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The purpose of this study was to determine whether ward nurses have basic knowledge regarding 12 Lead ECG recordings and their interpretation, to be performing ECGs safely and as frequently as is documented at ward level. An availability study of 40 nurses (at random) in general ward areas was performed. The individuals were instructed to complete a 14 item questionnaire on basic 12 Lead ECG knowledge. Reasons for attending ECGs in ward areas, and previous inservice education were elicited. Anonymity was assured, and the questionnaire completed by staff in normal ward conditions, as opposed to exam-like conditions. Results revealed that overall knowledge was insufficient, considering the percentage of ECGs attended for chest pain. Findings suggest inservice education is required and desired by the participants.
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Leanne Amos, RN, Certified Midwife, Coronary Care Certificate, ACN. Leanne's nursing experience includes caring for patients undergoing haemodialysis and peritoneal dialysis as well as caring for patients with spinal injuries and neurogical problems. Leanne currently works in the Coronary Care Unit at St. Vincent's Hospital, Sydney. |
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An extensive search of the literature failed to locate previous research addressing the issues of ECG performance by nurses in general wards.
At St Vincent's Hospital Sydney over a period of 10 months, approximately 1000 ECGs were performed by ward nurses 'out of hours' (i.e. not between 8am and 5pm), a time when fewer experienced staff in this particular field are available for interpretation. Brannigan (1984, 25 - 26), referring to the use of continued cardiac monitoring in general ward areas states,
... if the object of the monitoring is to enable the nurse to detect abnormal changes of cardiac rhythm, the prime object fails. Many of the nurses who administer the care of these patients are unable to decipher what the monitor is showing.
This situation appears to be pertinent with the performance of 12 Lead ECGs in ward areas researched. Brannigan also argues that the extended role of the nurse implies better care given to the patients.
In practice though, this is not so - if anything, the overall effect on the patient, and to a lesser extent on the nurse, may be detrimental.
The attachment of ECG machines and delays or inability to interpret ECGs competently may increase patient anxiety levels. Emphasis on the seriousness of the problem is evident due to the need for patient attachment to such a technical device. Furthermore, excess levels of circulating catecholamines released during anxiety may prove detrimental to patients with cardiac disease.
On a positive note. Brannigan suggests that increased technology may encourage nurses to learn about ECGS, so that they may be:
... able to detect a dangerous change in cardiac rhythm and simultaneously note changes in clinical condition calling for prompt treatment.
The purpose of this study was to determine whether ward nurses have adequate knowledge to perform 12 Lead ECGs and interpret them at a basic level. The nurse practitioner attending an ECG contributes to total patient care, allowing for detection of dangerous situations, recognition of changes in clinical condition and requests for appropriate intervention.
Factors motivating this research were:
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Forty nurses with experience ranging from one to four years or more were surveyed. They were selected at random from ward areas which documented using the ECG machine most frequently out of hours. These wards included:
Both morning and evening staff were approached. Anonymity of name and area of work was assured. Participation was voluntary, although approximately half the subjects approached refused to participate when the topic of ECG was mentioned.
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This was an availability study and was attended on a Monday and Tuesday in October 1989, between 2 pm and 4 pm. The questionnaire consisted of 14 multiple choice and short answer questions. Subjects were given approximately 30 minutes to complete the questionnaire, the majority completing within 5 minutes. Nurses who had previously attended inservice education, and the percentage of nurses who actually attended these ECGs on their designated wards, were distinguished.
A normal ECG was attached to the paper with the first four questions relative to the ECG. Other diagrams included a normal sinus complex to be labelled, rhythm strips of dangerous situations requiring immediate treatment, and a diagram to be labelled on lead placement, in order to avoid discrepancy of description. Those requesting further knowledge on ECG were acknowledged.
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Forty subjects were studied. A broad cross section of nursing experience was covered.
| Year | % of Sample |
| 1 | 38% |
| 2 | 13% |
| 3 | 8% |
| 4 | 41% |
Table 1. Post Graduate Experience
Further isolation of experience was not distinguished, as the purpose of the study was not to determine which year of experience faired best. 38% of subjects had previously attended inservice education on 12 Lead ECGS.
Figure 1. Survey Results In Percentages
The mean score for correct answers was 42%. Those who had attended education sessions scored 55%, as opposed to 35% for those who had not attended.
Seventy-nine percent of all nurses surveyed perform ECGs on their wards. Reasons given for performing the majority (61%) of ECGs were chest pain and pre-operatively. 'Other' reasons included pulmonary embolism, irregular pulse. post cardiac catheter and angioplasty. 39% of these ECGs were reviewed immediately, 35% in 1-2 hours, 4% in 3-4 hours, 9% at >4 hours and 13% never.
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Figure 2. Reasons why ECGs were attended
Questions pertaining directly to the ECG were answered quite well by those in the educated group but poorly by those who had not attended education. in general, detection of heart rate was answered poorly by both groups, the average mark being 36%. Labelling of a normal sinus rhythm complex was answered well overall. Lead placement of V1 and V4, which have definite placement, were answered very poorly, i.e. only 26% of the inservice group and 8% of the no inservice group marked the positions correctly. The most common problems were that V1 was placed too high, V4 too low and wide lead placement on ribs.
Response was also very poor for detection of infarction and ischaemia. With regard to infarction, 33% stated they knew what the rhythm strip indicated and, of these, 26% were correct. Answers ranged from nodal rhythm, cardiac arrest and ventricular fibrillation. In response to ischaemia, only 8% were prepared to state the rhythm and of these, only one person correctly identified ischaemia. This is the main reason for performing an ECG for chest pain - the pertinent detection of early ECG changes.
Nurses who had attended inservice education scored slightly better throughout the questionnaire with 95% of subjects surveyed expressing their desire and need to attend inservice education.
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The results obtained suggest the majority of nurses in general ward areas do not have sufficient knowledge of 12 Lead ECGS, and would like to participate in inservice education.
The most relevant questions relating to nursing care and patient outcomes were answered most poorly, with little variation between the group attending inservice and those not. These questions included the identification of injury and ischaemia. It is essential for the nurse to recognise the need for rapid intervention, especially if thrombolytic therapy is indicated. Noted in the survey was the pre-existing time delay, i.e. the availability of the wardsmen to collect the ECG machine from CCU and the possibility that the machine was already in use.
Lead placement is fundamental knowledge for all those performing ECGS, regardless of their ability to interpret ECGS. Only 15% of those surveyed correctly placed the leads. Incorrect lead placement could lead to inaccurate interpretation especially if not reviewed by the medico.
Advances in ECG technology will be introduced in general ward areas in the near future. Although this may eliminate problems of interpretation and encourage prompt review of ECGS, the fundamentals of lead placement remain essential knowledge. Inaccurate lead placement can cause an incorrect diagnosis printout which appears on the ECG. It is essential that the nurse recognises the importance of correct placement as this could affect medical intervention.
It is agreed that ward nurses do not need extensive knowledge on 12 Lead ECGS, but the findings of this study illustrate insufficient knowledge when the majority of ECGs are performed for chest pain and 79% of nurses attend ECGS. This warrants ward nurses to have basic knowledge.
The majority of nurses were keen to be part of a research questionnaire until the topic of ECGs was mentioned. Almost half the subjects refused or were reluctant to participate. This may be due to 'fear of the unknown'. The purpose was to detect the need for educational assistance, not to threaten or intimidate nurses, which, unfortunately, was the general consensus.
A large number of pre-operative ECGs were performed in ward areas. The general comment that ECGs are often not sighted until the patient arrives in theatre suggests further investigation in this area is required.
Nurses attending inservice education scored slightly better throughout the research. This, however, does not significantly support the benefits of inservice education. The question of how recently education was attended may be relevant in this situation. With 95% of subjects surveyed expressing the desire and need to attend inservice, and the initial reaction to the questionnaire, further inservice education was surely indicated.
The data collected prompts the following suggestions:
In conclusion, good patient care dictates that nurses have a basic knowledge of ECG recording and interpretation. Even with technological advances providing electronic ECG interpretation, nurses maintain a responsibility for understanding the significance of changes in the patient's condition and responding appropriately. A knowledge of ECGs contributes to the nurse's confidence in recognising and managing effectively the contingencies of patient care in a busy teaching hospital.
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