Cardiopulmonary Resuscitation Competency and Implementation Barriers among Security Guards in Urban China: A Mixed-Methods Study

Background Out-of-hospital cardiac arrest (OHCA) has a survival rate of just 1.2% in China, with bystander cardiopulmonary resuscitation (B-CPR) performed in only 4.5% of cases. Despite their formal designation as frontline responders, the CPR competency of security guards remains largely unknown. This study assessed their CPR knowledge, attitudes, behaviors, self-efficacy, and skills, and explored barriers to implementation. Methods A convergent mixed-methods design was employed across six public settings in Shanghai (2020–2022). Quantitative data (n = 1,001) were analyzed using descriptive statistics, regression, and latent profile analysis (LPA). Qualitative interviews (n = 15) explored implementation barriers. The Pillar Integration Process (PIP) synthesized findings. Results Only 5.8% of guards demonstrated guideline-aligned CPR performance. Knowledge (mean: 35.1%), self-efficacy (55.0%), and behavioral scores (54.7%) were suboptimal. LPA identified three subgroups: low (77.0%), moderate (19.6%), and high behavior (3.4%). Low behavior was predicted by subway worksite (OR = 5.47), low self-efficacy (OR = 1.29), and lack of recent training (OR = 0.28). Thematic analysis revealed multilevel barriers: individual (skill decay), organizational (role ambiguity), societal (legal fears), and victim-level (hesitation toward gender/age). Integration via the Pillar Integration Process yielded a comprehensive explanatory framework (Fig. 2) capturing the dynamic interplay between psychological readiness, contextual barriers, and CPR behavior. Conclusions CPR competency gaps among security guards are critical yet modifiable. Targeted retraining, legal clarification, and institutional mandates are urgently needed to support China’s bystander response system and the Healthy China 2030 agenda.