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'What do I do next?' Nurses' confusion and uncertainty with ECG monitoring.

Telemetry monitoring is used on many hospital units. Goodridge, Furst, Herrick, Song, and Tipton (2013) identified a need for increased education/training in cardiac monitoring for the medical-surgical nurse who often needs to interpret cardiac rhythms outside a cardiac-specific unit. A nurse's ability to interpret a cardiac rhythm quickly and correctly is vital to initiating appropriate interventions and key to patient safety.

Nurses often report confusion and uncertainty due to their lack of knowledge related to electrocardiography (ECG) rhythm identification and intervention. Many hospital leaders have attempted to close the knowledge gap, but no specific evidence supported the amount and type of training, or how often training is needed (Costanzo, Ehrhardt, & Gormley, 2013; Forfa, 2013; Tai, Cattermole, Mak, Graham, & Rainer 2012). Furthermore, gaps in registered nurse (RN) telemetry training and retraining identified within facilities have led to patient safety concerns (Pecci, 2012; U.S. Department of Veteran Affairs, 2010).

Purpose

The purpose of this qualitative study was twofold: to identify RNs' perceived knowledge of and ability to respond to dysrhythmias to identify possible areas for improvement, and to identify the type and amount of education needed by RNs to be proficient with ECG rhythm analysis and patient treatment (eliminate confusion and uncertainty).

Review of Literature

A review of the literature was completed in the following databases for 2012-2016: CINAHL, Health Source Nursing, Medline, Ovid, and PubMed. Search terms included electrocardiography, ECG, EKG, telemetry, and dysrhythmia. The search then was narrowed by using the additional search terms accuracy, competence, proficiency, teaching, and training.

Very little research was available regarding evidence-based practices designed for telemetry monitoring by medical-surgical nurses. Thus, authors reviewed studies in other practice areas and also included earlier literature. In 2004, the American Heart Association (AHA) recognized this lack of information by publishing detailed standards of care for telemetry use (Drew et al., 2004). The AHA recommended ECG rhythm orientation for all nurses who have any exposure, even infrequent, to telemetry monitoring by didactic and return demonstration. Instruction should be based on a list of concepts understood by nurses with significant exposure to ECG monitoring. However, no specific recommendations were offered for nurses who do not have significant exposure to telemetry monitoring (e.g., medical-surgical nurses). Essentially, the AHA recommended leaders of each hospital determine what the minimum ECG proficiency should be for all nurses. This lack of specific recommendation by the AHA could create confusion and increase the likelihood that nurses, especially nurses with minimal exposure to telemetry monitoring, will not receive appropriate education or policy guidance. Notably, the AHA has not updated this manual despite significant increases in telemetry usage.

Advanced cardiac life support (ACLS) is the only education that defines a standard of knowledge for ECG interpretation for nurses caring for adult patients (AHA, 2016). Because telemetry monitoring is used widely, a national standard should be set for minimum ECG rhythm identification and treatment proficiency among nurses to ensure patient safety.

Costanzo and colleagues (2013) published results from their longstanding education consortium focused on dysrhythmia education. Nursing educators from 14 hospitals designed and offered a 24-hour instructor-led, computer-based ECG training program over 2 weeks for all newly hired nurses with no previous ECG education. Content included basic anatomy and physiology, normal and abnormal rhythms, and ventricular pacing with appropriate intervention. After completing the program, participants took a 50question standardized test of general ECG knowledge, rhythm identification, and interventions. Because the test was developed by the researchers, it was given for 2 months with the standard consortium examination that had known reliability data. Item analysis was completed after 2 months and two questions were revised for clarity. Ninety-nine percent (N=215) of participants achieved a score of 85% or better in no more than two attempts. Researchers did not try to determine if the increase in base knowledge translated to better psychomotor performance; they also did not investigate how long the increased knowledge lasted without repeat education.

Tai and colleagues (2012) conducted a prospective study evaluating nurse confidence levels when initiating defibrillation. Nurses from the Emergency Department at a teaching hospital in Hong Kong attended an educational session on defibrillation skills and identification of rhythms in cardiac arrest. Comparing pre-test and post-test scores, authors found no change in ECG rhythm identification but noted increased nurse confidence as well as improved decision making and psychomotor performance on defibrillation. Authors did not address how long the improvements lasted and when nurses should be re-educated.

In a study by Forfa (2013), a clinical educator identified a lack of ECG rhythm recognition, interpretation, and rhythm management by nephrology RNs and subsequently developed a review course. Fourteen RNs completed the review course before taking a required annual rhythm recognition course in which they were categorized as competent, additional practice needed, or needs remediation. Scores from the 2011 and 2012 annual rhythm recognition course were compared to evaluate impact of the 2012 review course. Though improvements in scores were seen in 2012, 35.7% (n=5) of nurses still required remediation. This suggested annual reviews and tests may be helpful but may not ensure continued competence.

A gap exists in the literature concerning nurses' perceived proficiency in ECG rhythm analysis and intervention. None of the reviewed articles evaluated these variables or offered data to inform the current study. In particular, literature concerning nurses who do not use the education on a daily basis was lacking.

Sample Selection

The study site was a 157-bed Midwestern hospital. The research team used a purposive sample of 11 RNs from the hospital's medical-surgical (n=6) and cardiac step-down units (n=5). All RNs who had completed orientation were invited to participate. Managers placed signs related to the study in common work areas to encourage staff participation. All staff were offered time away from the unit or paid if not on duty so they could participate. This approach increased the diversity of response as staff with diverse opinions or experiences could self-select for participation. After 11 interviews were completed, researchers believed data saturation occurred and no more RNs were interviewed.

Ethics

This study received Institutional Review Board approval from the University of Wisconsin Oshkosh and the hospital in which the study was conducted. All potential participants were informed of the study purpose and requirements, as well as the voluntary nature of their involvement, before providing consent. Participants were informed their answers would help guide development of a new ECG education program. They were compensated for their time by the hospital by being relieved during their paid shifts or being paid to come to the hospital when not scheduled to work. Only aggregate results were shared with hospital leaders.

Methods and Design

The literature was used as a basis for the seven-question semi-structured interview guide used in this descriptive qualitative study. Interviews were completed by two doctorally prepared nurse researchers with experience in qualitative research. Then-BSN students (now RN authors) took notes during the interviews. Each participant completed an informed consent and demographic questionnaire, and answered the semi-structured questions (see Table 1). Researchers asked participants to be frank and honest in their responses. Participants were ensured all information would be held in strict confidence, and they were free to withdraw from the study at any time. The interviews occurred in a private room adjacent to the hospital library.

Analysis

Spiegelberg's (1975) techniques of intuiting, analyzing, and describing were used for data analysis. This technique allowed researchers to uncover emerging themes, patterns, and insights. All interviews were audio-recorded and transcribed verbatim for consistent review and data analysis. Recordings and transcribed text were reviewed once by the entire team and twice by the two doctorally prepared researchers. Data were coded, concepts defined, and emerging themes identified. The research team focused on confirmability when discussing the emerging themes. After determining the major overarching theme and sub-themes, members completed an additional literature search to determine if emerging themes were congruent with past studies.

Trustworthiness

The trustworthiness of this study was established through ensuring credibility, dependability, conformability, and transferability (Lincoln & Guba, 1985). Organizational leaders noted RNs on the study units had verbalized concerns related to safely caring for patients with telemetry monitoring. Researchers established credibility via informal conversations and feedback sessions following presentations at state and national nursing conferences. Credibility was evident when RNs attending state and national nursing conferences confirmed study findings resonated with their own thoughts, feelings, and experiences. Several RNs identified situations in which staff in their agencies verbalized discomfort with telemetry monitoring due to infrequent exposure and unclear behavioral expectations.

Dependability was demonstrated through the researcher's reflective appraisal of the project. Themes were grounded in the interviews and literature. Although there was congruence, limitations to this study included a small sample size and representation of a single geographic location. To increase dependability, this study should be replicated in other similar units within the Midwest and beyond.

Regarding confirmability, one of the doctorally prepared authors has 38 years of intensive care experience and has been an ACLS instructor for over 20 years. This author has heard descriptions of clinical RNs in the hospital and remotely calling telemetry technicians and intensive care RNs with questions about rhythm interpretation and actions for a patient's dysrhythmia. Additionally, the author presented study findings at a national research conference and received RNs' feedback indicating results were similar to issues in their hospitals. Common concerns involved having infrequent exposure to ECG monitoring and feeling uncertain and uncomfortable.

To enhance the transferability of current study results, researchers have included the semi-structured interview guide (see Table 1). They also have described sample selection, research team composition, and data analysis. However, the person who wishes to transfer the results to a different context or setting is responsible for judging how sensible the transfer would be.

Findings/Discussions

The main overarching theme was Confusion and uncertainty: What should I do next? to reflect nurses' feelings in caring for patients receiving telemetry monitoring. Researchers also identified three general subthemes regarding RNs' use of telemetry in treating hospitalized patients: (a) Use it or lose it, (b) Losing my independence: Relying on unlicensed telemetry technicians, and (c) Help! I am out of my comfort zone.

Overarching Theme

Nurses reported confusion and uncertainty in caring for patients with telemetry monitoring. Two nurses who were considered clinical resources and self-identified as nurse leaders were not comfortable with ECG analysis or what to do when the telemetry technician called to report a rhythm change. As one resource nurse stated,
   We don't even look at the
   strips to determine what
   the rhythm is ... I will flat
   out ask (the telemetry technician)
   is this something I
   should call the doctor for?
   ... because they (telemetry
   technicians) know more
   than I do ... it is usually not
   an RN sitting in there, but I
   trust them a lot more than
   I would trust myself to
   know what the heck they
   are talking about, because
   they see it every day.


A second resource nurse noted, "Yeah, if somebody would come to me ... and say this patient had whatever abnormal rhythm ... I would honestly not know the answer... my first thing would be to call the doctor because I don't know." Another clinical RN commerited, "The paper may say that we are (proficient) but I know I for one, and I know there are others, we're just not confident in it." Though some nurses mentioned ACLS education and training increased their confidence, they did not believe extra training every 2 years was sufficient to maintain their sense of proficiency. One nurse stated, "It really was a waste of time for me because once I left the classroom, I never saw it again." Another nurse agreed, "The biggest thing to me is consistently using it in order to be proficient."

Subtheme 1: Use it or Lose it

The most common explanation for uncertainty was the need for information to be used often or it would be forgotten. Even though some nurses were pleased their organizations sent them through ACLS, they believed they did not retain the knowledge because they did not use it often enough. One RN stated, "For me, I feel like, if you don't use your skills, you lose your skills." This use it or lose it theme appeared in all interviews. Every nurse expressed a desire for more education, more frequent use, or both to maintain proficiency. One nurse stated, "The class was fine, but to be proficient, you have to use it, and on my unit, we never use it." Another nurse speaking about ACLS noted, "It's just that when you walk out of there, and then don't see it again for a long a period of time, I think that's where things get forgotten."

This perception may have contributed to nurses' anxiety and worry. One nurse commented, "It's like not being a cardiac nurse ... it's like, let's go, let's get them off the floor, because I don't want something to go wrong ... oh my God, they're not gone yet." Another nurse seemed even more anxious, stating, "I just feel like nursing is getting so ... they're stretching us too thin and no amount of teaching is going to help, unless you use it on a multiple-day basis." This nurse displayed characteristics of anxiety during this portion of the interview, tapping her leg and speaking quickly.

Subtheme 2: Losing My Independence: Relying on Unlicensed Telemetry Technicians

This lack of knowledge likely was the basis for nurses' belief they were unable to work independently. Nurses described lack of knowledge and confidence in how to read the rhythms. Additionally, they often were uncertain of a rhythm's seriousness and what to do when called by the telemetry technician with information about an abnormal rhythm. This insecurity led RNs to ask telemetry technicians for guidance on what to do next, and for help in differentiating the rhythm as serious or relatively benign. For example, as one nurse indicated when the telemetry technician calls, "I will flat out say--is this something I should call the doctor for?" A nurse stated, "I trust them (the telemetry technician) a lot more than I would trust myself to know what the heck they're talking about ... they see it every day." Another nurse said, "Granted they're not professional people, but technically they know more than I do, and I'm a professional person."

Subtheme 3: Help: I Am Out of My Comfort Zone

The sense of fear and panic in the nurses' statements was unmistakable. One RN explained her discomfort when caring for a patient with a dysrhythmia: "Not being a cardiac nurse, the minute RNs (on medical-surgical unit) hear the patient should go, it's like, let's just go, let's get them off the floor, because I don't want something to go wrong." Similarly, another nurse stated, "It makes me nervous when they sit there (patients) ... sometimes, it's ... a little too long for my liking." When describing her discomfort with dysrhythmias, another nurse said, "I don't even feel comfortable enough knowing what would be considered, you know, extremely lethal." These statements emphasized the need for increased education and training for all nurses working with telemetry monitoring. Nurses suggested working in small groups to discuss and think critically about potential and past cases. They also indicated regularly scheduled hands-on experience in the telemetry room (e.g., 1 hour per month) and annual computer-based and instructor-led training would be beneficial. Finally, one participant suggested rotating with intensive care nurses would be valuable.

Nursing Implications

This study identified confusion and uncertainty as notable factors in ECG rhythm analysis and intervention by medical-surgical and cardiac step-down RNs. Findings indicated nurses believe they require more frequent training and exposure in these two areas. Authors suggest policies and procedures must be developed to assist nurses in responding to dysrhythmias appropriately, quickly, and confidently. This is congruent with AHA's recommendation that agencies should specify the desired steps medical-surgical RNs should take with rhythm changes in monitored patients (Drew et al., 2004).

To increase RN knowledge, perceived proficiency, and comfort in caring for patients with telemetry monitoring, nurses in the study suggested several modes of education be used (e.g., online, paper and pencil, case-based scenarios, hands-on experience with ECG rhythm strips). To reduce reliance on unlicensed personnel, a list of resource contacts should be developed so RNs can obtain assistance quickly (e.g., intensive care RN, cardiac RN, house supervisor). Evidence-based hospital standards must be developed and disseminated to all nurses, to include a hierarchy of resources for nurse consultation and a step-wise process for assessment. A format for reporting the dysrhythmia to the provider could be developed to ensure complete, concise communication. A laminated card listing this step-wise process could be attached to the back of the RN's name badge as a quick reference. Color-coded, laminated reference sheets also could be stored in each patient room. In the event of a dysrhythmia, these tools could ensure response consistency.

Limitations

In this qualitative study, a small number of informed participants shared their personal narratives. Their answers reflected their own experiences within their own environments. Moreover, the study measured only participants' perceptions of proficiency related to ECG rhythm identification, rather than using an objective measure of knowledge.

Recommendations for Future Research

Future research is needed to determine the amount of education needed to help RNs feel comfortable and proficient in ECG monitoring. Additionally, perceived knowledge and tested knowledge may not be the same. Future studies could focus on the optimal mode and frequency of ECG training. This content area could be studied with a larger, more diverse sample. Further research could investigate the effectiveness of case studies, as suggested by several participants, and the components necessary to create a significant learning experience from a case study.

Conclusion

Participants in this study reported confusion and uncertainty regarding caring for patients with ECG monitoring. They perceived these feelings to be due to lack of frequent exposure to monitored patients and/or education regarding their appropriate treatment. To increase comfort and proficiency, participants recommended case reviews, more frequent online learning, hands-on experience, and specific step-by-step guidelines.

REFERENCES

American Heart Association (AHA). (2016). Advanced cardiovascular life support (ACLS). Retrieved from http://cpr.heart.org/AHAECC/CPRAndECC/Training/HealthcareProfessional/AdvancedCa rdiovascularUfeSupportACLS/UCM_473186_Ad vanced-Cardiovascular-LifeSupport- ACLS.jsp

Costanzo, A.J., Ehrhardt, B., & Gormley, D.K. (2013). Changing the rhythm of dysrhythmia education through blended learning. Journal for Nurses in Professional Development, 29(6), 305-308.

Drew, B.J., Califf, R.M., Funk, M., Kaufman, E.S., Krucoff, M.W., Laks, M.M., ... Van Hare, G.F. (2004). Practice standards for electrocardiographic monitoring in hospital settings: An American Heart Association Scientific Statement from the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young: Endorsed by the International Society of Computerized Electrocardiology and the American Association of Critical-Care Nurses. Circulation, 110(17), 2721-2746.

Forfa, M.J. (2013). Advancing nursing practice in rhythm recognition with an e-learning educational program. Nephrology Nursing Journal, 40(2), 159-163.

Goodridge, E., Furst, C., Herrick, J., Song, J., & Tipton, PH. (2013). Accuracy of cardiac rhythm interpretation by medical-surgical nurses. Journal of Nurses in Professional Development, 29(1), 35-40.

Lincoln, Y.S., & Guba, E.G. (1985). Naturalistic inquiry. Beverly Hills, CA: Sage Publications.

Pecci, A.W. (2012). VA finds large gaps in RN telemetry training, retraining. Health-Leaders Media. Retrieved from http://www.healthleadersmedia.com/nurseleaders/va-finds-large-gaps-rn-telemetry- training-retraining

Spiegelberg, H. (1975). Doing phenomenology. Dordrecht, NL: Martinus Niijhoff.

Tai, C.K., Cattermole, G.N., Mak, PS., Graham, C.A., & Rainer, T.H. (2012). Nurse-initiated defibrillation: Are nurses confident enough? Emergency Medicine Journal, 29(1), 24-27.

U.S. Department of Veterans Affairs, Office of Inspector General. (2010). Healthcare inspection: Telemetry monitoring issues, VA Eastern Colorado Health Care System, Denver, Colorado (VA Office of Inspector General Report No. 09-0104769). Retrieved from http://www.va.gov/oig/54/reports/VAOIG-09-01047-69.pdf

Bonnie Nickasch, DNP, APNP, FNP-BC, is Assistant Professor and Director, DNP Family Nurse Practitioner Emphasis, University of Wisconsin Oshkosh, Oshkosh, WI; and Family Nurse Practitioner, ThedaCare Physician Services, Appleton, WI.

Suzanne Marnocha, PhD, RN, CORN, is Professor, Assistant Dean, and Pre-Licensure Director, University of Wisconsin Oshkosh, Oshkosh, WI.

Lisa Grebe, BSN, RN, is Registered Nurse, ThedaCare Regional Medical Center, Appleton, WI.

Heather Scheelk, BSN, RN, is Registered Nurse, Intensive Care Unit, ThedaCare Regional Medical Center-Neenah, Neenah, WI.

Colette Kuehl, BSN, RN, is Dialysis Nurse, Purity Dialysis Center, Watertown, WI.
TABLE 1.
Semi-Structured Interview Guide

Questions

1. Please share what specific education you believe is necessary to
be proficient in ECG cardiac rhythm analysis and treatment.

2. How often and what type of education would help to maintain your
proficiency?

3. How many times a year on average do you care for a patient with
ECG monitoring (telemetry)?

4. Please share situations about cardiac rhythm analysis and
patient treatment that make nursing care more difficult.

5. Describe step-by-step what you would do if you receive a phone
call from the telemetry technician about a patient experiencing
cardiac rhythm problems.

6. Please share what you would do if you have a question about a
rhythm analysis or patient treatment.

7. Please share any suggestions you might have to improve the ECG
monitoring and patient treatment processes here.
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Title Annotation:Research for Practice
Author:Nickasch, Bonnie; Marnocha, Suzanne; Grebe, Lisa; Scheelk, Heather; Kuehl, Colette
Publication:MedSurg Nursing
Date:Nov 1, 2016
Words:3509
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