Getting into the rhythm

May 2015   Comments

Equipping nurses with the knowledge and practice they need to interpret ECGs

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The regionalization of clinical programs over the last few decades has produced both benefits and challenges for clinical care. At our tertiary care facility, patient and medical coverage changed considerably in two patient care units when the cardiac program was consolidated at another tertiary facility. A third unit faced significant changes when beds and resources were allocated to an isolated patient care area.

Despite these changes, the three units, part of the medical and surgical program, retained their ECG monitoring capabilities. Nurses at our facility receive a standardized ECG interpretation course and a theory course in the foundations of cardiac and respiratory nursing. However, the orientation processes, mentorship, shift rotations and resources that contribute to nurses’ competence and confidence in caring for ECG-monitored patients vary from unit to unit. In particular, the nurses on one unit told us that they did not have confidence in their ECG interpreting skills because they lacked access to ongoing education and had limited exposure to a wide variety of rhythms after they received their initial education and training. Nurses staffing the high observation unit (HOU) also informed us that they did not have sufficient exposure to ECG rhythms because their rotations with monitored patients were infrequent. Additionally, these nurses had few opportunities to discuss ECG rhythms with colleagues from other units because of their unit’s location in our facility.

We wanted to find ways to support nursing competence with ECG monitoring and improve patient safety. We first assessed the baseline competence and confidence of nurses in these three units. We evaluated competence using standard ECG interpretation criteria such as the accuracy of measurements of the components of the ECG and correct rhythm identification. To assess the nurses’ confidence, we modified an ECG rhythm strip template to include a 10-point Likert scale (1 [no confidence] to 10 [very confident]) and asked them to rate their confidence in their ECG interpretation. We asked all nurses caring for ECG-monitored patients in these units to analyze ECG rhythm strips using this template. We also asked the nurses on these units to complete an online survey that explored some of the factors that may contribute to their competence and confidence with caring for ECG-monitored patients.

Of the 73 eligible nurses, 32 female nurses and two male nurses completed the survey, yielding a response rate of 47 per cent. Most respondents held a baccalaureate degree. HOU nurses had fewer shifts in their cardiac monitoring area than the nurses from the other two units: 58 per cent of HOU respondents indicated they had three or fewer shifts per month, and none had 13 or more shifts a month caring for cardiac-monitored patients.

A critical care nurse educator graded the ECG rhythm strips for rhythm interpretation accuracy. The HOU nurses had some difficulty with ECG interpretation (average score 66 per cent) compared with the nurses from the other two units (average scores 72 per cent and 88 per cent). Not surprisingly, the HOU nurses rated their confidence level with ECG interpretation lower (rating of 6) than the nurses from the other two units (ratings of 7 and 8).

Pilot project
The concerns that HOU nurses had initially expressed were reiterated in their survey responses. We therefore invited nurses from the HOU to become part of a pilot group of nurses that would be retrained in ECG monitoring. Twenty-two nurses, or roughly one-third of the nursing staff on this unit, volunteered for a week of intensive ECG education and training. Following this week they were to be scheduled to work a minimum of seven shifts a month with cardiac-monitored patients to consolidate their ECG interpretation skills. The nurse educator for the unit was available for mentorship, and ongoing educational activities were offered, including biweekly case reviews and a rhythm-of-the-month contest with coffee cards as prizes.

This group of nurses was re-evaluated using the same measures after six months to see if their confidence and competence had improved. The confidence level of the 16 nurses who completed the followup survey rose on average from 6 on the initial survey to 7. The competence of these nurses in interpreting ECG rhythms also increased, from 66 per cent in the initial test to 91 per cent six months after they joined the pilot project, even though we challenged them with more difficult rhythm strips than in the initial test. Anecdotally, we noticed that the nurses in the pilot project appeared to become more engaged in rhythm interpretation and began to ask more questions about the relationship of their patients’ ECG findings and clinical presentation.

However, the allocation of shifts among nurses participating in the pilot project was not equitable during the project period. Of the 16 nurses who completed the followup survey, five reported being scheduled for fewer than three shifts per month and four completed eight or more shifts per month. Many nurses did not meet the target of seven shifts per month caring for cardiac-monitored patients.

Lessons learned
Scheduling was a challenge in the pilot project. It proved to be difficult to equitably distribute shifts among the nurses in the pilot group, with several of them not meeting the target of seven shifts per month. Uptake of the ongoing educational activities was also variable: some nurses attended many case review sessions while others did not attend any. Some nurses may not have been able to attend sessions because of scheduling conflicts and/or the timing of these sessions in relation to their work rotation. The rhythm-of-the month contest was available to all ECG-trained nurses on the unit, but the nurses did not consistently participate in this educational activity.

We thought that for this project to be a success the nurses needed to volunteer to be part of the pilot group; however, there ended up being an abundance of ECG-trained nurses on some shifts and a dearth on others. Perhaps we should have selected nurses for this project on the basis of unit coverage needs.

Next steps
Nurses in the pilot project who did not receive the recommended minimum of seven shifts per month with cardiac-monitored patients have been asked to submit their names to their manager and clinical resource nurses to be assigned more shifts with ECG-monitored patients in the coming months. A small group of additional nurses will undergo ECG education and training to fill gaps in the rotation and replace nurses from the pilot project who are on leave or have moved to other units. The educational sessions in the pilot project were funded by our facility, and our facility will continue to fund the educational activities for these additional nurses.

In addition, the nurse educator for the HOU is putting together a practice test to promote ongoing education and competency around ECG analysis/interpretation, particularly for the clinical resource nurses, as ward demands on another floor do not facilitate time in the HOU. The nurses caring for ECG-monitored patients have suggested that they collect the challenging strips in a binder so that the educator and one of us can discuss possible interpretations of these rhythms and the clinical findings and interventions associated with them.

We are continuing to promote the rhythm-of-the-month contest with reminders and prizes. Each month we offer a case scenario or an ECG simulation to help nurses more effectively integrate theory into practice and to increase hands-on learning. The pilot group recently underwent mentorship training and participated in a half-day ECG interpretation review session with clinical scenarios. We will re-evaluate their progress in another six months.

We found that with education, careful shift allocation and mentorship we were able to provide nurses with a supportive clinical environment that increased their competence and confidence with ECG rhythm interpretation. The findings of this project have guided the development of interventions and strategies to promote ECG skill acquisition and enhance patient safety in the HOU. Our goal is now to use these approaches in all of the cardiac-monitored units at our facility.


Acknowledgment
The authors wish to thank the ECG-trained nurses from units H4/H7, B3 and A3; directors Heather Shortridge, Jannell Plouffe, Raj Mongru and Bev Laurila; managers Sheila Tagesen, Gloria Kirouac and Nina Kostiuk; educators Whitney Bohn, Tara Bergner, Laura Walton, Kelly Hallock and Amanda Lucas; Lean coach Tamara Coombs; and the Health Sciences Centre Executive Team for Supporting Lean Training and Projects.

Karen Throndson, RN, MN

Karen Throndson, RN, MN, is a Clinical Nurse Specialist in the Cardiac Program, Health Sciences Centre.

Vanessa Davis, RN

Vanessa Davis, RN, is a clinical resource nurse, Health Sciences Centre.

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