Nurses' competency in electrocardiogram interpretation in acute care settings: A systematic review

Are Italian Newly Licensed Nurses Ready? A Study on Self-Perceived Clinical Autonomy in Critical Care Scenarios

The experience and self-confidence of healthcare professionals play critical roles in reducing anxiety levels during emergencies. It is important to recognize the potential impact of anxiety on performance. To enhance preparedness and confidence in managing emergencies, healthcare professionals benefit from regular training and simulations. Additionally, repeated exposure to emergency scenarios can help modulate physiological responses. Managing anxiety effectively is key, as heightened sympathetic stimulation associated with anxiety can adversely affect performance. This study aimed to investigate nurses' self-assessed ability to manage emergency guidelines and their self-confidence in performing tasks in critical care settings. A questionnaire was provided to 1097 nurses. We compared the self-confidence of experienced nurses (ENs) and newly licensed nurses (NLNs) in managing emergency department shifts or critical patients, and found that ENs are more confident in these scenarios. This phenomenon was also observed in subjects who had taken simulation courses, although they were still a low percentage. Most NLNs feel sufficiently ready to work in medium-intensity wards. Attending advanced training courses enhances nurses' self-confidence and may improve patient safety management., improving patient recovery, and minimizing errors. Attending courses improves the perception of autonomy of nurses in different scenarios.

EDUCATE: An international, randomized controlled trial for teaching electrocardiography

INTRODUCTION

Despite the critical role of electrocardiograms (ECGs) in patient care, evident gaps exist in ECG interpretation competency among healthcare professionals across various medical disciplines and training levels. Currently, no practical, evidence-based, and easily accessible ECG learning solution is available for healthcare professionals. The aim of this study was to assess the effectiveness of web-based, learner-directed interventions in improving ECG interpretation skills in a diverse group of healthcare professionals.

METHODS

In an international, prospective, randomized controlled trial, 1206 healthcare professionals from various disciplines and training levels were enrolled. They underwent a pre-intervention test featuring 30 12-lead ECGs with common urgent and non-urgent findings. Participants were randomly assigned to four groups: (i) practice ECG interpretation question bank (question bank), (ii) lecture-based learning resource (lectures), (iii) hybrid question- and lecture-based learning resource (hybrid), or (iv) no ECG learning resources (control). After four months, a post-intervention test was administered. The primary outcome was the overall change in ECG interpretation performance, with secondary outcomes including changes in interpretation time, self-reported confidence, and accuracy for specific ECG findings. Both unadjusted and adjusted scores were used for performance assessment.

RESULTS

Among 1206 participants, 863 (72 %) completed the trial. Following the intervention, the question bank, lectures, and hybrid intervention groups each exhibited significant improvements, with average unadjusted score increases of 11.4 % (95 % CI, 9.1 to 13.7; P<0.01), 9.8 % (95 % CI, 7.8 to 11.9; P<0.01), and 11.0 % (95 % CI, 9.2 to 12.9; P<0.01), respectively. In contrast, the control group demonstrated a non-significant improvement of 0.8 % (95 % CI, -1.2 to 2.8; P=0.54). While no differences were observed among intervention groups, all outperformed the control group significantly (P<0.01). Intervention groups also excelled in adjusted scores, confidence, and proficiency for specific ECG findings.

CONCLUSION

Web-based, self-directed interventions markedly enhanced ECG interpretation skills across a diverse range of healthcare professionals, providing an accessible and evidence-based solution.

Assessing the Level of Electrocardiographic Interpretation Competency among Emergency Nurses in Palestine

Introduction

The use of electrocardiograms (ECGs) is widespread among emergency room (ER) nurses for diagnosis and triage, making it crucial for them to have the appropriate level of competency in interpreting ECGs. This can lead to better healthcare and patient outcomes.

Objectives

This study aims to assess the competency level of emergency nurses in Palestine in interpreting normal ECG and certain cardiac arrhythmias, and to explore the association between socio-demographic characteristics and their ECG interpretation competency.

Methods

The study used a cross-sectional descriptive design, and 196 ER nurses were conveniently recruited to fill out a self-administered questionnaire based on previous literature. The data collected were analyzed using SPSS with strict adherence to ethical considerations.

Results

The results showed that 70.9% of the nurses were males, 65.3% held a bachelor's degree in nursing, 46.9% had 1-5 years of experience, and 60.7% had received previous courses on ECG interpretation. The mean competency level of the ER nurses was satisfactory at 60.714%, but 38.8% had a poor level of competency. This was significantly higher among nurses with higher educational levels (p-value < 0.001), those who had taken previous ECG courses (p-value = 0.045) and life support (p-value < 0.05), and those who were exposed to more ECG interpretations per day (p-value = 0.001).

Conclusion

There is a need to focus more on ECG competency levels in Palestinian literature and compare them between different departments. It is also essential to evaluate nurses' needs for continuous education.

Predictors of ECG Interpretation Proficiency in Healthcare Professionals

Accurate ECG interpretation is vital, but variations in skills exist among healthcare professionals. This study aims to identify factors contributing to ECG interpretation proficiency. Survey data and ECG interpretation test scores from participants in the EDUCATE Trial were analyzed to identify predictors of performance for 30 sequential 12-lead ECGs. Nonmodifiable factors (being a physician, clinical experience, patient care impact) and modifiable factors (weekly interpretation volume, training hours, expert supervision frequency) were analyzed. Bivariate and multivariate analyses were used to generate a Comprehensive Model (incorporating all factors) and Actionable Model (incorporating modifiable factors only). Among 1206 participants analyzed, there were 72 (6.0%) primary care physicians, 146 (12.1%) cardiology fellows-in-training, 353 (29.3%) resident physicians, 182 (15.1%) medical students, 84 (7.0%) advanced practice providers, 120 (9.9%) nurses, and 249 (20.7%) allied health professionals. Among them, 571 (47.3%) were physicians and 453 (37.6%) were nonphysicians. The average test score was 56.4% ± 17.2%. Bivariate analysis demonstrated significant associations between test scores and >10 weekly ECG interpretations, being a physician, >5 training hours, patient care impact, and expert supervision but not clinical experience. In the Comprehensive Model, independent associations were found with weekly interpretation volume (9.9 score increase; 95% CI, 7.9-11.8; P < 0.001), being a physician (9.0 score increase; 95% CI, 7.2-10.8; P < 0.001), and training hours (5.7 score increase; 95% CI, 3.7-7.6; P < 0.001). In the Actionable Model, scores were independently associated with weekly interpretation volume (12.0 score increase; 95% CI, 10.0-14.0; P < 0.001) and training hours (4.7 score increase; 95% CI, 2.6-6.7; P < 0.001). The Comprehensive and Actionable Models explained 18.7% and 12.3% of the variance in test scores, respectively. Predictors of ECG interpretation proficiency include nonmodifiable factors like physician status and modifiable factors such as training hours and weekly ECG interpretation volume.

Exploring Factors Influencing ECG Interpretation Proficiency of Medical Professionals

The electrocardiogram (ECG) is a crucial diagnostic tool in medicine with concerns about its interpretation proficiency across various medical disciplines. Our study aimed to explore potential causes of these issues and identify areas requiring improvement. A survey was conducted among medical professionals to understand their experiences with ECG interpretation and education. A total of 2515 participants from diverse medical backgrounds were surveyed. A total of 1989 (79%) participants reported ECG interpretation as part of their practice. However, 45% expressed discomfort with independent interpretation. A significant 73% received less than 5 hours of ECG-specific education, with 45% reporting no education at all. Also, 87% reported limited or no expert supervision. Nearly all medical professionals (2461, 98%) expressed a desire for more ECG education. These findings were consistent across all groups and did not vary between primary care physicians, cardiology FIT, resident physicians, medical students, APPs, nurses, physicians, and nonphysicians. This study reveals substantial deficiencies in ECG interpretation training, supervision, and confidence among medical professionals, despite a strong interest in increased ECG education.

ECG Interpretation Proficiency of Healthcare Professionals

ECG interpretation is essential in modern medicine, yet achieving and maintaining competency can be challenging for healthcare professionals. Quantifying proficiency gaps can inform educational interventions for addressing these challenges. Medical professionals from diverse disciplines and training levels interpreted 30 12-lead ECGs with common urgent and nonurgent findings. Average accuracy (percentage of correctly identified findings), interpretation time per ECG, and self-reported confidence (rated on a scale of 0 [not confident], 1 [somewhat confident], or 2 [confident]) were evaluated. Among the 1206 participants, there were 72 (6%) primary care physicians (PCPs), 146 (12%) cardiology fellows-in-training (FITs), 353 (29%) resident physicians, 182 (15%) medical students, 84 (7%) advanced practice providers (APPs), 120 (10%) nurses, and 249 (21%) allied health professionals (AHPs). Overall, participants achieved an average overall accuracy of 56.4% ± 17.2%, interpretation time of 142 ± 67 seconds, and confidence of 0.83 ± 0.53. Cardiology FITs demonstrated superior performance across all metrics. PCPs had a higher accuracy compared to nurses and APPs (58.1% vs 46.8% and 50.6%; P < 0.01), but a lower accuracy than resident physicians (58.1% vs 59.7%; P < 0.01). AHPs outperformed nurses and APPs in every metric and showed comparable performance to resident physicians and PCPs. Our findings highlight significant gaps in the ECG interpretation proficiency among healthcare professionals.

ICU nurses' knowledge and attitude towards electrocardiogram interpretation in Fujian province, China: a cross-sectional study

Introduction

The series of electrocardiograms (ECGs) can help track cardiac abnormalities in patients' conditions and make an earlier clinical decision. It is crucial for nurses working in critical care environments to acquire ECG knowledge for effective ECG monitoring and act accordingly in case of a change in patient condition. This study aimed at investigating intensive care unit (ICU) nurses' knowledge and attitude towards ECG interpretation in Fujian province, China. The study also analyzed the relationship between participants' demographic characteristics and level of ECG knowledge.

Methods

This study was done online at twenty-one hospitals in Fujian province using a quantitative cross-sectional design involving 357 registered nurses working in the ICU between October and December 2021. The selection of hospitals and potential participants involved purposive and convenient sampling methods, respectively. Binary logistic regression was carried out to determine factors that predict ICU nurses' knowledge of ECG interpretation, and a p-value <0.05 was deemed statistically significant.

Results

The majority of nurses (70.9%) demonstrated a low level of ECG knowledge. The mean score for ECG knowledge was 5.95 (SD = 2.14), with only 0.8% of ICU nurses answering all questions correctly. The majority portrayed positive attitude towards ECG interpretation; however, more than half (61.6%) believed that nurses should rely on a doctor's opinion about ECG interpretation. Previous ECG training (AOR = 3.98, 95% CI: 2.12-7.45); frequency of ECG interpretation in comparison with no frequency of ECG interpretation (1-3 times per day: AOR = 15.55, 95% CI: 6.33-38.18; 1-3 times per week: AOR = 18.10, 95% CI: 6.38-51.34); and current working unit in comparison to those working in cardiac ICU (general ICU: AOR = 0.45, 95% CI: 0.21-0.94; medical ICU; AOR = 0.28, 95% CI: 0.12-0.67; and surgical ICU; AOR = 0.05, 95% CI: 0.01-0.43) remained statistically significant after adjusting for confounders.

Conclusion

The present study revealed a low level of knowledge about ECG interpretation among ICU nurses. Although the participants demonstrated positive attitudes toward ECG interpretation, the negative attitude still existed. Nurses should acknowledge ECG interpretation as part of their duties and responsibilities in nursing care instead of merely relying on doctors' opinions.

Can triage nurses accurately interpret the electrocardiogram in the emergency department to predict acute cardiovascular events? A prospective observational study

AIMS

The prompt recording of the electrocardiogram (ECG) and its correct interpretation is crucial to the management of patients who present to the emergency department (ED) with cardiovascular symptoms. Since triage nurses represent the first healthcare professionals evaluating the patient, improving their ability in interpreting the ECG could have a positive impact on clinical management. This real-world study investigates whether triage nurses can accurately interpret the ECG in patients presenting with cardiovascular symptoms.

DESIGN

Prospective, single-centre observational study conducted in a general ED of General Hospital of Merano in Italy.

METHODS

For all patients included, the triage nurses and the emergency physicians were asked to independently interpret and classify the ECGs answering to dichotomous questions. We correlated the interpretation of the ECG made by the triage nurses with the occurrence of acute cardiovascular events. The inter-rater agreement in ECG interpretation between physicians and triage nurses was evaluated with Cohen's kappa analysis.

RESULTS

Four hundred and ninety-one patients were included. The inter-rater agreement between triage nurses and physicians in classifying an ECG as abnormal was good. Patients who developed an acute cardiovascular event were 10.6% (52/491), and in 84.6% (44/52) of them, the nurse accurately classified the ECG as abnormal, with a sensitivity of 84.6% and a specificity of 43.5%.

CONCLUSION

Triage nurses have a moderate ability in identifying alterations in specific components of the ECG but a good ability in identifying patterns indicative of time-dependent conditions correlated with major acute cardiovascular events.

IMPACT FOR NURSING

Triage nurses can accurately interpret the ECG in the ED to identify patients at high risk of acute cardiovascular events.

REPORTING METHOD

The study was reported according to the STROBE guidelines.

NO PATIENT OR PUBLIC CONTRIBUTION

The study did not involve any patients during its conduction.

The triage Nurse's ability in electrocardiogram interpretation in real clinical practice

AIMS AND OBJECTIVE

The study aimed to assess the triage nurse's skill in the recognition of abnormal electrocardiogram during actual clinical practice and to identify nurse- and patient-related factors associated with errors in electrocardiogram interpretation.

BACKGROUND

The nurse's ability to interpret the electrocardiogram has only been evaluated in simulation settings and has reported conflicting results.

DESIGN

A prospective single-centre observational study.

METHODS

During the evaluation of a patient with a cardiovascular symptom, the triage nurses were asked to define whether the 12-lead electrocardiogram performed during the triage evaluation was pathological or non-pathological for the presenting symptom. Patient characteristics and some nurse-related variables were recorded. Inter-rater agreement between the physician and nurse in the electrocardiogram interpretation was considered the primary outcome, while the association of a major acute cardiovascular event related to patient access in the Emergency Department was the secondary outcome. We have followed the STROBE checklist for the preparation of this manuscript.

RESULTS

Twenty nurses agreed to participate to the study and collect data. Of the 644 patients enrolled, 21.6% (139/644) reported a pathological electrocardiogram according to the ED Physician. The concordance between nurse and physician was modest with Cohen's Kappa of 0.666. An error in the electrocardiogram interpretation was present in 11% of the patients. Nurses who performed an electrocardiogram course within 1 year and studied electrocardiogram interpretation autonomously presented a lower error rate, while older patients and patients with more previous cardiovascular disease were found to be more associated with an error in electrocardiogram interpretation.

CONCLUSIONS

The study demonstrates that triage nurses have a fair ability to interpret the electrocardiogram.

RELEVANCE TO CLINICAL PRACTICE

Specific educational programmes for electrocardiogram interpretation could improve the skill of electrocardiogram interpretation by the nurse and enable this instrument to become an indispensable tool in triage assessment.

Competency in ECG Interpretation and Arrhythmias Management among Critical Care Nurses in Saudi Arabia: A Cross Sectional Study

Background: Electrographic interpretation skills are important for healthcare practitioners caring for patients in need of cardiac assessment. Competency in ECG interpretation skills is critical to determine any abnormalities and initiate the appropriate care required. The purpose of the study was to determine the level of competence in electrocardiographic interpretation and knowledge in arrhythmia management of nurses in critical care settings. Methods: A descriptive cross-sectional design was used. A convenience sample of 255 critical care nurses from 4 hospitals in the Al-Madinah Region in Saudi Arabia was used. A questionnaire was designed containing a participant’s characteristics and 10 questions with electrocardiographic strips. A pilot test was carried out to evaluate the validity and reliability of the questionnaire. Descriptive and bivariate analyses were conducted using an independent t-test, one-way ANOVA, or bi-variate correlation tests, as appropriate. A statistical significance of p < 0.05 was assumed. Results: Females comprised 87.5% of the sample, and the mean age of the sample was 32.1 (SD = 5.37) years. The majority of the participants (94.9%) had taken electrocardiographic interpretation training courses. The mean total score of correct answers of all 10 ECG strips was 6.45 (±2.54) for ECG interpretation and 4.76 (±2.52) for arrhythmia management. No significant differences were observed between ECG competency level and nursing experience or previous training. Nurses working in the ICU and CCU scored significantly higher than those working in ED. Conclusions: The electrocardiographic knowledge in ECG interpretation and arrhythmia management of critical care nurses is low. Therefore, improving critical care nurses’ knowledge of ECGs, identification, and management of cardiac arrhythmias is essential.

Assessment of electrocardiogram interpretation competency among healthcare professionals and students of Ardabil University of Medical Sciences: a multidisciplinary study

BACKGROUND

Electrocardiogram (ECG) interpretation is a core clinical skill that helps to rapid diagnosis of potentially life-threatening diseases. Misinterpretation of the electrocardiogram can lead to inappropriate clinical decisions with adverse outcomes. The main aim of this survey was to assess the competency of electrocardiogram interpretation and related factors among healthcare professionals and students of Ardabil University of Medical Sciences.

METHODS

This descriptive cross-sectional study included 323 staff and students of Ardabil University of Medical Sciences in northwestern Iran. Data were collected randomly from November to January 1400 using the Badell-Coll ECG Interpretation Competency Questionnaire and analyzed using SPSS V.14. Statistical analysis included descriptive statistics, independent t-test, ANOVA, Pearson correlation coefficient and multiple linear regression.

RESULTS

The results showed that the mean and standard deviation of electrocardiogram interpretation competency of health professional staff and students was 5.13 ± 2.25 (maximum score = 10). The large number of participants wasn't able to identify normal sinus rhythm (n = 251, 77.3%), acute myocardial infarction (n = 206, 63.8%) and pathological Q waves (n = 201, 62.2%). The results of multiple linear regression showed that the variables of education level, self-assessment of electrocardiogram interpretation competence, work experience, and type of hospital were able to predict the competence of ECG interpretation in participants.

CONCLUSIONS

Our findings showed that the participants' level of electrocardiogram interpretation competency was low. Hence, regular, standard training and education are recommended. Also, managers and educators of the health system should consider the role of positive self-assessment and exposure to ECG interpretation in improving the competence of staff and students to interpret ECG.