1. Background
Nursing is a practical profession that entails continuous care activities from simple care to comprehensive decision making in service delivery (1, 2). Although these care activities are important for nurses in all hospital units, cognitive and practical abilities of nurses in the critical care unit (CCU), particularly in the assessment of cardiovascular disease, is of significant importance (3). As one of the important care units, coronary care unit presents nurses with complex issues (4). Considering the mission and goals of coronary care nurses and the need for efficient and capable nurses in the CCU, it can be a top research priority to measure the knowledge and skills of nurses concerning electrocardiogram (ECG) interpretation in order to predict risks at an early stage and enhance mortality and morbidity management (5).
The assessment of nurses’ skills and knowledge of ECG interpretation is critical in several respects, e.g., deciding on the ways of formulating foundations for job promotion and higher education, determining the gap between theoretical and practical education for ECG interpretation, investigating the gap between the current educational content and educational needs, increasing nurse-physician interaction in continuous evaluation of patients with heart problems, and screening inefficient nurse staff (6, 7). New educational methods including peer-led, software- and web-based training, and self-study books, as well as new devices to accelerate ECG strip review process, indicate the importance of ECG in the nursing field (8). Currently, there is a wide range of educational techniques, which can be used to train people in health and care areas concerning the application of equipment, 12-lead electrocardiogram monitoring, and ECG interpretation (9-11). Besides, nurses need to have adequate information about ECG and should be able to interpret it because they are responsible for ECG monitoring in clinical conditions (12).
Although there is no special educational content regarding the lead aVR and its determining role in acute coronary syndrome, arrhythmia, pericarditis, and pulmonary emboli, or its diagnostic role in exercise testing and drug toxicity, aVR is known as a forgotten lead despite its high importance (13). Di Toro et al. studied eight patients in a clinical trial and found that the presence of the R-wave (Pseudo-R-wave) (P-wave at the end of QRS complex) in lead aVR with no other symptom in ECG is the only symptom needed for the diagnosis of AVNRT and that it increases the diagnosis sensitivity up to 15% (14).
Hence, the clinical nursing curriculum requires the evaluation of knowledge and performance regarding lead aVR and investigation of attitude, knowledge, skills, strengths, and weaknesses of its diagnostic aspects for treatment purposes so that a new approach can be adopted in educational contents in this respect (15, 16). Given the significance of lead aVR, Pahlm et al. proposed an interesting idea for diagnosing clinical problems based on this lead. In the classic view, an investigation of lead I, II, and III is initially done in the cardiac axis with a 60-degree distance between each, and then leads AVR, AVL, and AVR are examined in a 120-degree distance from each other. However, in the proposed view, all leads are simultaneously examined in the left side of the heart axis imaginary circle centered at 30° to one another so that clinical problems and nursing diagnosis can be achieved more quickly (17). Considering the fact that a one-minute faster diagnosis of the left main coronary artery by the nurse increases the chance of survival in patients by 2.2%, an investigation of lead aVR is important due to its prediction and diagnosis power (18-20).
2. Objectives
The current research aims at investigating the knowledge and performance of nurses concerning lead aVR.
3. Methods
It is a descriptive cross-sectional study conducted from March to April 2016. The nurses working in the CCU of Imam Reza Hospital and Ghaem Hospital in Mashhad constituted the research population, who were sampled by the census. The inclusion criteria comprised a minimum of one-year work experience in the CCU, informed consent to participate in research, and lack of training in the field of diagnostic use of lead aVR.
The data collection tool consisted of a questionnaire with three independent sections, including a demographics form, a knowledge questionnaire, and a performance measurement questionnaire. The two latter sections concerned the use of lead aVR, all designed by the researcher. The knowledge questionnaire was answered by self-report and contained 30 items with three answers (true/false/I do not know). The scores ranged from 0 to 60 and were categorized as poor or inappropriate knowledge (0 - 20), moderate knowledge (21 - 40), and desirable knowledge (41 - 60).
The performance measurement section was researcher-made based on experienced real scenarios, consultations made with the cardiology specialists of Imam Reza Hospital, and review of reliable books. The section included six items on a five-point scale with the same scoring system and classification as the knowledge section. The score of the performance section was between 0 and 60, and a higher score showed better performance. It should be noted that the latest and most authoritative reference books for diagnosis in nursing and medicine were used as the basis for the initial design of the items.
The response time was 30 minutes. To determine the validity of the questionnaire, it was reviewed by 20 faculty members of the Nursing and Midwifery School and Imam Reza Hospital both affiliated to Mashhad University of Medical Sciences. 15 individuals made corrective comments, and necessary corrections were made accordingly. Ethical approval (code: 930459) was obtained from the university. To determine the reliability of the questionnaire, a test-retest was administered. The questionnaires were distributed to 20 eligible nurses working in the specialized cardiac care unit within 10 days. The correlation coefficients obtained for the knowledge and performance sections were 0.88 and 0.90, respectively. SPSS version 16 software was used for data analysis.
Descriptive statistical tests (mean, standard deviation, and frequency distribution) were used to describe the research units, and to compare the obtained data, correlation coefficient, independent t-test, Kruskal-Wallis, and Mann-Whitney tests were used. The significance level was considered less than 0.05.
4. Results
The majority of the participants were female (84%), married (68.1%), and contractual employees (52.27%). The mean ± standard deviation (SD) of age was 30.2 ± 7.4 years with the majority of them (61.3%) being in the age range of 27 - 32 years. The mean ± SD of general and CCU work experience was 7.1 ± 5.3 and 3.2 ± 1.3 years, respectively. The majority of the nurses (67%) had a BSc degree, and the most important source of information on lead aVR was educational content presented during the BSc program. Other information related to socio-demographic characteristics is observed in Table 1.
| Variable | Values | Knowledge Score (P Value) | Performance Score (P Value) |
|---|---|---|---|
| Gender | |||
| Male | 14 (16) | 0.08A | 0.16C |
| Female | 74 (84) | ||
| Marital status | |||
| Married | 60 (68.1) | 0.74A | 0.88C |
| Single | 24 (31.7) | ||
| Employment status | |||
| Formal | 10 (11.3) | 0.09B | 0.24D |
| Contractual | 46 (52.27) | ||
| Service commitment | 8 (9.0) | ||
| Conditional | 24 (27.2) | ||
| Education | |||
| Bachelor | 81 (92.1) | 0.22A | 0.06C |
| Master | 7 (7.9) | ||
| Work experience, y | 7.1 ± 5.3 | 0.08B | 0.01D |
| CCU work experience, y | 3.2 ± 1.3 | 0.32B | 0.08E |
| Source of information about ECG | |||
| Academic period | 59 (67) | 0.11B | 0.55D |
| Workshops, conferences and seminars on heart | 12 (13.6) | ||
| Self-directed learning | 17 (19.3) |
aValues are expressed as No. (%) or mean ± SD.
bStatistical test: A, Mann-Whitney; B, Kruskal-Wallis test; C, t-test; E, ANOVA.
The mean score of nurses’ knowledge was 19.6 ± 5.1 (out of 60) and the majority of them (53.4%) had an inappropriate knowledge level. The highest level of knowledge was regarding physiology and morphology of the lead waves and the lead position in the cardiac axis (67%), while the lowest level of knowledge was on AVR application in bundle branch block (10.2%) and Takotsubo syndrome (9%). The statistical analysis indicated that there was no significant relationship between the knowledge score and the variables of age, gender, education level, type of employment, and other personal variables (Table 1).
The mean score of performance in the nurses was 17.3 ± 1.1 (out of 60), and the majority of them had an inappropriate performance level (67%). No statistically significant relationship was found between individual variables and performance (Table 1). However, there was a positive significant correlation between work experience and performance (P = 0.01; r = 0.6).
Two-third of nurses with inappropriate knowledge about lead aVR had inappropriate performance. The results of the Spearman correlation coefficient test showed a direct relationship between knowledge and performance scores of nurses (P < 0.001; r = 0.891) (Table 2).
Table 2.Correlation Between Knowledge and Performancea
| Variable/Level | No. (%) |
|---|---|
| Knowledge | |
| Inappropriate (0 - 20) | 47 (53.4) |
| Relatively appropriate (21 - 40) | 22 (25) |
| Appropriate (41 - 60) | 9 (11.6) |
| Total | 88 (100) |
| Performance | |
| Inappropriate (0 - 20) | 59 (67) |
| Relatively appropriate (21 - 40) | 29 (33) |
| Appropriate (41 - 60) | - |
| Total | 88 (100) |
aStatistical test: r: 0.891, P < 0.001 (Spearman correlation coefficient).
5. Discussion
In the present study, nurses showed an undesirable level of knowledge and performance concerning the manner of using the lead aVR as a tachycardia rhythm disorder or ventricular ectopic beat diagnostic tool in the atrioventricular node.
In a study conducted by Haghjoo et al. on patients with heart disease, the results showed that lead aVR is important for the correct diagnosis of arrhythmias and tachycardia (21). Therefore, it will be highly critical for nurses to have adequate information in order to diagnose the disorder in a timely manner and to implement appropriate treatment, which can both be lifesaving to patients and prevent unwanted complications.
The majority of similar studies report consistent results with those of the present study. Jang et al. studied nurses’ knowledge of the correct use of ECG in emergency departments, intensive care units, and CCU. The results showed that the majority of nurses working in coronary care units had moderate or weak knowledge levels (22). Ejaz et al. also examined the knowledge of nurses about risk factors of cardiovascular disease. The results of their study showed a significant lack of knowledge in nurses as members of treatment teams that have the closest relationship with patients (23). In a clinical trial, Stephens et al. assessed the level of knowledge and ability of nurses to identify the exact location of the ischemic heart based on ECG, concluding that nurses of different hospital wards had low competency. They also reported that the nurses’ level of knowledge significantly increased with the implementation of an educational intervention (24). Funk et al. assessed the level of knowledge, quality of nursing care, and patient efficacy, reporting that the implementation of educational interventions was effective to improve the level of knowledge and quality of nursing care (25). In this regard, Kalhori et al. showed that ICU nurses’ knowledge about appropriate cardiopulmonary resuscitation guidelines was inadequate and that their knowledge and practice scores significantly increased after they received periodic education (26). Zhang and Hsu maintained that the implementation of training courses is needed to increase the knowledge of nurses and improve the quality of nurses on the correct use of ECG (27).
Therefore, considering the inadequacy of knowledge and practice of nurses and the significance of correct diagnosis of cardiac disorder as a lifesaving issue, it is highly important to hold educational courses on how to place electrocardiographs including lead aVR in the right anatomical location, make a correct diagnosis of ECG, and provide proper information to the physician to take appropriate actions. Moreover, in a study by Funk et al. that examined nurses’ knowledge of the correct use of ECG, similar to Zhang and Hsu, they reported a poor knowledge level in nurses concerning the correct use of ECG (25, 27).
Another study by Stephens et al. enquired into the ability and knowledge of nurses working in different wards of the hospital to diagnose an ischemic ECG and type of ischemia, showing that nurses did not have sufficient knowledge. In addition, this study recommended the implementation of educational programs to enhance the knowledge of nurses about the correct use of ECG and emphasized the impact of implementing educational processes through clinical trial interventions (24). Ejaz et al. evaluated the knowledge and practice of nurses about risk factors of heart disease, concluding that their level of knowledge was poor. They maintained that a set of issues could have positive effects including nurses’ possession of sufficient knowledge about cardiovascular risk factors, as one of the major causes of mortality, especially knowledge of high blood pressure and vascular disorders, teaching patients to change their lifestyle, and improving health via treatment teams that have close relationships with patients (23).
In contrast, the results of some studies, such as the study of Kalhori et al. do not match the results of this study. In their study, the expert knowledge of nurses about cardiopulmonary resuscitation methods, based on the 2010 CPR guidelines, was desirable (26). The reason for the discrepancy in the results of this study and those of other studies can be attributed to the classes held before measuring the level of knowledge. Therefore, there is a need for educational and periodic courses to improve the level of knowledge of nurses about the use of diagnostic tools such as ECG. One study by Ebrahimian et al. which examined the level of knowledge of nurses in the interpretation of ECG, reported insufficient knowledge about ECG interpretation in nurses. There is a need to investigate the causes of this deficiency and minimize the problem by implementing educational interventions because heart disease would have irreparable consequences if not detected in a timely and correct manner (28). In a study that examined the effect of an educational program on the knowledge of ECG interpretation in nurses, Jung et al. reported that nurses’ knowledge before the educational program was undesirable. This level of knowledge in nurses increased after the educational course completed. Therefore, the implementation of training courses can increase the knowledge and awareness of nurses (22).
In this regard, it is proposed to hold in-service or short-term courses for nurses on lead aVR and implement periodic training programs for CCU nurses, given the sensitivity of cardiovascular evaluation, the important role of lead aVR, and the need for the provision of prompt information to the physician to monitor the patient.
5.1. Conclusions
ECG interpretation is one of the important tasks of nurses concerning patients admitted to the CCU. Increasing the skill of nurses in this regard can help greatly follow up the patients and it leads to professional and advanced care in the CCU. Given the importance of lead aVR in detecting many disorders and considering the lack of nurses’ knowledge in this respect, this study highlighted the need to promote these skills through modifying the nursing curriculum and providing continuous education courses.
