alsaffar, Z., Almzain, J., Almansour, L., Alzaher, A., Altalaq, H., Bawady, A., Alhabib, Z., & Alsulaiman, M. (2026). CPR knowledge and resuscitation self-efficacy among nurses across diverse healthcare settings in Saudi Arabia: a mixed-methods cross-sectional study. BMC Nursing. https://doi.org/10.1186/s12912-026-05312-5

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05312-5

Keywords: CPR, resuscitation, nursing, self-efficacy, Saudi Arabia, cardiac arrest, mixed-methods, primary healthcare, clinical training, simulation, debriefing, BMC Nursing