Research Article - Clinical Practice (2018) Volume 15, Issue 4
Critical care nurses' knowledge and practice regarding life-threatening ventricular dysrhythmias
- Corresponding Author:
- Nahla Shaaban Khalil
Critical Care Nursing Department,Faculty of Nursing Nursing,Cairo University
E-mail: nahlakhalil28@yahoo.com
Abstract
Background: Life-threatening ventricular dysrhythmia is the most common fatal dysrhythmias encountered in coronary care units. The ability of the nurse to quickly analyze abnormal ECG rhythm as well as initiating appropriate intervention is critical. The aim of the study was to assess the nurses' knowledge and practice related to management of life-threatening ventricular dysrhythmias. Methods: A descriptive exploratory design was utilized and conducted in all available coronary care units at a teaching university hospital in Egypt including 41 nurses working in these units. Nurses' baseline, knowledge questionnaire and observational checklists regarding dysrhythmia management were utilized. Results: Most of the studied nurses have got unsatisfactory knowledge level and practices concerning management of life-threatening ventricular dysrhythmias. Moreover, nurses' practices were positively correlated with knowledge, age and years of experience. Conclusion and recommendations: It can be concluded that critical care nurses' knowledge and practices regarding life-threatening ventricular dysrhythmias were inadequate and need to be improved. As well, enrichment of nurses' knowledge and practice regarding lethal dysrhythmias detection and management is highly recommended with replication of this study on a larger probability sample from the different geographical locations of in Egypt.
Keywords
coronary care unit, ventricular tachycardia, ECG, ventricular dysrhythmias
Introduction
Critically ill patients have life-threatening health problems that necessitate continuous monitoring and intervention to restore health and prevent complications. Cardiac arrhythmias especially ventricular dysrhythmias is the most common health problem encountered in coronary care unit (CCU). It is not only associated with prolonged length of stay but it associated with sudden cardiac death [1].
Ventricular dysrhythmia is a disturbance in the normal rhythm of the electrical activity of the heart that originates in the ventricles and range from asymptomatic rhythm like premature ventricular contractions to symptomatic lethal rhythm including ventricular tachycardia (VT), ventricular fibrillation (VF), pulseless ventricular tachycardia, pulseless electrical activity, asystole, torsade de point, and idioventricular rhythm resulting in sudden death. Prompt assessment of life-threatening ventricular dysrhythmias (LTVD) and the patient response to the rhythm is critical. However, it is important for critical care nurse (CCN) to recognize potentially lethal arrhythmias that may occur in different clinical settings [2].
Many clinical conditions of patients predispose to LTVD notably myocardial infarction, chronic diseases such heart failure and cardiomyopathy. As well, other clinical correlates include electrolyte disturbances, hypoxemia, acidosis and drug toxicity [3].
During an episode of LTVD, the patient may show cardiac decompensating including hypotension, chest pain, syncope, and respiratory distress. Moreover, the patient develops compromised hemodynamic rapidly as patient deteriorates developing unconsciousness, pulseless and apnea [4].
The role of critical care nurse in dysrhythmias management focuses on symptomatic relief, promotion of comfort and taking emergency actions in fatal dysrhythmias including assessment of disturbed rhythm, obtaining 12- lead ECG to identify the type of arrhythmia, and delivering adequate oxygen to reduce heart workload. As well, while administering medication as prescribed, the nurse should monitor the possible adverse drug reactions and be performing aimed nursing interventions. In cases such as ventricular fibrillation and cardiac arrest, the nurse should perform rapid and safe defibrillation and other cardiac life support protocols to preserve oxygen supply to vital organs [5].
Because of nature of critical care nurses' profession, they spend significant time alongside their patients and are often the first to identify the ventricular dysrhythmias and cardiac arrest. Thus, they are the ones who respond by performing CPR either alone or as a member of a resuscitation team. Previous studies have often detected that nurses have an average knowledge and poor skills in light of international guidelines and recommendations. Therefore, Training programs in the nursing management of lethal dysrhythmias according to nurses need may make a significant contribution to relieving nurses’ discomfort and an increase in their selfconfidence. As a result, effectiveness in dealing with such cases individually or as members of a resuscitation team could also be improved. [6].
The Aim of the Study
This study was aimed to evaluate critical care nurses' knowledge and practice related to management of life-threatening ventricular dysrhythmias.
Methods
To collect data, a non-probability convenient sample of 41 nurses working in three coronary care units at Mansoura university hospital were recruited utilizing descriptive analysis study. An official consent was obtained from hospital administrators to initiate data collection from nurses. As well, an official approval was attained from the ethics committee at the faculty of nursing, Mansoura University. In order to assess critical care nurses' knowledge regarding nursing management of ventricular dysrhythmias, a designed questionnaire was developed by the researchers based on extensive literature review. It included 40-item questionnaire distributed as follows; 20 multiple choice questions, 10 true/false, and 10 rhythm strips pertinent to lifethreatening ventricular dysrhythmias.
The administered questions covered knowledge related to pathogenesis, causes, and identification of life-threatening ventricular dysrhythmia, connecting the patient to bedside ECG monitor, lethal rhythm interpretation, performing cardiopulmonary resuscitation and administering emergency defibrillation. Each correct answer took "one" score and the false answer got "zero" score. The scoring system categorized as follows; scores fewer than 80% was considered the unsatisfactory level and the scores equal or more than 80% considered satisfactory level. This percentage was decided by a panel of experts, who critically viewed that 80% is the least accepted level to work in such a critical environment. A pilot study was carried out to ensure feasibility of the study, difficulty index of questions, and time estimation required for data collection. Test-Retest was utilized to confirm the stability of questionnaire items through calculation of the Pearson correlation coefficient which was (0.87) at 0.001.
Observational checklist of nurses' management of dysrhythmias was developed by the researchers based on the latest evidence-based protocols in managing lethal dysrhythmias. It included 8 items covering the following skills: emergency management of fatal dysrhythmia, the connection of patients to bedside ECG monitor, recording 12- lead ECG, identification of lethal ventricular dysrhythmia, performing cardiopulmonary resuscitation, administering external defibrillation, administering emergency medications and crash cart preparation. The scoring system was distributed as follows; "right and complete done "action step took two grades, "incomplete done" took one grade and incorrect/not done took zero grade. The total score of the questionnaire was 86 grades. The scores were categorized as follows; performance level below 80% was considered unsatisfactory and equal or more than 80% were considered satisfactory.
The reliability test of the designed observational checklist was calculated using alpha Cronbach's test and the values of alpha Cronbach's was 0.83. The nurses' practices regarding management of ventricular dysrhythmia practiced were observed by the researchers utilizing checklists for three times in different shifts for each nurse. These data were collected from December 2016 to April 2017. Later, descriptive as well as inferential statistics were carried out utilizing statistical package for social sciences (SPSS) version 21. The utilized tests were frequency, means, independent t-test and one way ANOVA test.
Results
Nurses' Baseline characteristics
More than half of the studied nurses, their age ranged between 26 and 30 with a mean age of 26.3 ± 3.7. As well, nearly half of the nurses, their years of experience were between 5-9 and were holding a technical nursing degree (43.9%).
Nurses' knowledge and practices in dysrhythmias management
It is apparent from the TABLE 1 that the nurses have got low total mean knowledge score (15.731 ± 8.485) out of 40 scores.
| Items | Maximum score | Mean ± SD |
|---|---|---|
| 1. General information about life threating ventricular dysrhythmias. | 13 | 5.413 ± 2.331 |
| 2. Knowledge about ECG interpretation. | 4 | 1.547 ± 1.531 |
| 3. Knowledge about emergency defibrillation | 7 | 3.712 ± 1.749 |
| 4. Knowledge about cardiopulmonary resuscitation | 5 | 1.561 ± 1.542 |
| Total | 40 | 15.731 ± 8.485 |
Table 1: Total and subtotal mean knowledge scores regarding life threating ventricular dysrhythmias among studied nurses (n=41).
It is apparent from the FIGURE 1 that almost all nurses have unsatisfactory knowledge level regarding ECG interpretation (97.56), general information about life-threatening ventricular dysrhythmias (85.36), and cardiopulmonary resuscitation & ECG procedure (87.8).
Figure 1: Percentage distribution of subtotal knowledge scores levels about life threatening ventricular dysrhythmia among the study subjects..
As can be seen from the TABLE 2 and FIGURE 2 that the total nurses' practice mean score was 27.073 ± 13.2 out of 86 score. In relation to performance sub-items, it revealed the items that demonstrated higher mean scores among nurses were the administration of emergency drugs in cases of lethal dysrhythmias, connecting patient to cardiac monitor, and recording 12-lead. On the other hand, ECG interpretation, Emergency defibrillation, Cardiopulmonary resuscitation, and Emergency crash cart were the lowest mean scores and level.
| Items | Total score | Mean ± SD |
|---|---|---|
| 1. Emergency management of life threating ventricular dysrhythmias. | 7 | 2.707 ± 2.052 |
| 2. Connecting patient to cardiac monitor. | 11 | 5.975 ± 2.621 |
| 3. Recording 12 - lead ECG. | 13 | 5.638 ± 3.222 |
| 4. ECG interpretation. | 5 | 0.412 ± 1.221 |
| 5. Emergency defibrillation. | 20 | 2.512 ± 2.811 |
| 6. Cardiopulmonary resuscitation. | 9 | 3.924 ± 2.537 |
| 7. Emergency drugs for LTVD. | 14 | 7.246 ± 3.051 |
| 8. Emergency crash cart. | 7 | 0.824 ± 0.919 |
| Total | 86 | 27.073 ± 13.203 |
Table 2: Mean total and subtotal practice scores of the studied group subject regarding life threating ventricular dysrhythmias. (No. 41).
Figure 2: Percentage distribution of nurses' practice score level about life threatening ventricular dysrhythmias (n=41).
Comparison of nurses' total knowledge scores by their demographic characteristics revealed no significant differences in knowledge scores among them except years of experience and attending previous courses concerning management of dysrhythmias. On the other hand, Comparison of nurses' total practice scores by their demographic characteristics revealed no significant differences in practice scores among them except age and attending training courses a seen in the TABLE 3.
| Variables | knowledge | practice | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Satisfactory | Unsatisfactory | χ2 | P value | Satisfactory | Unsatisfactory | χ2 | P value | |||||
| No | % | No | % | No | % | No | % | |||||
| Age group (years) | ||||||||||||
| 20- ≤ 25 | 0 | 0 | 14 | 40 | 5.501 | 0.239 | 3 | 50 | 11 | 31.4 | 7.647 | 0.015 |
| 26- ≤ 30 | 6 | 100 | 17 | 48.6 | 2 | 33.3 | 21 | 60 | ||||
| 31 – ≤ 40 | 0 | 0 | 3 | 8.6 | 0 | 0 | 3 | 8.6 | ||||
| >40 | 0 | 0 | 1 | 2.9 | 1 | 16.7 | 0 | 0 | ||||
| Educational level | ||||||||||||
| diploma | 2 | 33.3 | 11 | 31.4 | 3.083 | 0.214 | 1 | 16.7 | 12 | 34.3 | 1.217 | 0.544 |
| Technical | 1 | 16.7 | 17 | 48.6 | 4 | 66.7 | 15 | 42.9 | ||||
| Bachelor | 3 | 50 | 7 | 20 | 1 | 16.7 | 8 | 22.9 | ||||
| Years of working experience | ||||||||||||
| < 1 | 0 | 0 | 8 | 22.9 | 12.748 | 0.013 | 1 | 16.7 | 5 | 14.3 | 1.081 | 0.897 |
| 1- <5 | 0 | 0 | 9 | 25.7 | 1 | 16.7 | 8 | 22.9 | ||||
| 5- < 10 | 5 | 83.3 | 12 | 34.3 | 2 | 33.3 | 15 | 42.9 | ||||
| 10 –< 15 | 0 | 0 | 6 | 17.1 | 2 | 33.3 | 6 | 17.1 | ||||
| ≥ 15 | 1 | 16. 7 | 0 | 0 | 0 | 0 | 1 | 2.9 | ||||
| Attending training programs / workshops | ||||||||||||
| yes | 4 | 9.75 | 2 | 4.87 | 25.856 | *** 0.001 |
4 | 9.75 | 2 | 4.87 | 15.232 | *** 0.001 |
| no | 0 | 0 | 35 | 85.36 | 2 | 4.87 | 33 | 80.48 | ||||
-Statistically significant difference ≤ 0.05
- No Statistically significant difference >0.05
-Highly Statistically significant difference <0.001
Table 3: Comparison of total knowledge scores and total practice scores regarding life threating ventricular dysrhythmias by their background variable (NO=41).
As can be seen from TABLE 4, a significant positive correlation was found between nurses' knowledge and practice scores (r=0.4; p=0.001). Also, a significant correlation was found between knowledge scores and years of experience (r=0.50; p=0.001).Finally, positive correlation was found between nurses' practice and age(r=0.61; p=0.001).
| Variable | Knowledge | practice |
|---|---|---|
| r / p value | r / p value | |
| knowledge | ……… | 0.407 / 0.001 |
| Practice | ……… | ……… |
| Age | 0.156 / 0.162 | 0.614 / 0.001 |
| Years of experience | 0.503 / 0.001 | 0.148 / 0.185 |
Table 4: Correlation of selected background variableswith knowledge and practice related to life threating ventricular dysrhythmias (NO.=41).
Discussion
The analysis of data in the present study showed that the majority of nurses had unsatisfactory knowledge and practices regarding management of life-threatening ventricular that included; normal ECG, pathogenesis of ventricular dysrhythmias, rhythm interpretation, and cardiopulmonary resuscitation measures. The researchers interpreted the reasons for nurses' inadequate knowledge to an absence of incorporation ECG course in a nursing curriculum of the taught nursing program. Other relevant factors included lack of in-service training program, disseminated posters, and guidelines in nurses' work areas. Moreover, another possible explanation for that phenomenon is lack of funding aimed at organizing nurses' regular workshops. Another factor for lack of nurses’ knowledge in the current study was nurses' workload which made the delay of nurses' abilities and motives to acquire and update their knowledge. Finally, in certain ICU settings, there are available trained physicians whose tasks are an interpretation of cardiac data and delegate certain intervention actions to nurses. However, nurses' understanding of those data could even save the patient’s life in time.
Our study finding is agreed with a similar study done by [7] who reported that more than two third of nurses, their knowledge regarding ventricular dysrhythmias was unsatisfactory. As well, our finding is consistent with another similar study done by [8] who assessed the critical care nurses' knowledge related to cardiac dysrhythmias at Benha University Hospital as well as [9] who studied the standards of nursing care for cardiac arrhythmic patient at Ain Shams University hospital and revealed that that majority of the nurses were having an unsatisfactory knowledge about cardiac dysrhythmias, connecting patient to monitor, recording 12- lead ECG, cardiopulmonary resuscitation, defibrillation, emergency cart and emergency medication. On the same line, our finding supported with other study done by [10] in another similar developing country in India and recommended that the nurses must be able to identify elevation of the 1st segment and life-threatening arrhythmias. On the other hand, our finding contradicted with similar study submitted by [11] who found that most of nurses have above average level of knowledge regarding the interpretation of life-threatening arrhythmias and its emergency management.
Concerning nurses’ knowledge and performance sub-items regarding cardiopulmonary resuscitation and nurses' practices of external defibrillation , the existing findings showed that the majority of the nurses had low mean knowledge and practice scores The researcher interpreted that reasons for lack of knowledge and practice about cardiopulmonary resuscitation due to absence of pre-employment orientation programs and in-service training courses. This finding is in the same line with [12] who studied the effect of cardiopulmonary resuscitation training program on knowledge and practices of internship technical institute of nursing students at South Valley university- Egypt and found that the majority of the studied nurses’ knowledge and practice were inadequate before program implementation and improved after program implementation.
The researchers examined the association between total knowledge and total practice scores regarding life-threatening ventricular dysrhythmias. It revealed a positive correlation between total knowledge and total practice scores. This correlation may be interpreted as lack of knowledge and may have an effect on nurses’ practices regarding life-threatening ventricular dysrhythmias. This finding is in agreement with [8], who stated that many nurses were aware of their inadequate knowledge and related it to inadequate care practices. Lack of understanding may worsen management of patient's lethal ventricular dysrhythmias.
The researchers examined other factors that may have relevance to lack of knowledge and practice regarding life-threatening ventricular dysrhythmias, such as age, educational level, and years of experience. Our findings revealed a significant positive correlation between nurses' practices and both age and years of experience. The researcher point of view that the relationship between age and measures of the quantity of knowledge which might be expected to be positive because knowledge presumably derives from experience and experience is often assumed to increase continuously with advancing age. Our finding is agreed with [11] study who found a statistically significant association between studied sample’s knowledge scores and years of experience. On the other hand, our finding contradicted with [13] findings which revealed that there was no significant statistical difference in the mean score of knowledge in relation to years of experience.
Concerning investigation of the corelation between nurses' knowledge, practice and attendance of training sessions, the result of the present study revealed that there was a statistically significant association between nurses' knowledge, practice, and attendance of training courses about LTVD. This result is in the same line with [14] who studied nurse' performance regarding cardiopulmonary resuscitation in cardiac care unit at the Alexandria university hospital and revealed that there was a significant co-relation between nurse knowledge scores and attendance of training session. On the other hand, our finding is inconsistent with [15] who stated that there was no association found between nurse knowledge, practice scores, and attendance of previous training courses.
Conclusion
The present study concluded that critical care nurses have insufficient knowledge and practice concerning management of lifethreatening dysrhythmias. Moreover, a positive significant correlation was found between knowledge and practice. As well, a significant positive correlation was detected between knowledge and both nurses’ age and years of experience. Finally, attending related training courses affected both nurses' knowledge and practices positively. However, the overall total mean knowledge and practice scores are low.
Recommendation
Based on findings of the present study, the following suggestions were recommended
- Conduction of in-service program regarding identification and management of dysryythmias.
- Periodic evaluation of nurses' knowledge and practice regarding dysrhythmias management.
- Replication of the study on a large probability sample selected from different geographical areas in Egypt.
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