Nurses’ Competency on Electrocardiography Interpretation in Adult Emergency Room: Addis Ababa, Ethiopia, 2021. Multicenter Cross-sectional Study

doi:10.21203/rs.3.rs-3146197/v1

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Nurses’ Competency on Electrocardiography Interpretation in Adult Emergency Room: Addis Ababa, Ethiopia, 2021. Multicenter Cross-sectional Study

https://doi.org/10.21203/rs.3.rs-3146197/v1

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published 01 Jun, 2024

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Background: Electrocardiography is a graphic representation of the electrical activity of the heart. According to previous literature, nurses have poor knowledge and skills about basic electrocardiography interpretation. For instance, a previous survey conducted in Turkey showed that only 38.1 percent of nurses were able to recognize ventricular fibrillation, 54.3% myocardial infarction, and 33.3% third-degree atrioventricular block.

Objective: This study was aimed at assessing Nurses’ competency in electrocardiography interpretation in adult emergency rooms in Addis Ababa, Ethiopia, in 2021.

Method: An institutional-based descriptive, cross-sectional study design was used to conduct the study. A total of 175 nurses in five randomly selected hospitals with adult emergency rooms were included in this study. Semi-structured, self-administered questionnaires were used to collect the data. Data were entered into Epi data and analyzed using SPSS version 26. A Fisher’s exact test was used to identify the relationship between dependent and independent variables.

Results: Of 203 respondents, 175 actively participated, for a response rate of 86.2%. From those 175 nurses, 159 (90.9%) were not competent (scored < 65%), and the mean score was 6.82 ± 3.65 SD.

Conclusion: The overall level of competency of nurses in electrocardiography interpretation is low. This implies most nurses in the emergency room do not monitor and manage a patient's electrocardiography for manifestations of arrhythmias, electrolyte disturbance and other cardiac abnormalities. Level of education and training were a determinant factor to enhance their competency.

Electrocardiography interpretation

arrhythmias

competency

Electrocardiography (ECG) is a graphic representation of the electrical activity of the heart. The heart has four chambers: two atria and two ventricles [1]. The electrical activity generated from the sinoatrial node (SA node) goes through atrial muscle fibers and delays the depolarization of the atrioventricular node (AV node). The contraction of the atria is associated with the ECG wave called the P wave, then when ventricular depolarization occurs, it causes the QRS complex, and finally, when ventricular repolarization occurs, the T wave occurs [2].

Electrocardiography is a frequently used, non-invasive procedure for recording electrical activities in the heart. Nowadays, ECG is used for patients presenting with cardiac diseases, and it’s considered the first diagnostic tool in chest pain. It provides objective information about the structure and function of the heart [3]. Also, ECG is a focal point of modern medicine because it gives a whole background on diagnosing acute coronary syndromes and cardiac arrhythmias [4].

Nurses are normally the first responders to an in-hospital cardiac arrest in health care facilities, and they must be proficient in basic resuscitation skills [5]. Basic ECG rhythms, such as normal sinus rhythm, sinus tachycardia, sinus bradycardia, atrial fibrillation, atrial flutter, heart blocks, ventricular fibrillation, and asystole, should be recognized by any nurse [6]. The nurse is required to be in charge of monitoring and clinical decision-making based on data collected from the monito [6].

Research in Iraq was conducted to determine nurses' knowledge of early intervention for patients with ventricular tachycardia at Baghdad teaching hospitals, and the results showed that the overall knowledge of the nurses was adequate [7]. That led to a lot of problems, such as poor quality of nursing care and poor clinical outcomes [8]. In addition, inappropriate interpretation usage often raises healthcare costs and may cause delays in the admission process, which is an unpleasant burden that the hospital and its patients must bear [9].

There is a need to improve nurses' electrocardiography awareness and experience to provide better health care outcomes for patients and prevent errors in ECG interpretation and interventions. The determination of the knowledge and practice of nurses on electrocardiography may be useful in improving their level and enhancing their initiation to become more professional in the interpretation of electrocardiography [10]. However, no previous studies have been found on this subject in Ethiopia. Therefore, this study aimed to assess Nurses’ competency in electrocardiography interpretation in adult emergency rooms in Addis Ababa, Ethiopia, in 2021.

Study design, area and period

An institutional-based descriptive cross-sectional study design was conducted in Addis Ababa city from March to April 2021. The study was conducted in five randomly selected public hospitals administered by the Federal Republic of Ethiopia in Addis Ababa city at the Emergency room. Those are Tikur Anbessa Specialized Hospital, St. Paulo referral hospital, AaBet referral hospital, Alert referral hospital, and St. Petro referral hospital [11].

Inclusion criteria

All registered nurses who are working and have experienced greater than six months.

Exclusion criteria

Nurses who have less than six months of working experience

Sampling procedures and techniques

A convenient sample technique was used to involve 175 nurses who were working in the adult emergency room in selected public hospitals.

Data collection tool and technique

The data was collected using semi-structured, self-administered questionnaires. The tool has two parts: participant sociodemographic characteristics (10 questioners’) and questioners used to assess the level of nurses competency in electrocardiography interpretation (20 questioners’). All questionnaires are adopted from the ECG guidelines [2]. The data were collected by five BSc Nurses and supervised by one MSc nurse. The training was given for data collectors and supervisors on the method of extracting the needed information, how to fill in the information on a structured checklist, and the ethical aspect of approaching the hospital administrator.

Data quality management

A pretest was performed using 5% of the study sample size in a similar hospital other than the study setting. The activities of data collectors and supervisors were closely monitored by the principal investigator. The collected data were checked for completeness, accuracy, and clarity.

Operational definition

Competency: It is considered competent if the percent score is equal to or above 65% and

Not competent if the percent score was less than 65% from 20 knowledge questioners’ [12]

Statically analysis

Data were checked, coded, and given an identification number before being entered into Epi Data version 4.6. Then it was exported to SPSS version 26 for analysis. Both descriptive and analytical statistical procedures were utilized. Descriptive statistics like percentage, mean, median, and standard deviation were used for the analysis of socio-demographic data and the competency of nurses in ECG interpretation. And its association was analyzed using the Fisher exact test instead of the chi-square (X2) because > 20% of the expected frequency was less than 5, which violated the chi-square assumptions. Finally, the variable whose p-value was 0.05 was considered statistically associated.

Socio demographic characteristics

Of the 203 respondents, 175 had actively participated, with a response rate of 86.2%. According to the level of education, most respondents (134, or 76.6%) were BSc nurses. The majority of respondents (115, or 65.7%) had 1–5 years of work experience. Most respondents (127, or 72.6%) said that there is no ECG machine available in their institution. The majority of the participants (147, or 84%), didn’t get in-service training about ECG. All participants’ (175, or 100%) said that there is no arrhythmia treatment algorithm in their institution (Table 1).

Table 1

Socio-demographic characteristics of nurses in adult emergency unit, Addis Ababa public hospitals 2021 (N = 175)
Level of education	MSc	15	8.6
	BSc EMCCN	20	11.4
	BSC	134	76.6
	Diploma	6	3.4
Work experience	< 1 year	2	1.1
	1−5	115	65.7
	6–10	54	30.9
	> 10	4	2.3
Is there ECG machine	Yes	48	27.4
Is there ECG machine	No	127	72.6
Have you got in service training	Yes	147	84.0
Have you got in service training	No	28	16.0
Is there arrhythmia algorism	Yes	0	0
Is there arrhythmia algorism	No	175	100.0
Work place	Tikur Anbessa	50	28.6
	Alert	16	9.1
	Abet	37	21.1
	S. Paulo s	57	32.6
	S Petro s	15	8.6

Note: BSC: Bachelor of Science, MSc: Master Science, EMCCN: emergency medicine and critical care nursing

Competency of nurses about ECG interpretation

The competencies in ECG interpretation among nurses were generally poor. As of 175 nurses, 159 (90.9%) were not competent (scored < 65%) (Fig. 1). The mean score was 6.82 ± 3.65 SD. The detailed results showed that almost all of the participants (173) (98.5%) correctly identified asystole from the ECG strip. Anterioseptal myocardial infarction (MI), inferior wall MI, and Wolf-Parkinson-White syndrome are less frequently identified on ECG strips (4%, 3.4%, and 2.7%, respectively) (Table 2).

Table 2

Nurses competence on ECG interpretation (reading) in the emergency unit, Addis Ababa public hospitals, 2021
ECG finding	Frequency		present
ECG finding	No	Yes	No	Yes
Sinus tachycardia	58	117	33.1	66.9
Sinus bradycardia	37	138	21.1	78.9
Normal sinus rhythm	61	114	34.9	65.1
Asystole	2	173	1.1	98.9
Atrial Flutter	95	80	54.3	45.7
PVC	158	17	90.3	9.7
Torsade de Point	134	41	76.6	23.4
1st degree AV block	145	30	82.9	17.1
3rd degree AV block	150	25	85.7	14.3
left bundle branch block	159	16	90.9	9.1
right bundle branch block	163	12	93.1	6.9
Wolf- Parkinson-white syndrome	172	3	98.3	2.7
supra ventricular tachycardia	103	72	58.9	41.1
Anterioseptal MI	168	7	96	4
Inferior wall MI	169	6	96.6	3.4
Atrial fibrillation	107	68	61.1	38.9
Ventricular tachycardia	63	112	36	64
Ventricular fibrillation	66	109	37.7	62.3
Peaked T wave	155	20	88.6	11.4
second degree AV block	141	34	80.6	19.4
Note: AV: atrioventricular, MI: myocardial infarction, PVC: Premature ventricular contractions

Associated factor of nurses competence on ECG interpretation based on fisher’s exact test

The Fisher exact test was used to assess the association between demographic characteristics and nurses competency level towards ECG reading. There is a statistical association between nurses' competency and their level of education, ECG training, and workplace (p-values = 0.0001, 0.0002, and 0.036, respectively) (Table 3).

Table 3

The association between demographic characteristics and nurses level of competency
Demographic variable	Number of respondents(N = 175)
	Effect of demographic variables on respondents competency
	Level of competency
	Competent		Not competent			Test used	P- value
level of education	N	%	N		%
MSc	6	40	9	60		Fisher exact test	0.0001*
BSc EMCCN	5	25	15	75
BSc	2	1.5	132	98.5
Diploma	0	0.0	6	100
Work experience
> 1 year	1	50	1	50		Fisher exact test	0.267
1–5 years	14	9.6	104	90.4
6–10 years	4	7.6	50	92.6
Greater than 10 years	0	0.0	4	100
Is there ECG machine
Yes	11	8.7	116	91.3		Fisher exact test	0.771
No	5	10.4	43	89.6
Have you got ECG training
Yes	10	35.7	18	64.3		Fisher exact test	0.0002*
No	6	4.1	141	95.9
Work place
Tikur Anbessa	5	10	45	90		Fisher exact test	0.036*
Alert	4	25	12	75
AaBet	1	2.7	36	97.3.
St. Paulo’s	3	5.3	54	94.7
St. Petros	3	20	12	80
Note: * statistically associated at p-value < 0.05

ECG interpretation is an important knowledge and skill for nurses to use to manage those who have cardiovascular diseases or arrhythmias. A good ECG interpretation skill can save the life of the patient and increase the quality of care in the emergency department; therefore, this study was aimed at assessing the competency of nurses working in the adult emergency room at ECG interpretation: a multicenter study in Addis Ababa, Ethiopia [12]. In this study, the majority of the respondents (90.9%) were not competent, and only 9.1% of respondents were competent about ECG interpretation. This finding is comparable with the study conducted in Asyut, which showed that nurses had 15% satisfactory knowledge and 85% unsatisfactory knowledge [13].

But this study contradicts a study conducted in Egypt (44%) and Kenya (67%), where respondents had good knowledge about ECG interpretation, respectively [14, 15]. This difference might be due to differences in study setting, population, and educational curriculum. For instance, the educational curriculum in Ethiopia does not incorporate ECG interpretation. Particularly in this study, almost all (98.9%) of the respondents identified Asystole from the ECG strip. This finding is nearly similar to a study conducted in Kenya, which showed that 100% of respondents identified asystole from the ECG strip [16]. In this study, more than half (62.3%) of respondents had ventricular fibrillation identified on the ECG strip. This finding is nearly similar to a study conducted at the University of Jember, which showed that 67.7% of respondents identified ventricular fibrillation [17].

In this study, 45.7%, 14.35%, and 64% of respondents have identified atrial flutter, third-degree AV block, and ventricular tachycardia, respectively. This finding is contradicted by a study conducted at the University of Jember that showed that 84.6%, 60%, and 87% of respondents identified atrial flutter, third-degree AV block, and ventricular tachycardia, respectively [17]. This difference might be due to differences in educational curriculum and training on ECG. For instance, in Ethiopia, nurses did not take an ECG course, and most of them did not take skill-building training on ECG. In this study, 78.9%, 65.5%, 9.7%, and 14.3% of the respondents have identified sinus bradycardia, normal sinus rhythm, PVC, and 1st degree AV block, respectively. This finding is different from a study conducted in Saudi Arabia that showed that 88.4%, 83.6%, 62.3%, and 34.2% of respondents identified sinus bradycardia, normal sinus rhythm, PVC, and 1st degree AV block, respectively [18]. This might be due to the fact that the majority of respondents were doing ECGs in their clinical practice, and most of them considered ECG interpretation a priority for the nursing profession.

Among different variables, the level of education, ECG training, and workplace of nurses were statistically associated with the competency of ECG interpretation. This study showed that level of education was statistically associated with nurses' competency in ECG interpretation. This finding is similar to the study conducted in Kenya, which showed that there was an association between educational qualification and the knowledge score of nurses on ECG interpretation. [19]. This study also similar to a study conducted in Egypt showed that there was an association between nurses’ level of qualifications and knowledge on ECG interpretation [20]. This study showed that in-service training about ECG was statistically associated with nurses' competency in ECG interpretation. This finding is similar to the study conducted in Tanzania and Turkey, which showed that there was a statistical association between training and nurses level of knowledge on ECG interpretation [21, 22].

This study showed that work experience was not statistically associated with nurses' competency in ECG interpretation. However, this study contradicts a study conducted in Egypt that showed a statistically significant association between work experience and knowledge about ECG interpretation [14]. This might be due to the fact that the majority of respondents had more than two years of ICU experience, and having critical patients who need frequent monitoring may increase nurses exposure.

IMPLICATIONS OF THE STUDY

The study helps healthcare providers, policymakers, and programmers make interventions to improve nurses’ competence in ECG interpretation. The study was used as baseline information for researchers to conduct further action-based studies. It also provides clear evidence of the effects of training and curriculum design on nurses’ education. Therefore, they can make an evidence-based decision for prevention and to promote nurses competency.

Generally, in this study, nurses’ level of competency about ECG interpretation was lower than in other studies done in different countries. Training and educational qualifications were determinants of improving the level of competency in ECG interpretation. The author recommended that the ECG curriculum be incorporated into nursing education. The health manager could be under supervision to enhance competency. The nurses could improve their competency through reading and increasing their professional qualifications. The health care team also provides in-service training.

AV Atrioventricular

ECG Electroencephalography

EMCCN emergency medicine and critical care nursing

MI Myocardial infarction

QRS Q wave, R wave and S wave

SA sinoatrial node

Authors’ contribution

Yigremew Haimanot Belay developed the proposal, analyzed the data, and wrote and interpreted the results.

Demelash Gezahegn as well as Professor Berhanu Melaku drafted the manuscript, revised the proposal, checked the data, and revised the manuscript.

Ousman Adal Tegegne drafted and revised the manuscript. The authors have read and approved the final manuscript.

Funding: No funding sources are available yet.

Availability of data and materials

The data that support the findings of this study are available upon reasonable request from the corresponding authors.

Ethical approval and consent to participants

The ethical review board of the College of Health Sciences at Addis Ababa University approved this study. No. 2189 edu.net for ethical approval). Certify that the study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Informed consent was obtained from all subjects.

Consent for publication: not applicable

Competing interest

The authors declare that they have no competing interests.

Acknowledgements

The authors are grateful to the data collectors, emergency coordinators, and all study participants for their contributions to the study's success.

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No competing interests reported.

Download PDF

Journal Publication

published 01 Jun, 2024

Read the published version in International Emergency Nursing →

Version 1

posted

You are reading this latest preprint version

Nurses’ Competency on Electrocardiography Interpretation in Adult Emergency Room: Addis Ababa, Ethiopia, 2021. Multicenter Cross-sectional Study

Status:

Journal Publication

Version 1

Abstract

Figures

INTRODUCTION

METHODS

Study design, area and period

Inclusion criteria

Exclusion criteria

Sampling procedures and techniques

Data collection tool and technique

Data quality management

Operational definition

Statically analysis

RESULT

Socio demographic characteristics

Competency of nurses about ECG interpretation

Associated factor of nurses competence on ECG interpretation based on fisher’s exact test

DISCUSSION

IMPLICATIONS OF THE STUDY

CONCLUSION

Abbreviations

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1