RAJIV GANDHI UNIVERSITY OF
HEALTH SCIENCES
SYNOPSIS ON
THE M.SC.(N) DISSERTATION
A STUDY TO ASSESS THE EFFECTIVENESS OF SELF
INSTRUCTIONAL MODULE ON KNOWLEDGE OF
ELECTROCARDIOGRAM AMONG STAFF NURSES IN A
SELECTED HOSPITAL IN MANGALORE
Submitted By:Ms. Anitha Paul
1st year M.Sc. Nursing student,
Srinivas Institute of Nursing
Sciences,
Valachil Padavu, Arkula,
Mangalore – 574 143.
Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.
ANNEXURE – II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR
DISSERTATION
1. NAME OF THE CANDIDATE
AND ADDRESS
(IN BLOCK LETTERS)
MS. ANITHA PAUL
1st YEAR M. Sc. (NURSING)
MEDICAL SURGICAL NURSING
SRINIVAS INSTITUTE OF NURSING
SCIENCES,
VALACHIL PADAVU, ARKULA,
MANGALORE – 574 143.
2. NAME OF THE INSTITUTION
SRINIVAS INSTITUTE OF NURSING
SCIENCES,
VALACHIL PADAVU, ARKULA,
MANGALORE – 574 143.
3. COURSE OF STUDY
SUBJECT
M.Sc. NURSING
MEDICAL SURGICAL NURSING
4. DATE OF ADMISSION 01-06-20115. TITLE OF THE TOPIC.
A STUDY TO ASSESS THE EFFECTIVENESS OF SELF
INSTRUCTIONAL MODULE ON KNOWLEDGE OF
ELECTROCARDIOGRAM AMONG STAFF NURSES IN
A SELECTED HOSPITAL IN MANGALORE
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6.
6.1
BRIEF RESUME OF INTENDED WORK
Introduction
“The most beautiful things in the world cannot be seen with the eyes, but
can only felt with the human heart”.
- Nursing journal of India
The heart is a hollow, cone-shaped organ approximately the size of an
adult’s fist, weighing less than 0.450 Kgs. Cardiac muscle cells possess an
inherent characteristic of self-excitation, which enables them to initiate and
transmit impulses. The SA node, located at the junction of the superior venacava
and right atrium act as the normal pacemaker of the heart generating an impulse
60-100 times per minute. This impulse travels across the atria via the internodal
pathways to the atrioventricular (AV) node. It then passes through the bundle of
His at the atrioventricular junction and continues down the interventricular
septum through the right and left bundle branches and out to the purkinje fibers.1
Electrocardiography (ECG or EKG from the German
Elektrokardiogramm) is a transthoracic interpretation of the electrical activity of
the heart over a period of time, as detected by electrodes attached to the outer
surface of the skin and recorded by a device external to the body. The etymology
of the word is derived from the Greek word ‘electro’, because it is related to
electrical activity, ‘kardio’, for heart, and ‘graph’, a Greek root meaning
"to write".2
Fig 1:ECG wave
An initial breakthrough came when Willem Einthoven, working in Leiden,
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Netherlands, used the string galvanometer that he invented in 1903. Einthoven
assigned the letters P, Q, R, S and T to the various deflections, naming of the
waves in the ECG and described the electrocardiographic features of a number of
cardiovascular disorders. In 1924, he was awarded the Nobel Prize in Medicine
for his discovery. 2
Epidemiologists in India and international agencies such as the World
Health Organization (WHO) have been sounding an alarm on the rapidly rising
burden of cardiovascular disease (CVD) for the past 15 years. The reported
prevalence of coronary heart disease (CHD) in adult has risen four-fold in 40
years and even in rural areas the prevalence has doubled over the past 30 years. In
2005, 53% of the deaths were on account of chronic diseases and 29% were due
to cardiovascular diseases alone. It is estimated that by 2020, CVD will be the
largest cause of disability and death in India.3
With the epidemiologic transition, the CVD burden continues to rise in
developing countries including India. The projected rise in disease burden due to
CVD is expected to make it the prime contributor of total mortality and
morbidity. Almost 2.6 million Indians are predicted to die due to coronary heart
disease (CHD), which constitutes 54.1% of all CVD deaths in India by 2020.
Additionally, CHD in Indians has been shown to occur prematurely, that is,
at least a decade or two earlier than their counterparts in developed countries.
Demographic and health transitions, gene-environmental interactions and early
life influences of fetal malnutrition are the likely causes of increased CVD burden
in India.4
Need For The Study
Cardiovascular disease is the leading cause of death and disability in the
United States. Over 64 million people have some type of cardiovascular disease.
Coronary heart disease is responsible for 1 in 5 deaths in the United States.
The economic costs of CVD, both direct and indirect, to the nation are estimated
at $368 billion annually.1
Coronary heart disease is becoming more common in the developing
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world such that in India, cardiovascular disease (CVD) is the leading cause of
death.5 The deaths due to CVD in India were 32% of all deaths in 2007 and are
expected to rise from 1.17 million in 1990 and 1.59 million in 2000 to 2.03
million in 2010 6. Although a relatively new epidemic in India, it has quickly
become a major health issue with deaths due to CVD expected to double during
1985–2015 7. Mortality estimates due to CVD vary widely by state, ranging from
10% in Meghalaya to 49% in Punjab (percentage of all deaths). Goa (42%),
Tamil Nadu (36%) and Andhra Pradesh (31%) have the highest CVD related
mortality estimates.8 State-wise differences are correlated with prevalence of
specific dietary risk factors in the states. Moderate physical exercise is associated
with reduced incidence of CVD in India (those who exercise have less than half
the risk of those who don't).7
The ECG is an essential tool in evaluating the heart rhythm.
Electrocardiography detects and amplifies the very small electrical potential
changes between different points on the surface of the body as the myocardial
cells depolarize and repolarize, causing the heart to contract. The same electrical
impulses spread outward from the heart to the skin, where they can be detected by
electrodes attached to the skin. The ECG displays the electrical action of the
heart. The ECG is the gold standard for noninvasive diagnosis of cardiac
arrhythmias and conduction abnormalities and useful tool in evaluating the
function of implanted devices such as pacemaker and implanted defibrillators.9
According to Drew BB, the critical care nurses should learn how to use ST
segment monitoring to detect acute ischemia, which is often asymptomatic in
patients with acute coronary symptom. ECG monitoring is becoming more
common in both in-patient and out-patient care settings. Nurses have significant
diagnostic influences in areas of cardiac rhythm monitoring and dysarrhytmia
identification. It is essential that nurses who care patients at risk for cardiac
dysarrhytmia have a thorough understanding of accurate electrode placement.10
Monitoring the routines of critical care nurses has indicated that nurses do
not select leads according to diagnosis (or history of coronary disease).
4
A survey was conducted on769 ICU in 2009 by AACN. The results revealed that
53% of the nurses stated that routine leads (standard lead choice) were used to
monitor patients regardless of the diagnosis.11
A qualitative study was conducted on arrhythmia knowledge with the
objective to identify and describe critical care nurse’s perception of arrhythmia
knowledge. The sample consisted of 70 critical care nurses who worked in acute
care settings where they read ECG data and made treatment decisions. The data
collection method included 5 focus groups which were conducted over a period of
12 months. Group size ranged from 4 to 8 participants. The result showed a
deficit in nurse’s ability to recognize and identify specific arrhythmia, including
heart block, aberrant conduction and tachyarrhythmia.12
A descriptive study was conducted in North West America among nurses
on interpreting 12 lead ECG for acute ST-elevation of myocardial infarction. The
objective of the study was to assess the nurse’s knowledge of interpreting ECG.
The sample consisted of 75 nurses who were given asset of 6 patients and asked
to identify the presence or absence of ischemia and were unable to determine
the correct leads, location and amplitude of ST-segment elevation. For 3
non-ischemia ECG’s 37(49%) of the nurses identified them as a normal ECG,
47 (63%) determined that an early repolarization pattern was ischemic and
34 (45%) indicated that a left bundle branch block pattern was ischemic.
These results not only identify educational opportunities but also provide
important information for researchers implementing clinical trials.13
Nurses will continue to need ongoing education and mentoring in correct
application of ECG leads and principles of monitoring. Audits of nursing practice
should include physical placement of electrodes and lead selection. The results
from audits will highlight improvement in practice and ongoing educational
needs. Involvement of staff nurses in the audit process is an excellent method of
highlighting evidence-based practice at the bedside.11
Nurses play a critical role in arrhythmia identification and management at
the bedside. On the basis of the nurse’s interpretation of the electrocardiographic
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6.3
(ECG) monitor recording, the nurse may simply gather more data, notify the
physician who makes treatment decisions based on the rhythm interpretation of
the nurse, or institute pharmacologic and counter shock therapies consistent with
unit-specific protocols. Therefore understanding the nurse’s perception of
arrhythmia knowledge, and ultimately, developing tools to evaluate this
knowledge, and competence in the recognition of ECG rhythms, are of critical
importance to nursing.12 So the investigator felt the need to conduct the study on
this group.
Review of Literature
An experimental study was conducted on nurse’s ability to identify
anatomic location and leads on 12-lead electrocardiograms with ST elevation in
myocardial infarction in United States, 2010. The objective of the study was to
determine the nurse’s knowledge to identify the presence of ST elevation in
myocardial infarction (STEMI), selection and location of leads. The sample
consisted of 75 nurses from the emergency department, coronary care unit and the
progressive care. The nurse’s were given 6 patient scenarios (3 STEMI and
3 non - STEMI) and a corresponding 12-lead ECG. This was followed by a
brief in-service education on ECG by hand held tool. The nurse then interpret the
same six ECGs (in a different order) using the hand held tool. The results showed
that identification of STEMI location improved when the tool was used. Lead
identification improved in 2 of the 3 STEMI scenarios.14
A study was conducted to determine the proficiency of ICU nurse’s and
emergency room (ER) nurses in performing ECG procedure and nursing
management in selected hospitals in Iligan city, Philippines in 2010.The objective
of the study was to assess the knowledge on fundamentals of ECG, including 12
lead placement, nursing management and the basic interpretation of rhythm strips.
The sample consisted of 66 ICU and ER nurses and data were collected by using
questionnaire. The results revealed that the overall total average score yielded a
mean proficiency of 58.02% of the respondents which was below the expected
range of 75%.
This showed the insufficiency of ICU and ER nurses on the knowledge
and skill on ECG. The study concluded that skill enhancement program and
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continuing education should be provided to both ICU and ER nurses to render
quality nursing care to the patients.15
A study was conducted on Cardiac Surgical Nurse’s in North America
regarding the use of Atrial Electrograms to Improve Diagnosis of Arrhythmia in
2010. The objective of the study was to determine whether use of atrial
electrograms significantly improves nurse’s ability to diagnose cardiac
arrhythmias. A sample of 282 nurses completed a test consisting of 5
electrocardiographic rhythms for which use of atrial electrograms might improve
interpretation. A standardized educational session on obtaining and interpreting
atrial electrograms was given to 165 nurses who had not previously received such
education. In a second test, the same rhythms were provided along with atrial
electrograms to 261 nurses. The results showed that use of atrial electrograms
significantly increased overall arrhythmia interpretation scores.16
A descriptive study was conducted to evaluate the nurse’s current
knowledge related to electrocardiographic (ECG) monitoring. The objective of
the study was to determine the nurse’s knowledge on ECG monitoring. The
sample consisted of 1739 nurses working on adult cardiac units in 17 hospitals
(15 in the US, 1 in Canada, 1 in Hong Kong) from September 2008 to June 2009.
The results had shown that nurses had the highest mean score (52; SD ± 6) on the
essentials of ECG monitoring and had the lowest mean score (36; SD± 23) on
ischemia monitoring. The study concluded that nurse’s knowledge about ECG
monitoring can be improved and education should particularly target less
experienced nurses.17
A prospective study was conducted to determine the accuracy of
diagnosing atrial fibrillation on ECG by primary care practitioners and
interpreting diagnostic software in England, 2007. The objective of the study was
to assess the accuracy of general practitioners and practice nurses in the use of
different types of ECG to diagnose atrial fibrillation. The sample consisted of 49
general practitioners and 49 practice nurses who were given 2595 patients.
The results showed that general practitioners detected 79 out of 99 cases of atrial
fibrillation on a 12 lead ECG. The practice nurses misinterpreted 114 out of 1355
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6.4
6.5
cases of sinus arrhythmia as atrial fibrillation. The study concluded that many
primary care professionals cannot accurately detect atrial fibrillation on an
electrocardiogram.18
An experimental study was conducted to assess the effectiveness of
planned teaching programme among GNM students on ECG in West Bengal in
2002. A sample of 30 final year GNM students were selected by lottery method
and data were collected by questionnaire and observation checklist. The results
shown that sum of the mean knowledge scores of students were 26.23 in pretest
and 73.66 in post-test, the ‘t’ value was 26.86.The findings suggested that the
planned teaching programme had effect on the knowledge of GNM students.19
Statement of the Problem
A study to assess the effectiveness of self instructional module on
knowledge of electrocardiogram among staff nurses in a selected hospital in
Mangalore.
Objectives of the Study
Objectives of the study are to
To assess the pre-test knowledge of staff nurses regarding
electrocardiogram.
To develop and evaluate the effectiveness of self instructional module.
To find out association between the selected socio demographic variables
of staff nurses with their pre-test knowledge scores on electrocardiogram.
Operational Definitions
Effectiveness :
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6.7
Effectiveness refers to improvement in the post-test scores of nurses after
the administration of self instructional module on electrocardiogram
which is measured and expressed in terms of knowledge scores.
Self Instructional Module :
Self instructional module refers to a booklet which covers the information
and instructions regarding anatomy and physiology of heart, recording and
interpretation of normal and abnormal ECG to enhance the knowledge of
staff nurses regarding electrocardiogram.
Knowledge :
Knowledge refers to the awareness of staff nurses on electrocardiogram.
Electrocardiogram :
The electrocardiogram is a graphical record of the electrical impulses that
are generated by depolarization and depolarization of the myocardium.
Staff Nurses :
Staff nurses refers to those qualified registered nurses working in a
selected hospital in Mangalore.
Assumptions
Staff nurses may not have adequate knowledge regarding
electrocardiogram.
Self instructional module will enhance the knowledge of staff nurses on
electrocardiogram.
The knowledge may vary according to the selected demographic variables.
Delimitations
The study will be limited to:
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7
7.1
7.2
Staff nurses who are working in a selected hospital in Mangalore.
Gain in knowledge scores.
Assessment of effectiveness of SIM on recording of 12-lead ECG and
interpretation of selected arrhythmias.
50 staff nurses.
Hypotheses
H1:- There will be a significant difference between the post-test knowledge
scores and pre-test knowledge scores of electrocardiogram.
H2:- There will be a significant association between the mean pre- test
knowledge score on electrocardiogram and the selected demographic
variables.
MATERIALS AND METHODS
Source of DataThe data will be collected from staff nurses who fulfill the inclusion
criteria and are willing to participate.
Research Design
The research design selected for this study is pre- experimental, one
group pre test post test design
O1 X O2
(DAY 1) (DAY 1) (DAY 7)
O1 - Pre Test
O2 - Post Test
X - Administration of SIM.
SCHEMATIC OUTLINE OF RESEARCH DESIGN
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DESIGNPre-experimental one group pre-test post-test design
POPULATION
Staff Nurses
SAMPLE TECHNIQUENon-probability purposive
sampling
FINDING, DISCUSSION AND CONCLUSION
STUDY SAMPLE50 Staff nurses working
in a selected hospital
STUDY SETTING Selected hospital in
Mangalore
TOOLSelf administered closed
ended structured questionnaire
Frequency & Percentage of socio -
demographic variables
Mean, Standard deviation and percentage of knowledge on
ECG
Paired’t’ test for significance of difference between the pre
test & post test scores.Chi-square test for association
between pretest and socio demographic variables
VARIABLES
DEPENDENT
Knowledge on ECG
INDEPENDENT SIM on ECG
ATTRIBUTES Gender, age, experience, qualification, in-service
education on ECG
ANALYSIS
Setting
The study will be conducted in a selected hospital in Mangalore.
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7.3
7.4
7.57.5.1
7.5.2
7.5.3
7.5.4
7.5.5
PopulationThe population selected for this study will be staff nurses working in a
selected hospital in Mangalore.
Method of Data CollectionSampling Procedure
Sampling procedure will be non probability purposive sampling.
Sample Size
The data will be collected from 50 staff nurses who meet the inclusion
criteria.
Inclusion Criteria
Staff nurses working in medical-surgical wards.
Both male and female staff nurses.
50 staff nurses
Exclusion Criteria
Staff nurses who were:
Not willing to participate in the study.
Not available at the time of data collection.
Instrument Used
Instrument used for the study is closed ended knowledge questionnaire.
The questionnaire is divided into two sections.
Section A :- Demographic variables including gender, age, experience,
qualification, in-service education on ECG.
Section B :- A structured knowledge questionnaire is used to assess the
knowledge of staff nurses on electrocardiogram.
Data collection method
Data will be collected after obtaining permission from the concerned
authorities of the selected hospital in Mangalore. The investigator selects 50 staff
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7.5.6
7.6
7.7.1
7.7.2
nurses through non-probability purposive sampling. The objectives of the study
will be explained to the participants and a formal written consent will be taken
from the subjects. Investigator will introduce herself to the participants and then
the closed ended knowledge questionnaire is administered. After 30 minutes the
questionnaire will be collected back and a well designed SIM on
electrocardiogram will be distributed to the sample. After 7days the post-test will
be conducted by using the same questionnaire.
Data Analysis PlanBased on the objectives data analysis will be done using descriptive and
inferential statistics. Findings will be presented in the form of tables and figures.
Descriptive statistics
To describe the demographic variables and level of knowledge, frequency,
percentage, mean and standard deviation will be used.
Inferential statistics
1. The Chi-square test will be used to find the association of mean pre-test
knowledge scores with selected demographic variables.
2. Paired ‘t’ test will be used to assess the effectiveness of self instructional
module.
Does the study require any investigation or intervention to be conducted on
patient or other human or animals? If it so please describe briefly.
No. This study does not involve any investigation or intervention.
However a self instructional module will be given to the staff nurse’s on
knowledge of electrocardiogram. The study does not involve any injury,
injections or harm to the subjects.
Has ethical clearance been obtained from your institution in case of 7.7.1?
Yes. Ethical clearance will be obtained from the ethical committee of the college
of nursing prior to the conduction of study. Administrative permission will be
obtained from the concerned authorities of the hospital. Written consent will be
obtained from the staff nurses and confidentiality will be maintained.
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