Knowledge, Practice, and Associated Factors on Electrocardiograph Interpretation Among Nurses Working in Emergency and Intensive Care Units of Selected Public Hospitals in Addis Ababa, Ethiopia, 2024

doi:10.21203/rs.3.rs-4826823/v1

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Knowledge, Practice, and Associated Factors on Electrocardiograph Interpretation Among Nurses Working in Emergency and Intensive Care Units of Selected Public Hospitals in Addis Ababa, Ethiopia, 2024

https://doi.org/10.21203/rs.3.rs-4826823/v1

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Background

Fast ECG interpretation is crucial in reducing patient mortality and morbidity related to heart conditions. Despite its importance, many healthcare providers struggle with proficiency in ECG interpretation.

Objective

This study aimed to assess nurses' knowledge, practice, and associated factors regarding electrocardiograph interpretation in emergency and intensive care units of selected public hospitals in Addis Ababa, Ethiopia.

Methods

A cross-sectional study was conducted to assess nurses' knowledge, practice, and associated factors related to electrocardiograph interpretation in selected public hospitals in emergency and intensive care units in Addis Ababa, Ethiopia. Data were collected using structured, self-administered questionnaires and analyzed using SPSS. Descriptive statistics, bivariate analysis, and logistic regression models were used to assess associations between variables.

Results

Only a quarter of the study participants had good knowledge (n = 60, 23.5%) and good practice (n = 69, 27.1%) regarding ECG strip interpretation. The most frequently recognized ECG strip was asystole. Factors associated with good knowledge and practice included being master’s degree holders, having ECG training, and working in intensive care units.

Conclusion

This study revealed a concerning lack of knowledge and practice among nurses in ECG interpretation. The findings highlight the need for training programs and experience-sharing initiatives to improve nurses' proficiency in ECG interpretation and ultimately enhance patient outcomes.

electrocardiograph

nurse

practice

intensive care unit

emergency department

Electrocardiography (ECG) is an essential, non-invasive modern tool to assess the electrical and muscular activities of the heart (1). It has a high capacity to detect any abnormalities in people with cardiovascular diseases (2, 3). Cardiovascular diseases have increased worldwide, causing morbidity in half a billion people and mortality in 20.5 million people (4). Early electrocardiography enhances patient survival (5).

Health professionals who work in emergency departments and intensive care units, especially nurses who are first responders for patients, should be proficient in skills such as electrocardiography interpretation. The increasing shortage of physicians has shifted the responsibility of electrocardiography interpretation to nurses, making their proficiency mandatory (6, 1, 7). Electrocardiography interpretation competency requires understanding the features and concepts of electrocardiography strips and critical thinking (8). Despite its importance, healthcare providers struggle with electrocardiography interpretation (9).

Poor electrocardiography interpretation knowledge and practice is a global issue, affecting both low-income countries like Ethiopia and high-income countries. A study in China found that 70.9% of intensive care unit nurses had low electrocardiography knowledge, consistent with a study in Saudi Arabia (1, 10–12). Similarly, studies in Egypt and Addis Ababa showed that 80% and 90.9% of the studied nurses had unsatisfactory levels of knowledge (11). This lack of understanding among nurses can lead to inadequate management of potentially life-threatening cardiac arrhythmias (6).

A nurse's lack of proficiency in electrocardiography interpretation can have significant consequences for patient care, including delays in diagnosis and treatment, medication errors, poor outcomes, and complications. Additionally, it has legal and ethical implications and compromises patient safety, quality of care, and healthcare costs (3, 13). Bridging these gaps requires a comprehensive approach, including specialized training, clinical experience, certification, ongoing education, simulation and skill laboratories, and collaboration among different healthcare disciplines (14). However, there is a lack of data regarding the knowledge and practice of nurses in electrocardiography interpretation, specifically in Ethiopia. This study aimed to address the gaps in nurses' knowledge and practice of electrocardiography interpretation. The results can be used to enhance nursing education and training (13).

Study Design, Area, and Period

An institutional-based cross-sectional study was conducted in five randomly selected public hospitals in Addis Ababa, Ethiopia, from March to April 2024. These hospitals include Tikur Anbessa Specialized Hospital, St. Peter Specialized Hospital, AaBet Referral Hospital, Menelik Referral Hospital, and Zewditu Memorial Hospital, focusing on emergency and intensive care units.

Inclusion Criteria All nurses with at least six months of work experience during the data collection period in the randomly selected public hospitals were included in the study.

Exclusion Criteria All nurses who were unavailable during the study period due to maternity leave, annual leave, or sick leave were excluded.

Sample Size Determination The sample size was calculated using a single population proportion formula. \(\:\frac{{\:\left(\frac{Z\alpha\:}{2}\right)}^{2}P\left(1-P\right)}{{d}^{2}}\)n = where 𝑛 is the sample size, z@/2 = is the critical value for the normal distribution at the 95% confidence level, d is the margin of error, and P is the proportion and the value was taken as 50%, as there is no prior study in both emergency and intensive care units in Ethiopia.. After adding a 10% non-response rate, the final total sample size was 277.

The study population was less than 10,000; therefore, a sample size correction formula was applied. For the second objective (factors), the authors used the Epi Info version 7 computer program, assuming a 95% confidence interval, 80% power, and the ratio of exposed to non-exposed for various factors. However, the calculated sample size for the second objective was smaller than the sample size derived from the first objective.

Sampling Method and Procedure Firstly, five public hospitals in Addis Ababa were selected using simple random sampling (lottery method) from a total of 12 public hospitals with intensive care unit and emergency department setups. The final sample size was proportionally allocated to each department and hospital based on their size. Finally, a simple random sampling method was used to select study participants in each stratum until the desired sample size was fulfilled.

Data Collection Tool A structured, self-administered questionnaire was used. The questionnaire was adopted from different literature (1, 9, 10, 13, 15, 16, and 17) and electrocardiography interpretation guidelines (18) and modified according to our setup. The questionnaire contained three sections. The first section focused on the demographic characteristics of nurses and consisted of 12 questions. The second section consisted of 12 true or false questions regarding nurses' knowledge of electrocardiograms. The third section focused on nurses' practice in electrocardiography interpretation and management for chosen electrocardiography strips, containing 20 multiple-choice questions. Ten 12-lead II electrocardiography strips were presented.

Operational Definition

Good Knowledge: A nurse who scored > 65% on knowledge-related questions.

Poor Knowledge: A nurse who scored < 65% on knowledge-related questions.

Good Practice: A nurse who scored > 65% on electrocardiographic interpretation and/or management.

Poor Practice: A nurse who scored < 65% on electrocardiographic interpretation and/or management.

Data Quality Control and Management Two data collectors with a background in research education received training. During the data collection process, the principal investigator checked the data at each point to ensure completeness and identify any missing information. A pre-test of the self-administered questionnaire was conducted on 5% of the final sample size at Yekatit 12 Hospital.

Statistical Analysis After verifying completeness, data was coded and entered into Epi Data version 4.6, then exported to SPSS version 27 for analysis. Outliers and multicollinearity were checked using standard residuals and the variance inflation factor, respectively, removing variables with a factor over ten. Binary logistic regression identified associations between the dependent and independent variables; those with a p-value under 0.25 advanced to multivariable analysis. Variables significant at a p-value less than 0.05 and with an adjusted odds ratio within the 95% confidence interval were considered factors associated with knowledge and practice of nurses on electrocardiography interpretation. Results were presented using figures, tables, graphs, and charts.

Socio-Demographic Characteristics

Out of a total sample size of 277, 255 participants agreed to participate, resulting in a response rate of 92%. The mean age of the study participants was 30.02 ± 4.7 years, with the majority being male (n = 157, 61.6%). Most participants worked in the emergency department (n = 135, 52.9%), and the majority were college or university graduates holding a bachelor's degree (n = 188, 73.7%) (Table 1).

Table 1

Socio-Demographic Characteristics of Nurses Working in Emergency Rooms and Intensive Care Units of Public Hospitals in Addis Ababa, Ethiopia, 2024 (n = 255) 4o
Variables	Category			FREQUENCY (N)	PERCENTAGE (%)
Sex of nurses	Male Female			157 98	61.6 38.4
Work place	Aabet Hospital Menelik referral hospital St peter specialized hospital Tikur anbesa specialized hospital Zewditu memorial hospital			69 31 43 66 46	27.1 12.2 16.9 25.9 18.0
level of education	Bsc in ECCN Bsc. Nursing Msc			26 188 41	10.2 73.7 16.1
Area of practice	ICU ED			135 120	52.9 47.1
Year of experience	1-5years 6–10 years 11–15 years			165 88 2	64.7 34.5 0.8
BLS training	Yes No			94 161	36.9 63.1
ACLS training		Yes No	52 203		20.4 79.6
Presence of ECG machine in hospital		Yes No	248 7		97.3 2.7

Description of Knowledge of ECG Interpretation

The participants' percentage knowledge score out of a total score of 100%, using a > 65% score as the cut-off value, showed that 60 participants (23.5%, 95% CI: 0.19–0.29) had good knowledge, while the majority, 195 participants (76.5%, 95% CI: 0.71–0.82), had poor knowledge about ECG interpretation. Most nurses correctly answered that the "QRS complex represents right and left ventricular depolarization" (n = 207, 81.2%). However, only 125 participants (49%) could appropriately recognize the order of ECG waves and intervals (Table 2).

Table 2

Description of Knowledge of ECG Interpretation of Participants Working in Public Hospitals in Addis Ababa, Ethiopia (n = 255)
Knowledge Assessment question	Correct N (%)	Incorrect N (%)
The correct order of ECG waves and interval?	125 (49)	130(51)
P wave represents left and right ventricular Depolarization	152(59.6)	103(40.4)
QRS complex represents right and left ventricular Depolarization?	207(81.2)	48(18.8)
T waves represent ventricular depolarization?	193(75.7)	62(24.3)
Pathologic Q waves are a sign of previous myocardial Infarction	169(66.3)	86(33.7)
Normal PR interval is between 0.12–0.20	199(78)	56(22)
The ST segment should be flat and isotonic	174(68.2)	81(31.8)
Atrial fibrillation could have a regular rhythm?	124(48.6)	131(51.4)
If in an ECG the P wave does not appear, there is Conduction problem between the atriums?	180(70.6)	75(29.4)
Atrial flutter is characterized by a regular ventricular Rhythm with a consistent R-R?	104(40.8)	151(59.2)
Ventricular fibrillation is characterized by no identifiable P waves and T waves, but the QRS complex is identifiable?	68(26.7)	187(73.3)
ST depression in ECG indicated ischemia myocardial?	155(60.8)	100(39.2)
Description of Practice in ECG interpretation

Participant’s percentage practice score was above 65% out of a total score of 100%. Using > 65% score as the cut-off value, (n = 69, 27.1 with 95% CI (0.217–0.33) participants were found to have good knowledge and 186(72.9%) with CI (0.67–0.783). Practice related question results indicated that most frequently known items were interpretation and recognition of sinus Bradycardia 194 (76.1%), Asystole 195(76.5%), and Myocardial infarction 146 (57.3%). poorly identifies stripes were Atrial flutter 85(33.3%) and SVT 97(38%). Moreover, more than half of the participants were correctly able to identify the correct management of Asystole 165(64.7%), Myocardial infarction 152(59.6%) (Table 3).

Table 3

Description of Practice in ECG interpretation of participants working at and public hospital of Addis Ababa, Ethiopia (n = 255)
practice Assessment question	Correct N (%)	Incorrect N (%)
Sinus Bradycardia	194(76.1)	61(23.9)
Sinus Bradycardia management	174(68.2)	81(31.8)
Ventricular tachycardia	102(40)	153(60)
Ventricular tachycardia management	125(49.0)	130(51)
Atrial flutter	85(33.3)	170(66.7)
Atrial flutter management	133(52.2)	122(47.8)
Asystole	195(76.5)	60(23.5)
Asystole management	165(64.7)	90(35.3)
Myocardial infraction	146(57.3)	109(42.7)
Myocardial infarction management	152(59.6)	103(40.4)
Second-Degree Heart block	115(45.1)	140(54.9)
Second-Degree Heart block management	155(60.8)	100(39.2)
Atrial fibrillation	103(40.4)	152(59.6)
Atrial fibrillation management	127(49.8)	128(50.2)
SVT (supraventricular tachycardia)	97(38)	158(62.6)
SVT (supraventricular tachycardia) management	126(49.4)	129(50.6)
Ventricular fibrillation	97(38)	158(62)
Ventricular fibrillation management	96(37.6)	156(62.4)
Sinus Tachycardia	106(41.6)	149(58.4)
Sinus Tachycardia management	79(31)	176(69)

Factors Associated with Knowledge and Practice of ECG Interpretation for Nurses

The logistic regression model with multivariable analysis showed that level of education, workplace, and ECG training were associated with the knowledge and practice of nurses in ECG interpretation. Nurses working in intensive care units had three times more knowledge [AOR = 2.79; CI: 1.27–6.16] and practice [AOR = 2.72; CI: 1.26–5.88] in ECG interpretation. Nurses with a master's degree were six times more likely to have good knowledge [AOR = 6.74; CI: 1.7–26.45] and five times more likely to practice [AOR = 5.64; CI: 1.41–22.47] than those with a bachelor's degree. Nurses who received training had two times more knowledge [AOR = 2.89; CI: 1.11–7.47] and four times more practice [AOR = 4.31; CI: 1.7–10.94] than those who did not receive training.

Table 5

Factors Associated with Knowledge and Practice of ECG Interpretation for Nurses Working in Emergency Rooms and Intensive Care Units of Public Hospitals in Addis Ababa, Ethiopia
Variable for knowledge	AOR (with 95% CI)	P-value
Work place ICU	2.79(1.27–6.16)	0.011*
Educational level Msc	6.74(1.71–26.45)	0. 006**
ECG interpretation training Yes	2.89(1.11–7.47)	0.030*
Variable for practice	AOR (with 95% CI)	P-value
Work place ICU	2.72(1.26–5.88)	0.011*
Educational level Msc	5.64(1.41–22.47)	0.014*
ECG interpretation training Yes	4.31(1.7-10.94)	0.002***
Note: *Significant at P < 0.05, AOR adjusted odds ratio

In this study, the majority of participants had a mean age of 30.02 ± 4.7 years, were male, held a Bachelor of Science degree, and were employed in the emergency department. The study examined the ECG interpretation knowledge and practice of nurses, with only 23.5% demonstrating adequate knowledge and 27.1% showing good practice. Specific ECG interpretation questions showed varying levels of accuracy among participants, with some questions having high correct response rates, such as identifying the QRS complex and recognizing myocardial infarction, while others, like ventricular tachycardia and atrial flutter, had lower accuracy. Education level, practice area, and training were identified as significant factors influencing ECG interpretation knowledge and practice among nurses. These findings emphasize the importance of continuous education and training initiatives to enhance nurses' competency in ECG interpretation.

The findings of this study indicate that the level of knowledge and practice among nurses in ECG interpretation is significantly low, with only 23.5% and 27.1% demonstrating adequate knowledge and practice, respectively. Interestingly, these results align with a similar study conducted in China, where the majority of ICU nurses (70.9%) exhibited a low level of ECG knowledge (13). This study is also supported by a similar study conducted in Saudi Arabia (10). Another study conducted at Kenyatta National Hospital revealed that 61% of nurses lacked the ability to accurately interpret 12-lead ECG rhythms (15). Likewise, a study conducted in Indonesia revealed that a significant percentage (70.9%) of nurses struggled with accurately interpreting ECGs (19). The study in Addis Ababa also concluded that the majority of participants (90.9%) lacked competence in ECG interpretation (11). The slight variance in these results could potentially be attributed to the inclusion of intensive care unit staff, who exhibited slightly higher levels of knowledge compared to emergency department nurses.

However, in contrast to these findings, another study conducted in Spain on emergency nurse competence found that an impressive 93% of participants were able to correctly interpret ECGs (20). The decrease in the prevalence of knowledge and practice may be due to the fact that many nurses who underwent cardiac-related training did not receive recent training. Many of the study participants had training 2–5 years ago. These results emphasize the necessity of consistently updated training.

In this study, 51% of the nurses were not familiar with the correct order of ECG waves and intervals, while over half of the participants in Pakistan answered correctly. The question about whether "atrial fibrillation could have a regular rhythm" was answered incorrectly by 51.4% of participants, which contrasts with the study in Turkey, where 61.5% answered correctly (1). The majority of correct answers in this study were for questions such as “P wave representing left and right ventricular depolarization” (59.6%), “QRS complex representing right and left ventricular depolarization” (81.2%), and "ST depression in the ECG indicates myocardial ischemia" (60.8%). Additionally, 70.6% answered correctly about the “conduction problem between the atria if the P wave does not appear in an ECG." These results are similar to the study in Turkey (1). Furthermore, a study in China also showed that 89.9% correctly identified the QRS complex representing ventricular depolarization, and 86.3% recognized that the absence of a P wave indicates a problem with atrial conduction (13).

The ECG interpretation practice in this study revealed that the most prevalent irregular heartbeats were asystole at 76.5%, sinus bradycardia at 76.1%, and myocardial infarction at 57.3%. A study in Turkey similarly indicated that asystole was correctly identified in 94.1% of cases (1). Additionally, a study at Dow University Hospital in Pakistan concluded that 61.7% successfully traced an acute myocardial infarction (15).

The most inaccurately answered question was ventricular tachycardia at 40%, followed by atrial flutter at 33.3%, atrial fibrillation at 40.4%, and ventricular fibrillation at 38%. Conversely, findings from a Turkish study showed that the most commonly recognized aspects were the interpretation and identification of ventricular tachycardia (87.7%) and atrial flutter (84.6%), with approximately half correctly identifying ventricular fibrillation and atrial fibrillation (1). Another study at Dow University Hospital revealed that 72.5% accurately identified atrial flutter, 60.0% ventricular fibrillation, and 53.33% successfully traced atrial fibrillation (15).

This study revealed significant differences in nurses' ECG interpretation knowledge based on their working areas within the hospital. Nurses in the intensive care unit demonstrated higher knowledge levels at 6.3% compared to those in the emergency department at 17.6%. This variation could be attributed to the fact that ICU nurses primarily care for patients with heart conditions, and the lack of cardiac care units in many Ethiopian public hospitals leads to cardiac patients being admitted to the ICU. This exposes ICU nurses to more ECG cases. In contrast, a study at Dow University Hospital in Pakistan found similar ECG competence scores between nurses in the CCU and ED at 20.0% and 19.5%, respectively. ICU nurses scored lower at 15.6%, indicating a discrepancy in ECG knowledge levels among different hospital units (15).

The findings of this study indicate a significant relationship between the level of knowledge of ECG interpretation and cardiac-related training (P = 0.006 for knowledge and P = 0.014 for practice). Numerous research studies have supported these findings. For instance, a study conducted in Spain found that nurses who had recently received training scored higher in ECG interpretation compared to those who had not (20). Similarly, a study conducted in Turkey also reported a significant relationship between nurses' knowledge of ECG and previous ECG training (1). In terms of the practice of ECG interpretation among nurses, a study conducted in Malaysia revealed that the practice level was significantly lower among nurses who had not taken an ECG course in the ED (U = 128.5, p = 0.003) or ICU (U = 302, p = 0.001) (25). Similarly, a study conducted in Addis Ababa demonstrated a significant correlation between nurses' competency in ECG interpretation and their training (11).

Among the nurses who possess a master's degree, a higher percentage of correct answers were observed in the present study compared to those with Bachelor of Science and ECCN qualifications (P = 0.030 for knowledge and P = 0.002 for practice). This finding is supported by a study conducted in Malaysia (19). A recent study conducted in Addis Ababa revealed that there was no significant difference in the interpretation of ECG among participants based on their gender, age, and work experience. This result is similar to this study and consistent with a study conducted in Saudi Arabia (10, 11).

Implications of the Study

This study helps to identify specific areas where staff might need additional support. At the same time, this research will serve as a basis for creating training, new clinical guidelines, and protocols that can emphasize the importance of accurately interpreting ECGs. Moreover, such findings are useful to policymakers and hospital administrators whenever they want to address gaps in staff knowledge, allocate resources, and enhance quality care within emergency departments and intensive care units. Additionally, it can help identify areas where further study is needed.

The findings revealed a concerning lack of knowledge and practice among nurses. The accuracy of responses to specific ECG interpretation questions varied, with some questions receiving high response rates and most showing lower accuracy. This study emphasizes the importance of providing ongoing learning opportunities and experience-sharing programs for nurses. Factors such as education level, practice area, and previous training have been found to significantly influence ECG interpretation knowledge and practice. Therefore, it is crucial to provide education programs and continuous training to help nurses stay updated with the latest advancements in ECG technology and interpretation.

CCU	Cardiac Care Unit
CI	Confidence Interval
CVD	Cardiovascular Disease
ECG	Electrocardiograph
ED	Emergency Department
ICU MI	Intensive Care Unit Myocardial Infarction
SPSS TASH	Statistical Product and Social Service Tikur Anbessa Specialized Hospital

Authors’ Contributions

MTM: Selected the title, drafted the proposal (conceptualized and designed the study), analyzed and interpreted the data, and drafted the manuscript.

WTN: Approved the title, proposal, and thesis with some revisions.

LBD: Approved the proposal and thesis with some revisions, finalized the thesis, revised the manuscript, and provided constructive comments.

OA: Commented on the thesis and finalized the manuscript.

All authors have read and approved the final manuscript.

Availability of Data and Materials

The data supporting the findings of this study are available within the manuscript.

Ethical Approval and Consent to Participate

Informed consent to participate was obtained from all participants in the study. The study was reviewed and approved by the Institutional Review Board Addis Ababa University (IRB) of [Addis Ababa University], approval number [aau.2345]. The IRB ensured that all ethical guidelines were followed, and participants were fully informed about the nature and purpose of the research before consenting to participate.

Consent for Publication

Not applicable

Funding:

No funding was received for this study.

Consent to Participate

Not applicable.

Competing Interests

The authors declare that they have no competing interests.

Acknowledgements

The authors are grateful to the data collectors, the Addis Ababa University College of Health Sciences Department of Emergency and Critical Care, the health professionals in the pediatric emergency unit, and all study participants for their contributions to the study's success.

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No competing interests reported.

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You are reading this latest preprint version

Knowledge, Practice, and Associated Factors on Electrocardiograph Interpretation Among Nurses Working in Emergency and Intensive Care Units of Selected Public Hospitals in Addis Ababa, Ethiopia, 2024

Status:

Version 1

Abstract

Background

Objective

Methods

Results

Conclusion

INTRODUCTION

METHOD

Study Design, Area, and Period

Operational Definition

RESULTS

Socio-Demographic Characteristics

Description of Knowledge of ECG Interpretation

Factors Associated with Knowledge and Practice of ECG Interpretation for Nurses

DISCUSSION

Implications of the Study

CONCLUSION

Abbreviations

Declarations

Authors’ Contributions

Availability of Data and Materials

Ethical Approval and Consent to Participate

Consent for Publication

Consent to Participate

Competing Interests

Acknowledgements

References

Additional Declarations

Status:

Version 1