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Erasmus Mundus Master Course in Emergency and Critical Care Nursing


(EMECC NURSING)

“AWARENESS ON ADVANCED CARDIAC LIFE SUPPORT AMONG NURSES”

AUTHOR

SUNITA POKHREL BHATTARAI

FEBRUARY, 2017

Master´s Thesis

http://www.masternursing.eu/inicio



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(EMECC NURSING)

“AWARENESS ON ADVANCED CARDIAC LIFE SUPPORT AMONG NURSES”

Master’s Thesis

Name of Author

Sunita Pokhrel Bhattarai



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LIST OF ACRONYMS AND ABBREVIATIONS

ACLS Advanced cardiac life support

AHA American Heart Association

ALS Advance Life Support

BLS Basic Life Support

CCU Coronary Care Units

CMS Center for Medical Simulation

CPA Cardiopulmonary arrest

CPR Cardiopulmonary Resusciation

ECC Emergency Cardiac Care

ECG Electrocardiography

ED Emergency Departments

ER Emergency

ICU Intensive Care Unit

INE Instituto Nacional de Estatística

MICU Medical Intensive Care Unit

SICU Surgical Intensive Care Unit

SPSS Statistical Package for Social Science



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TABLE OF CONTENTS

1. INTRODUCTION ................................................................................................................... 1

1.1 RATIONAL OF THE STUDY ................................................................................................. 3

1.2 OBJECTIVES ........................................................................................................................... 4

2.LITERATURE REVIEW ............................................................................................................ 5

3. METHODOLOGY ................................................................................................................... 11

3.1 Research Design .................................................................................................................. 11

3.2 Paradigm and Research Type .............................................................................................. 11

3.3 Delineation of Space (context) and Time ............................................................................ 11

3.4 Study Population ................................................................................................................. 12

3.5 Sampling.............................................................................................................................. 12

3.6 Inclusion Criteria ................................................................................................................. 12

3.7 Exclusion Criteria ................................................................................................................ 12

3.8 Data collection..................................................................................................................... 12

3.9 Process of Data Collection .................................................................................................. 13

3.10 Reliability and Validity of the Questionnaire ................................................................... 14

3.11 Data Analysis Process ....................................................................................................... 14

3.12 Variables............................................................................................................................ 15



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3.13 Operational Definitions ..................................................................................................... 16

3.14 Ethical Consideration ........................................................................................................ 17

3.15 Limitation .......................................................................................................................... 17

4.RESULTS .................................................................................................................................. 19

5. DISCUSSION ........................................................................................................................... 30

6. CONCLUSION ......................................................................................................................... 32

7. RECOMMENDATION ............................................................................................................ 33

REFERENCES

ANNEX I

ANNEX II

ANNEX III



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TABLES

Table 1: Study Participant’s Basic Characteristics ....................................................................... 19

Table 2: Working Area of the Participants’. ................................................................................. 21

Table 3: Respondents’ Clinical Competence ................................................................................ 21

Table 4: ACLS Training ............................................................................................................... 22

Table 5: Time of ACLS Training Taken ....................................................................................... 22

Table 6: Performed ACLS ............................................................................................................ 22

Table 7: Patient's outcome after ACLS ......................................................................................... 23

Table 8: Outcome of Awareness Based Questions ....................................................................... 23

Table 9Awareness among the Student Nurse and the Professional Nurse ................................... 24

Table 10 Cross Tabulation based on Clinical competence and Outcome ..................................... 25

Table 11: Country and Awareness Outcomes Cross Tabulation .................................................. 25

Table 12: Cross Tabulation based on Education and Outcome of Awareness based Questions .. 25

Table 13: Cross Tabulation of Economic Status and Outcome of Awareness ............................. 26

Table 14Work Experience and Outcome Cross Tabulation ......................................................... 27

Table 15 ACLS Training and Outcome Cross Tabulation............................................................ 27

Table 16 Clinical Competence and Outcome of Awareness Cross Tabulation ............................ 28

Table 17 Outcome of Awareness and Patient's Condition Cross Tabulation .............................. 28



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FIGURES

Figure 1 Conceptual Framework of the study............................................................................... 10

Figure 2 Distribution of the Study Participants. ........................................................................... 11

Figure 3 Process of data collection ............................................................................................... 14



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ACKNOWLEDGEMENT

This study has been conducted to identify the awareness of Advanced Cardiac Life Support among

the nurses in Nepal and Portugal.

First, I would like to thank my thesis supervisor Professor, José Amendoeira for his great co-

operation, continuous support, valuable comments, feedback and advice on this study enhancing

the successful completion of the study. I want to acknowledge Dr. Cátia Luís nursing school of

Santarem for helping me in translation of my survey tool.

I express my deep gratitude to campus chief Muna Rana for giving me permission for data

collection, Instructor Srijana Chaudhary, Indira Chaurasiya, sister Pramila Shrestha and nursing

ward in-charges at Shahid Gangalal National Heart Center for helping me during the entire period

of data collection. Thankful to Binita Tamrakar for helping me in the process of ethical approval

process at Intuitional review board at Shahid Gangalal National Heart Center.

This study was made possible by continuous cooperation of my daughter Aahana, my husband and

my parents.

Last but not the least, I would like to extend my thanks to all the people who helped directly or

indirectly during this entire study.



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ABSTRACT

Objective of this study is to identify the awareness regarding Advanced Cardiac Life Support

(ACLS) among student and the professional nurses. Health care professional are expected to have

awareness on Advanced Cardiac Life Support guidelines to revive unresponsive patient This study

is conceptualized based on the Patricia Benner’s nursing theory Novice to Expert theory. A cross-

sectional study was conducted to identify the awareness regarding Advanced Cardiac Life Support

(ACLS) among nurses using online survey. Questions and Answers were validated in accordance

with American Heart Association’s ACLS pre-assessment test and results were analyzed. The

response rate for this online survey is 33.5%. Among the 66 participants 4.5% were male and

94.5% were female. Mean age of the participants was 29.42(SD± 7.9). Participants from Nepal

were 74.2% and 24.8% from Portugal. Mean score of awareness based questions among the

respondents were 12.92 (SD±7.812). Only 10.06% of them passed the American Heart

Association’s standard 84% of the awareness based questions test and greater than 50% score was

achieved by 34.84%. There are no statistically significant findings in terms of age, sex, work

experience and working area in this study. Statistically significant correlation was not seen (p=0.9)

between the training of ACLS of the participants and the awareness. This study shows no statistical

significant between the educational background (p=0.06), ACLS performed (p=0.2) and ACLS

training taken 3 months ago, (p=0.9), 6 months ago (p=0.9), 1 year ago(p=0.9), 2 years ago,(p=0.7)

and more than 2 years(p=0.9) and awareness. ACLS provided by ACLS- trained or non-trained

participants, the survival rate was two-fold higher when the participant assisting the patient was

ACLS trained. There was no significant association found between different clinical competence



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(p= 0.00), demographic variables and patient outcomes with the awareness of ACLS. This study

highlights the level of awareness of ACLS among the student nurses and Professional nurses is

poor. Student nurses were less aware than the professional nurses. Poor awareness makes more

challenging for the nurses working in critical care settings. This study findings concludes that

nurses were less aware of ACLS. Therefore, this study recommends to incorporate ACLS courses

into the nursing curriculum and Certification Program should be initiated for the nurses working

in critical care settings as refreshing training should be organized in the hospital.

KEY WORDS: Advanced Cardiac Life Support, Nurses, Awareness.




1. INTRODUCTION`

The American Heart Association (AHA) frames and periodically updates Cardiopulmonary

Resuscitation (CPR) and Emergency Cardiac Care (ECC) guidelines on how to provide basic and

advanced cardiac life support (BLS/ACLS) to resuscitate valuable lives(AHA,2015). Initially,

emergency medical services have invested substantial resources to establish advanced life support

(ALS) programs (Isenberg DL, 2005). This helps for high- performance team dynamics and

communication, system of care, recognition and intervention of cardiopulmonary arrest,

immediate post-cardiac arrest, acute dysrhythmia, stroke, and acute coronary syndromes

(ACS)(American Heart Association, 2015). Nurses are expected to have current

knowledge/awareness of BLS/ACLS guidelines to revive unresponsive and cardiac arrest

patients(Nambiar, 2016). Unlike in Western countries, there are no strict licensing protocols in

Nepal and other developing countries that mandate physicians, nurses and paramedics to be trained

in current BLS/ACLS guideline.

Nepal is a country with 26,494,504 of population and youth male and female literacy rate is 89.9%

and 77.5% respectively. Total health expenditure per capita 68$. The health workforce doctors and

nurses along with midwives are 0.17 and 0.51 per thousand population respectively (MoHP,2014).

According to the Instituto Nacional de Estatística (INE) Portugal has 10,562,178 population in

2011 (Wikipedia , 2016) with adult literacy rate 95.43%.Portugal has one of the lowest nurse to

population and to physician ratios in develop countries, and one of the highest physician to

population ratios (James Buchan, 2013).




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Nursing professionals are usually the first to witness a cardiac arrest at the hospital (H. Gombotz,

2006).It is important that nurses must be able to respond correctly in the event of a cardiac arrest

in hospital (Bruce SA, 2009). Most of the nursing educational institutes have resuscitations training

within their curricula to meet these expectations and to ensure that students are competent at

commencing life support in case of cardiac arrest and it is very important component in nursing

education because nurses are involved in every level of resuscitation from early identification to

post-care and rehabilitation (Hagyard-Wiebe, 2007). Therefore, knowledge regarding the location

of emergency equipment as well as checking and stocking for resuscitation is required, they should

have the education and ability to perform the tasks (Practice Resource Network., 2008).

Knowledge breeds knowledge and the clinical skills and knowledge needed to care for patients

continue to change dramatically (Hall, 2015). It is the individual nurse’s professional

responsibility to ensure he or she is updated with current guidelines and it is also the employer’s

responsibility to assist the nurse in maintaining the competence by providing opportunities to

practice mock scenarios for maintaining the psychomotor skills and critically thinking abilities

required to manage a cardiac arrest effectively (Hagyard-Wiebe T. , 2007). Several studies show

that medical and nursing staff lack knowledge and skills in acute care(Jasmeet Soar, 2015)

Therefore, with this background we can see that many studies have been conducted to evaluate the

knowledge and skill before and after ACLS training by using the self –administer questionnaire

and observing the practical skill by using check list. But studies for identifying the awareness

hasn’t been conducted before in Nepal. The aim of this study is to identify the awareness of ACLS



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among nurses working in critical care settings in hospital and academic institutions in Nepal and

Portugal.

1.1 RATIONAL OF THE STUDY

Nursing care is an integral part of health service delivery in hospitals, care homes as well as

community. Over the time nursing profession has been professionalized as being a part of business.

The need of well qualified nurses in developed countries became a catalytic factor for booming

nurse producing industry in a developing country like Nepal (Subedi, 2014).Hence, public

expectations from healthcare professionals in emergency care are also high both in Nepal and

Portugal.

This study focuses on the awareness on core components of advanced cardiac life support among

the nurses such as ECG interpretation, pharmacology and application. It is very important to

integrate in nursing curriculum as well as training to the professional nurses. Therefore, this study

will help to identify the level of awareness among the student nurses and professional nurses and

helps to make attention to the concern bodies in the academic institutions and hospital authorities.



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1.2 OBJECTIVES

ACLS guidelines have evolved over the past several decades. AHA developed the most recent

ACLS guidelines in 2010 using the comprehensive review of resuscitation literature performed by

the International Liaison Committee on Resuscitation (ILCOR), and these were updated in 2015.

Guidelines are reviewed continually but are formally released every five years (Pozner, 2016).

It is not possible to enroll all health care staff in the hospital for such a training as it is time

consuming and the cost of such training programs is high. Training and certification would easily

cost more money and it is a significant cost for staff to afford it (Saravana Kumar, 2014).

General Objective:

The aim of the study is to assess the nurses’ existing awareness on Advance Cardiac Life Support

among student nurses and professional nurses.

Specific Objectives:

1. To identify the existing awareness among student nurses and professional nurses.

2. To assess the factors that affects the awareness for ACLS.



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2.LITERATURE REVIEW

Advance cardiac life support (ACLS) is a systematic approach of resuscitation efforts, and the aim

of the resuscitation is to sustain the neurological functioning and the same quality of life that

previously experienced by the patient. Advanced cardiac life support (ACLS) was designed to

achieve this aim and survival from cardiac arrest depends largely on prompt initiation of

cardiopulmonary resuscitation. Day by day cardiac arrest is becoming the major healthcare issue,

and according to recent publications approximately half of the in-hospital cardiac arrests happen

in intensive care units (Efendijev, 2014). Cardiac arrest is considerably increased in recent decades

and low rates of cardiopulmonary resuscitation (CPR) is performed which results only 1.6%

cardiac arrest patient survived in hospital (Davidson Ocen, 2015).

An organized team response and trained nursing staff in the emergency room critical patient area

are the main factors to determine cardiopulmonary resuscitation (CPR) success rates(A Villamor,

2014).Although nurses must be able to respond quickly and effectively to cardiac arrest, numerous

studies demonstrated poor performances (Sissel I Eikeland Husebø, 2012). Similarly, nurses'

knowledge and skill retention of resuscitation is reported to be poor (Hamilton, 2013).

Nursing professionals are usually the first to witness a cardiac arrest at the hospital (H. Gombotz,

2006).It is important that nurses must be able to respond correctly in the event of a cardiac arrest

in hospital (Bruce SA, 2009). Most of the nursing educational institutes have resuscitations training

within their curricula to meet these expectations and to ensure that students are competent at

commencing life support in case of cardiac arrest and it is very important component in nursing

education because nurses are involved in every level of resuscitation from early identification to



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post-care and rehabilitation (Hagyard-Wiebe, 2007). Therefore, knowledge regarding the location

of emergency equipment as well as checking and stocking for resuscitation is required, they should

have the education and ability to perform the tasks (Practice Resource Network., 2008).

Knowledge breeds knowledge and the clinical skills and knowledge needed to care for patients

continue to change dramatically (Hall, 2015). Although we have come a long way in

multidisciplinary resuscitation education, there remains a gap in the standardization of ACLS

training as a requirement for nurses’ employment both nationally and internationally. Training in

these principles to improve the quality of ACLS performed by healthcare clinicians is feasible and

recommended (Pozner, 2016). It is estimated that ACLS training costs approximately one billion

dollars annually. It is the individual nurse’s professional responsibility also the employer’s

responsibility to assist the nurse in maintaining this competence by providing opportunities to

practice mock scenarios for maintaining the psychomotor skills and critical thinking abilities

required to manage a cardiac arrest effectively. to ensure he or she is updated with current

guidelines (Hagyard-Wiebe T. , 2007).

Cardiac arrest is a major public health issue, with more than 500, 000 deaths of children and adults

per year in the United States (Stiell IG, 2012). In Europe, major European institutions report

cardiovascular diseases are the first cause of death in adults, with cardiac arrest and sudden death

(Freddy K. Lippert, 2010). Those diseases are increases day by day in developing countries. This

should be treated in very short period. As we know that among all the health professional nurses

are the one who stay 24 hour with patient and discover the cardio pulmonary attest and provide

care. Therefore, the advanced cardiac life support (ACLS) is an essential competency which all



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nurses should acquire ( B. Prasanatikom, 2010). ACLS requires the ability to manage the patient’s

airway, initiate intravenous access, read and interpret electrocardiograms, and deliver emergency

pharmacology that aims to treat or reverse the cause of the arrest. Even though nurses are expected

to perform ACLS many literatures suggested that has nurses’ poor knowledge of ACLS and lack

of confidence to work. One study on in-hospital resuscitation: association between ACLS training

and survival to discharge has shown the presence of at least one professional trained in ALS

increase the survival of cardiac arrest victim(Lima S. G., 2009). Dane et al reported increase of the

survival in around four times when the nursing professional was trained in ALS (Dane, 2000).

Primarily mushrooming of nursing colleges is a big challenge to improve the quality of nursing

care in Nepal. Almost 6, 000 certificate level of nurses and Bsc. Nurses were produced. It is very

important to know how competent they are to work with direct patient in the hospital. To develop

the competency in ACLS center for Medical Simulation (CMS) has been established since 2014.

Apart from this hospital hasn’t conducted any formal trainings to nurses in Nepal. So, it is

important to know the existing awareness of ACLS among nurses. This area is chosen because

critical care settings are normally well equipped with experienced professional services, including

intensive care units (ICUs) and emergency care services. And the awareness on ACLS is also

important for critical care settings Nurses and student nurses to develop work competency.

Therefore, with this background we can see that studies have been conducted to evaluate the

knowledge and skill before and after ACLS training by using the self –administer questionnaire

and observing the practical skill by using check list (Hamilton, 2013). But studies for identifying

the awareness in general hasn’t been conducted before. The aim of this study is to identify the



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awareness of ACLS among nurses working in critical care settings in hospital and academic

institutions in Nepal and Portugal.

Awareness is the knowledge and understanding of a situation. To be aware for something

knowledge is very important component. Working in a critical care settings requires constant

updates in knowledge (EAPCI, 2016).This framework has been developed. This study is based on

framework developed by Cardiovascular Council of Nurses and Allied Professions (CCNAP)

(Felicity Astin, 2015) and study in Spain based on nurse education and professional profile and

seeks to measure nurse expertise and hospital context to characterize their potential impact in

patient health outcome (Faura T, 2014).

The nurse theorist, Patricia Benner, provides us with a useful model that describes a continuum of

nursing experience made up of five levels ranging from novice to expert (Benner P, 1982). This

study used this model to identify the level of awareness of ACLS among nurses (student and

professional).

Benner’s Model Novice to Expert Theory

Benner’s (1984) model of Novice to Expert shows the importance of experience in developing

expert nurses. According to (Benner,1984) knowledge developing in nursing expands practical

knowledge through theory and clinical experience. The Dreyfus model applied to nursing practice

is described in five stages : Novice, Advanced Beginner, Competent, Proficient , and Expert

(Benner,1984). Nursing students are novices and they have limited understanding of the

applicaation of textbook terms in the cliniccal settings (Benner,1984). Advanced beginners are



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nurses that demonstrates acceptable performances through experience of actual situation in which

knowledge is applied to nursing (Benner,1984). Competent nurses have experiences related

situations in nursing practice and have utilized strategies to achieve efficiency and organization

(Benner,1984). The Proficient nurses views experiences holistically and develps meaning through

long-term goals (Benner,1984) . The Proficient nurse has learned what to expect in certain situation

and understand how to adjust actions in response to events (Benner,1984). The Expert nurse

understands each situations and focuses on the specific problem without having to eliminate others

options first (Benner,1984).

This study consider novice level to the student who is in final year in Nursing program and had

experience in critical care setting, advanced beginner less than one year ,competent 2-3 years ,

Proficient 3-5 years and Expert more than 5 years of clinical experience in critical care setting.

The four paradigms

Nursing: Nursing is an academic discipline and practice profession which consists of two

components academic and practice which helps to qualify to provide evidenced-based care to

patient to achieve the optimal level of patient’s wellness.

Person: Person is a nurse providing nursing care to critically ill or unresponsive patient.

Health: Health is the state of critically ill patient or unresponsive patient’s outcome after the

nurses’ effort associated with clinical competence, awareness, and environment that affects the

awareness .

Environment: It is a context,settings or situation that affects the awareness of care giver and helath

status of care recipient.



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Figure 1 Conceptual Framework of the study

Levels of work experiences

in critical areas

Level 1: Novice (beginning of

the study in critical care or

emergency)

Level 2: Advanced Beginner

(experience less than 1 year)

Level3: Competent

(experience between 2-3

years)

Level 4: Proficient (experience

between 3-5 years)

Level 5: Expert (experience

more than 5 years)

Nursing: Care based

on Nurses’

awareness of

Advanced Cardiac

Life Support in the

aspect of Rhythm

identification,

Pharmacology and

practical Implication

Environment

(Situation)

i. Economic

condition

ii. Education

iii. Training of

ACLS

iv. Time gap for

training

v. Experience of

working with

unresponsive

patient

vi. Frequency of

working with

unresponsive

patient

Health: Patient Outcomes

Person(Nurse): Age Sex,



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This chapter dealt with the review of published and unpublished literature related to the research

study. This enabled the investigator to have deep insight into the problem under study and helped

to develop tool, methodology and in completing the research study.

3. METHODOLOGY

3.1 Research Design

The cross -sectional (Bryman, 2012) study was conducted in critical care areas in hospital settings

and academic institution to identify the awareness regarding advance cardiac life support among

nurses.

Figure 2 Distribution of the Study Participants.

3.2 Paradigm and Research Type

This study is quantitative in term of positivist.

3.3 Delineation of Space (context) and Time

The study was started in second week of December and ends in first week of January 2016/2017.

Inclusion

Portugal N=17 Nepal N=49

Student Nurse:

N=13 Professional: Nurse=36 Student Nurse=8 Professional Nurse N=9



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3.4 Study Population

This study was conducted in intensive care units (ICUs), Coronary Care Units(CCU), Medical

|Intensive care unit(MICU), Surgical Intensive Care Unit(SICU) and Emergency Departments at

Shahid Gangalal National Heart Centre in Kathmandu and Hospital of Santarém in Portugal and

for academic institution Birgunj Nursing Campus in Birgunj and Escola Superior de Saúde de

Santarém to identify the awareness regarding advance cardiac life support among nurses.

3.5 Sampling

Non-probability (convenient) sampling method was used in this study.

3.6 Inclusion Criteria

The inclusion criteria for this research study:

Student Nurses who are studying in final year for Nursing.

Working registered nurses in critical care setting.

Nurses who are willing to participate

Nurses who are available at the time of data collection

3.7 Exclusion Criteria

Nurses who are not willing to participate in the study were excluded.

Nurses who were on leave for various purposes e.g. sick leave, maternity leave, study leave

etc. during data collection period were not included in the study.

Nurses in managerial level e.g. nursing in charge, nursing supervisor.

3.8 Data collection

For data collection, online survey was used to collect information from the respondents including

multiple choice format. This online survey method is used because it is user-friendly, saves time

and it also reduces the likelihood of errors in the processing of data(Bryman, 2012). Online



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surveying practice varies greatly. For example, in Australia, the University of South Australia uses

a system supporting solely online administration of surveys, while Murdoch University and Curtin

University among others are moving the same way (Nulty, 2008).

3.9 Process of Data Collection

After the ethical approval was accepted from the Nepal Health Research Council and Institutional

Review Board from Hospital Nursing supervisor was informed and explained about the data

collection process, nursing supervisor informed all the nursing unit in-charge and informed about

the study and online survey process and unit in- charge provided the survey link to all the interested

participants. For the Nursing college permission was taken from the chief of the college and survey

link was provided to selected students in Nepal.

In Portugal, after my research title was approved by the school of nursing in Santarem my

supervisor facilitated me to make the network with the students and hospital in an organized way

and helped me for data collection by providing the online survey link to the participants. In

addition, he also helped by sending messages for reminding them to fill the survey tool.



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Figure 3 Process of data collection

3.10 Reliability and Validity of the Questionnaire

Internal reliability was measured by calculating the correlation between the variables(Bryman,

2012). Measurement scale were consistent (Bryman, 2012)to evaluate the awareness among

nurses’ tools were adopted from the American Heart Association for self -assessment test. To

establish the validity in the study, study tools were asked to judge with experience and expert in

the related field. In addition, content validity was tested and reviewed by expert and process of

assessment was explained to the expert. Study tool was translated in the Portuguese by the

authorized person and again the retroversion by another expert from Portuguese to English after

translation. The content validity of the questionnaire was examined by compiling the content of

the instrument with available literature review on the topic.

3.11 Data Analysis Process

Data collection was followed by data analysis and interpretation of collected data. Collected data

was analysed and interpreted in accordance with study objectives.

Hospitals

Academic Institution

Nursing Supervisor

Ward In-charge

Participants

Campus Chief

Faculty Head



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Data editing was done to make the uniformity of the data. Sampling errors were identified and

incomplete respondent were removed.

Data Coding was done into numerical values or assigning numbers to the various categories of a

variable was used in data analysis.

Data classification / distribution: Percentage distribution was calculated for the followings:

Demographic and Variables Part one: Age, Sex, Education, Economic condition, Work

Experience, Training on ACLS, Time of Training, Experience of working with unresponsive

patient, Frequency of working with the unresponsive patient.

Awareness related Variables: Aware and Aware

Statistical data distribution: Mean average was calculated to the appropriate variables.

4. Tabulation of the data: The finding of the study was displayed by inserting the frequency

tables and contingency tables.

Data was analysed by using the Statistical Package for Social Sciences (SPSS) Version 24.0

program. Descriptive statistics such as frequencies: percentiles, descriptive: mean, range and

standard deviation and cross tabulation: cross tabulation of different variables and correlations was

analyzed.

Relationships between demographic variables and awareness outcome was analyzed by using the

logistic regression and chi-square .

3.12 Variables

Dependent Variables: ACLS awareness

Independent Variables: Training of ACLS, Time gap for training, Experience of working with

cardiac arrest, Frequency of working with cardiac arrest.



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Demographic variables: Age, Gender, Education, Economic condition

Classification of the different types of variable that are generated during this study

Continuous Variables: Age, work experience, time of training or frequency of training

Ordinal Variables: Education, Clinical competence,

Nominal Variables/ Dichotomous variables: Gender, Training on ACLS, Economic

condition

3.13 Operational Definitions

Age: it is the age of the respondent

Gender: gender of respondent

Education: Education in nursing field i.e. certificate nurse, diploma nurse, bachelor nurse, master

and any other specialization

Economic condition: affordable or unaffordable for the ACLS training

Work Experience: total duration of work experience in nursing field

Training on ACLS: formal training with certificate for ACLS

Time of Training: time of training taken total in month

Frequency of taking or gap for training: how often training was taken 2 yearly as recommended

by AHA.

Aware: Respondent one who scored ≤84% of awareness based questions.

Unware: Respondent one who scored < 84% of awareness based questions.

Clinical Competence

Level I: Final year of Clinical Education with critical care setting experiences



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Level II: less than 1 year of work experience in critical care setting

Level III: on the job for 2 to 3 years and able to develop actions in terms of long goal or

plans

Level IV:3-5 years’ experiences

Level V: Expert more than 5 years of work experience

3.14 Ethical Consideration

Before conducting the study the title was approved by the supervisor and Instructional Review

Board of Institute of Polytechnic Santarem, Portugal, Nepal Health Research Council and

institutional review board from the hospitals, colleges in Portugal and Nepal. The study technique

was considered ethically safe or neutral and free from harm such as physical harm; harm to

participants’ development; loss of self-esteem; stress. The development of the study was mindful

of manner of wordings to be emotionally neutral. The study didn’t include identifying personal

information; therefore, confidentiality was maintained. Informed consent was attached to the

questionnaire so that participants can make decision whether they like to participate or not.

Online Survey link was send to all the participants attached one who agreed to participate in the

study. A covering letter was attached to link page, explaining the details of the study. Participation

were voluntary. The right to decline or to withdraw from the study at any stage was explained. All

data were kept locked up, accessible only to the researcher.

3.15 Limitation

Since this is an online questionnaire based study, awareness cannot be assessed in detailed. The

study tools used only the theoretical part so skill cannot be studied. Time frame for data collection



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is short because it took long time for ethical approval from hospital and research council. Lack of

internet services for participants cannot participate in the study. This study included only the nurses

who are working in the critical care setting and final year nursing students from the academic

institution. This study adopted the non-probability sampling method therefore, there might be bias

and small sample size so that this study findings cannot be generalized to other population.



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4.RESULTS

The objective of this study is to assess the nurses’ existing awareness on Advance Cardiac Life

Support among student and professional nurses. Study tool for this study contains two parts, part

one for socio-demographic information and part two for awareness based questions. There were

30 questions total based on awareness fractioned in three sections, section 1 namely Rhythm

Identification (10 questions), section 2 pharmacology (10 questions), and section 3 practical

application (10 questions). The rhythm identification section tested the ability to identify the most

common normal and abnormal ECGs, which include ventricular fibrillation, ventricular

tachycardia, etc. The pharmacology section tested when and how to use medications correctly in

those complicated ACLS scenarios, and the practical application section asked participants to

identify rhythms and choose correct interventions or drugs. Each question has equal worth

therefore, each question contains one mark. There were total 96 respondents until the deadline of

data collection. Out of total 96 respondents 32 of them were excluded because of the missing data.

The response rate for online survey was 33.5%. The basic characteristics of the study participants

were summarized in the Tables 1.

Table 1: Study Participant’s Basic Characteristics

Gender n=66

Frequency Percent

Male 3 4.5

Female 63 95.5

Country

Frequency Percent



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Nepal 49 74.2

Portugal 17 25.8

Education

Frequency Percent

Ongoing Certificate Level of

Nursing

1 1.5

Completed Certificate Level of

Nursing

10 15.2

Ongoing Bachelor Level of Nursing 12 18.2

Completed Bachelor Level of

Nursing

32 48.5

Master’s Degree in Nursing 8 12.1

Specialized course taken (please

specify the area)

3 4.5

Economic Status

Frequency Percent

Affordable to ACLS 44 66.7

Unaffordable to ACLS 22 33.3

Total 66 100.0

The minimum age of the participants was 19 years and maximum aged 53 years. Mean age was

29.42(SD± 7.9).

Among all the respondents 4.5% of them were male and 95.5% of them were female. Three- fourth

of the respondents were from Nepal and remaining one-fourth were from Portugal.

Majority of the respondents 48.5% had completed Bachelor level of Nursing followed by, ongoing

Bachelor level of nursing, completed certificate level of nursing, master’s degree in Nursing with

18.2%, 15.2% and 12.1% respectively. Only 1.5 % of the respondents were studying certificate

level of nursing and 4.5% of them had had some specialized courses.



21


Respondents were asked about the economic status to identify whether they were affordable or

unaffordable for ACLS training two-third (66.7%) of them were identified that they were

affordable and one- third (33.3%) were unfordable.

Work experience were calculated from the respondent it varies from less than 1 year to 30 years

(SD±7.5).

Table 2: Working Area of the Participants’.

Working Area

Frequency Percent

Cath lab 4 6.0

MICU 5 7.6

Student 7 10.6

Cardiology 10 15.2

CCU 10 15.2

SICU 10 15.2

ER 21 31.8

Total 66 100.0

Working area of the participants were summarized in Table 2. Majority of the respondents 31.8%

were working at Emergency Department (ER), respondents from surgical intensive care unit

(SICU), Coronary care unit (CCU), and Cardiology were 15.2% in each, 10.6% were students,

Medical intensive care units (MICU) and Cardiac Catherization lab 7.6 and 6% respectively.

Table 3: Respondents’ Clinical Competence

Clinical Competence

Frequency Percent

Level I 6 9.1



22


Level II 23 34.8

Level III - -

Level IV 22 33.3

Level V 15 22.7

Total 66 100.0

Level II clinical competence were identified with the highest percentage 34.8% followed by Level

IV 33.33%, Level V 22.7% and Level I 9.1%. Table 3

Table 4: ACLS Training

ACLS Training

Frequency Percent

Yes 29 43.9

No 37 56.1

Total 66 100.0

Here, 43.9% of the respondent had received the ACLS training. More than half respondents hadn’t

taken ACLS training. Table 4

Table 5: Time of ACLS Training Taken

When ACLS

Frequency Percent

3 months ago, 3 4.5

6 months ago, 5 7.6

1 year ago, 10 15.2

2 years ago, 4 6.1

More than 2 years 7 10.6

Recently, training was taken by 4.5% of the respondents, 7.6% of the had taken 6 months ago,

15.2% 1 year ago, 6.1% 2years ago and 10.6% of had taken more than 2 years ago. Table 5

Table 6: Performed ACLS



23


Performed ACLS to Unresponsive Patient

Frequency Percent

Yes 44 66.7

No 22 33.3

Total 66 100.0

Two-third of the respondents had performed ACLS and one-third hadn’t performed ACLS to

unresponsive patients. When questioned was asked if they had performed how often was it

performed respondent’s highest frequency was performed for 10-15 times per months but most of

them performed for 3-4 times per month. Table 6

Table 7: Patient's outcome after ACLS

Patient’s Condition

Frequency Percent

Survived 37 56.1

Expired 9 13.6

Respondents’ were asked about the patient’s condition after performing the ACLS to unresponsive

patients 56.1% of them responded that patients survived and 13.6% responded they were expired.

Table 7

Awareness Based Results

Mean score of awareness based questions among the respondents were 12.92 (SD±7.812). There

were all together 30 awareness based questions. AHA guidelines for successful course completion

and pass the written test of ACLS the test score should be 84% or higher. Only 10.06% of them

passed the AHA standard scoring 84% of the awareness based questions test.

Table 8: Outcome of Awareness Based Questions

Outcome of Awareness



24


Frequency Percent

Aware 7 10.6

Unaware 59 89.4

Total 66 100.0

Nearly, 90% of the respondents were unaware only, 10.6% were of ACLS. Table 8

Table 9Awareness among the Student Nurse and the Professional Nurse

Awareness Outcome* Student Professional Nurse Crosstabulation

Status Total

Student

Nurse

Professional

Nurse

Outcome Aware Count 2 5 7

% within Student

Professional Nurse

9.5% 11.1% 10.6%

Unaware Count 19 40 59

% within Student

Professional Nurse

90.5% 88.9% 89.4%

Total Count 21 45 66

% within Student

and Professional

Nurse

100.0% 100.0% 100.0%

Awareness Outcome with student and professional nurse crosstabulation shows that student nurses

were less aware compared to professional nurses. Among the student nurses, more than 90% were

unware of ACLS whereas 88.9% of the professional nurses shows unware. Altogether 10.6% were

aware and 89.4% were unware of ACLS. To establish how confident we can be that there is a

relationship between the two variables awareness outcome with student nurse and professional

nurse by calculating the chi-square (χ2) test in which associated level of significance is p <0.8.

This means this relation between the variables is less significant in this study. Table 9



25


Table 10 Cross Tabulation based on Clinical competence and Outcome

Awareness Outcome Total

Aware Unaware

Clinical Competence Level I 0(0) 6(9.09) 6

Level II 2(3.03) 21(31.18) 23

Level IV 4(6.06) 18(27.27) 22

Level V: 1(1.51) 14(21.21) 15

Total 7(10.60) 59(89.40) 66

*Paracentesis contains Percentage.

This cross tabulation in Table10 shows level IV has the highest level of awareness on ACLS and

Level I respondents were totally unware, in Level II respondents 3.03% of aware which is followed

by level V with 1.51%. Pearson Chi-square shows week relationship with p<0.4 and coefficient

value is 0.1.

Table 11: Country and Awareness Outcomes Cross Tabulation

Country * Awareness Outcome Crosstabulation

Awareness Outcomes Total

Aware Unaware

Country Nepal 6(9.09) 43(65.15) 49(74.24)

Portugal 1(1.51) 16(24.24) 17(25.75)

Total 7(10.60) 59(89.40) 66(100.0) *Paracentesis contains Percentage

Nearly 75% of the respondents were participated from Nepal among them 9.09% and 1.51 % were

aware of ACLS respectively from Nepal and Portugal. Table 11

Table 12: Cross Tabulation based on Education and Outcome of Awareness based Questions

Education * Outcome of Awareness based Questions Crosstabulation



26


Awareness based questions

outcome

Total

Aware> 84% Unaware

84%

Education Ongoing Certificate Level of

Nursing

0 1 1

Completed Certificate Level of

Nursing

0 10 10

Ongoing Bachelor Level of Nursing 1 11 12

Completed Bachelor Level of

Nursing

5 27 32

Masters in Nursing 1 7 8

Specialized course taken (please

specify the area)

0 3 3

Total 7 59 66

The cross tabulation in Table 12 reveals education and outcomes of awareness shows that

respondents studying certificate level of nursing and one who had completed certificate level of

nursing were unware about ACLS and increases by education highest number of respondents had

completed Bachelor in Nursing and had highest number of awareness in this group. Relationship

between level of competence and awareness outcome was evaluated Pearson’s R value -0.5 and

P<0.6 which reveals the weak relationship between them.

Table 13: Cross Tabulation of Economic Status and Outcome of Awareness

Economic * Awareness Crosstabulation

Awareness Total

Aware Unware

Economic Affordable to ACLS 4(6.06) 40(60.60) 44(66.67)



27


Unaffordable to ACLS 3(4.54) 19(28.78) 22(33.33)

Total 7(10.60) 59(89.40) 66(100) *Paracentesis contains Percentage

Among the respondents who were affordable to ACLS 6.06% were aware and 4.54% were aware

for unaffordable. Table 13

Table 14Work Experience and Outcome Cross Tabulation

Work Experience * Outcome Crosstabulation

Outcome Total

Aware Unaware

Work

Experience

Less than 1 year 0(0) 7(10.60) 7(10.60)

1-3 1(1.51) 19(28.78) 20(30.30)

4-10 4(6.06) 22(33.33) 26(39.39)

Above 10 Years 2(3.03) 11(16.67) 13(19.69)


Table 14 presents respondents with 4-10 years of work experience were more aware compared to

less experienced. Work experience less than 1 year all unware. It has weak relationship between

work experience and outcome of awareness where p<0.2 and coefficient value is 0.5.

Table 15 ACLS Training and Outcome Cross Tabulation

ACLS Training * Outcome Crosstabulation

Outcome Total

Aware Unaware

ACLS Training Yes 2(3.03) 27(40.90) 29(43.93)

No 5(7.57) 32(48.48) 37(56.06)




28


The respondents with ACLS training 3.03% were aware and without training 7.57% were aware

of ACLS.ACLS training taken and awareness outcome for ACLS was calculated relation between

them shows p<0.2 and coefficient value is 0.5 which is week relationship in this study. Table 15

Logistic regression was calculated to show the relationship between gap of ACLS training has

been received and outcome of awareness of ACLS. It shows poor relationship between participants

received training before 3months, 6 month, 1 year, 2 years and more than 2 years and awareness

outcome with p<0.9, p<0.9, p<0.9, p<0.7, p<0.9 respectively.

Table 16 Clinical Competence and Outcome of Awareness Cross Tabulation

Outcome of Awareness * Clinical Competence Crosstabulation

Clinical Competence Total

Level I Level II Level IV Level V:

Aware 0 2(3.03) 4(6.06) 1(1.51) 7(10.60)

Unaware 6(9.09) 21(31.81) 18(27.27) 14(21.21) 59(89.40)

Total 6(9.09) 23(34.84) 22(33.33) 15(22.72) 66(100)

Table 16 shows the relationship between level of clinical competence and outcome of awareness.

None of them were aware from level one. In level II 3.03% were aware in Level IV and level V

6.06% and 1.51% respectively reveals awareness of ACLS. Contingency coefficient shows

insignificant relationship between clinical competence and awareness p<0.4.

Clinical Competence of all the levels with health outcome of the patient was calculated

contingency coefficient value was o.62 and p<0.00. This finding shows no relation between them.

Table 17 Outcome of Awareness and Patient's Condition Cross Tabulation

Outcome * Patient’s Condition Crosstabulation

Patient’s Condition



29


Survived Expired

Outcome Aware 4 2

Unaware 33 7

Aware respondents about the ACLS performed ACLS to unresponsive patients and 4 of them

responded that they were survived and 2 were expired, Similarly, Unware respondents performed

ACLS to unresponsive patients and 33 of them responded that they were survived and 7 of them

said they were expired. This also has the poor relationship in this study where coefficient value is

0.1 and less significant with p<0.3. Table 17



30


5. DISCUSSION

The primary outcome measure in this study was awareness of ACLS among the nurses working in

critical care areas in Nepal and Portugal. This study found low level of awareness in ACLS, with

mean score12.92{43.06%} (SD±7.812). Though, different measures of ACLS were used in similar

studies, the mean score of respondents in the current study was marginally higher compared to

41.6% in North- Kerala(Nambiar, 2016). A greater than 50% score was achieved by 34.84% of

the participants of the study which was less compared to 48.2% in North- Kerala (Nambiar, 2016).

It should be noted that 10.60% of participants in this surpassed the >80% standard set by AHA.

AHA guidelines require that students should achieve 84% or higher for successful course

completion and pass the written test of ACLS(AHA, 2016). This study shows better score

compared to 4.3% in North-Kerala(Nambiar, 2016) and study results shown by Sinha Akritia and

others where 1% respondent responded >80% and similar study results were shown by Shanta

Chandrasekaran et al where none of the participants scored above 85% while 85% of participants

scored less than 50%(Chandrasekaran S, 2010) . One study in China also shows that none of the

scored above 80% only the score ranges averagely 20.12 ± 4.13 out of 40 questions were correct,

ranging from 6 to 31 and which contributed to the total average accuracy rate of 50.31% (Xi,

2015). This study was conceptualized by adopting the P. Benner’s Novice to Expert theory. This

awareness of ACLS for nurses is influenced by various factors such as age and sex, environment,

and level of competence.

This study results shows that are no statistically significant findings in terms of Nurses’ age, sex,

work experience, ACLS training, gap of training, clinical competence and working area with



31


awareness of ACLS among nurses. This study has adopted Patricia Benner’s Novice to expert

theory to categories the level of clinical competence. There was no significant association found

between different clinical competence Level I, Level II, Level III, Level IV and Level V (p= 0.00),

demographic variables, patient outcomes, and with the awareness of ACLS. Nambiar showed

mean scores decreased with age. (Nambiar, 2016) Logistic regression shows insignificant relation

between age and sex with awareness p<0.2 and p<0.9 respectively. The study conducted in South-

Africa(Ehlers, 2014) had similar findings, although a study conducted in Belgium demonstrated

that accumulated work experience was associated with improved awareness and skills

(Verplancke, 2008) whereas, this study has poor relationship between work experience and

outcome of awareness where p<0.2 and coefficient value is 0.5

This study shows 43.93% of the participants had undergone formal training for ACLS. HN Harsha

Kumar et al have also shown poor level of training among the under graduate medical students(HN

Harsha Kumar, 2013).Low levels of training have been reported from Pakistan and the UK (Zaheer

H, 2009). Only 3.6% was shown in New Delhi (Akritia, 2014).

Statistically significant correlation was not seen (p=0.9) between the training of ACLS of the

participants and the awareness. Sinha Akriti showed significant correlation between formal

training and awareness (Akritia, 2014) and Other studies have also concluded that the knowledge

of trained personnel was better than those of untrained ones(Abbas A, 2011). This result may be

because of most of the other studies compared knowledge and awareness gain by a pre-training

and an immediate post-training questionnaire this study studies the existing awareness. Though it



32


not significant statistically, the mean score was low for trained participants compared to untrained

participants.

Study in Brazil demonstrates that the professional level of educational background influence the

rate of right answer(Lima, 2009).This study shows no statistical significant between the

educational background (p=0.06) ,ACLS performed (p=0.2) and ACLS training taken 3 months

ago (p=0.9), 6 months ago(p=0.9), 1 year ago(p=0.9), 2 years ago(p=0.7) and more than 2

years(p=0.9) and awareness.

Contingency coefficient shows insignificant relationship between clinical competence and

awareness p<0.4 and clinical competence of all the levels with health outcome of the patient was

calculated contingency coefficient value was o.62 and p<0.00. This finding shows no relation

between them. ACLS provided by ACLS- trained or non-trained participants, the survival rate

was two-fold higher when the participant assisting the patient was ACLS trained, and this variable

was considered as independent predictor in the logistic regression analysis. Similar study in

Georgia, United States reveled that survival rate was four-fold higher when the nurses assisting

the patient was ACLS trained(Dane FC, 2000).

6. CONCLUSION

This study highlights the level of awareness regarding the ACLS among the student nurses and

Professional nurses is poor. The study participants were from two different countries Nepal and

Portugal. Both male and female nurses were the study participants. Educational status of the

participants was ongoing certificate level, completed certificate level, ongoing bachelor level,

completed bachelor level, ongoing masters level of nursing and nurses with specialized course and



33


training were involved in the study. Clinical competence of the nurses were categories based on P.

Benner Novice to Expert Theory. Only 10.06% of the respondents were aware of ACLS. This

study shows insignificant relationship with the nurses age and sex and awareness of ACLS on

nurses. Similarly, it is also shows insignificant relationship with nurse’s economic condition,

education, training, work experience, and frequency of working with unresponsive patients. There

is no association between environment and patient health outcome. This study shows level of

clinical competencies Novice to Expert have insignificant relationship with health outcomes and

awareness of ACLS among nurses. This issue needs to be addressed promptly. To ensure better

and safer health-care, it is essential for all graduating nurses as well as professional nurses to be

well versed with ACLS. These findings show insignificant results this might be due to small sample

size for the study.

7. RECOMMENDATION

Nursing in acute-care settings has grown so complex that it is no longer possible to standardize,

routinize, and delegate much of what the nurse does. Poor awareness makes more challenging for

the nurses working in critical care settings. Therefore, graduating nurses should be well trained

before starting the job and professional nurses should be updated with the new updates of ACLS.

This study purpose recommendation to:

Clinical:

1. ACLS training should be provided to the nurses working in the critical care settings.

2. It is recommended that the courses should be not only included but also regular refreshing

courses are necessary with hands on experience.

Education



34


1.ACLS courses should be incorporated into the nursing curriculum.

Research

1. A large -scale study can be carried out to generalized the findings.

2. Further study is recommended by observing skill together with the awareness.

Management

1. Certification Program should be initiated from related higher authorities.




REFERENCES

A Villamor, A. Y. (2014). Emergency room advanced life support after cardiac arrest: outcomes

and survival, nursing care and team response. Criticla Care , 485 .

Aari, R. R.-C.-K. (2004). Biological and physiological knowledge and skills of graduating Finnish

nursing students to practice in intensive care. Nurse Education Today, 24(4), 293-300 8p.

Abbas A, B. S. (2011). Knowledge of first aid and basic life support amongst medical students:a

comparison between trained and untrained students. . JPMA, 80-82.

Abella BS, S. N. (2005). Cheat compression rates during cardiopulmonary Resusciation are

suboptimal: a prospective study during in-hospital cardiac Circulation. Circulation,

111(4):428.

Akritia, S. (2014). Basic Life Support and Advanced Cardiac Life Support. Journal of Young

Medical Researchers, 2-9.

Auble TE, M. J. (1995). Effect of out-of- hospital defibrillation by basic life support provider on

cardiac arrest moratlity: a meta-analysis. Ann Emerg Med, 25: 642-658.

B. Prasanatikom. (2010). Knowledge & skill retention after the advanced cardiac life support

workshop—A study in nursing in nursing practitioners at the Udonthani, Thailand.

European Resussciatation Council, 93.

Benner, P. (2012). Novice to Expert. 402-407.

Berden HJ, B. J. (1994). Resuscitation skills of lay public after recent training. Ann Emerg Med.,

1003–1008.




ii


Bruce SA, S. Y. (2009). A COLLABORATIVE EXERCISE: Between Graduate and

Undergraduate Nursing Students Using a COMPUTER-ASSISTED SIMULATOR in a

Mock Cardiac Arrest. Nurs Educ Perspect, 30 (1): 22-27.

Centre, R. (2015, 11 28). CAR NET. Retrieved from KNOWLEDGE ASSESSMENT

(EVALUATION) THEORY.

Chandrasekaran S, K. S. (2010). Awareness of BLS and ALS among Nurses. Indian J Anaesthesia,

121-126.

Christina Passaliemail, I. D. (2011). Evaluation of nurses’ and doctors’ knowledge of basic &

advanced life support resuscitation guidelines. Nurse Education in Practice, 365–369.

Dane FC, R.-L. K. (2000). In-hospital resuscitation: association between ACLS training and

survival to discharge. Resuscitation, 83-7.

Davidson Ocen, S. K. (2015). Prevalence, outcomes and factors associated with adult in hospital

cardiac arrests in a low-income country tertiary hospital: a prospective observational study.

BMC Emergency Medicine, 1-6.

Denise F. Polit, C. T. (2004). Nursing Research principles and Methods. USA: Lippincott

Williams & Wilkins.

Efendijev, I. R. (2014). Temporal trends in cardiac arrest incidence and outcome in Finnish

intensive care units from 2003 to 2013. Intensive Care Medicine, 1853-1861 9p.

Ehlers, V. &. (2014). ‘Cardiopulmonary resuscitation knowledge and skills of registered nurses in

Botswana. Curationis, 1259-1266.



iii


Field JM, H. M. (2010 Nov 2;122(18 Suppl 3)). Part 1: executive summary: 2010 American Heart

Association Guidelines for Cardiopulmonary Resuscitation and Emergency

Cardiovascular Care. Circulation, S640-56.

Francis C. Dane, K. S.-L. (2000). In-hospital resuscitation: association between ACLS training

and survival to discharge. Resuscitation., 47: 83-7.

Freddy K. Lippert, V. R. (2010). European Resuscitation Council Guidelines for Resuscitation

2010 Section 10. The ethics of resuscitation and end-of-life decisions. Journal of European

Resusciatation Council, 1445 - 1451.

H. Gombotz, W. B. (2006). In-hospital cardiac resuscitation outside the ICU by nursing staff

equipped with automated external defibrillators - the first 500 cases. Resuscitation, 70 (3):

416-22. .

Hagyard-Wiebe, T. (2007). Should critical care nurses be ACLS-trained? Dynamics, 18(4), 28-31

4p.

Hagyard-Wiebe, T. (2007). Should critical care nurses be ACLS-trained? Dynamics, 18(4), 28-31

4p.

Hall, A. (2015). Defining nursing knowledge. Nursing Times, 34. Retrieved from Nursing Times.

Hamilton, R. (2013). Nurses' knowledge and skill retention following cardiopulmonary

resuscitation training: a review of the literature. Journal of Advanced Nursing,, 51 (3)

(2005), pp. 288–297.



iv


HN Harsha Kumar, P. S. (2013). A cross-sectional study on awareness and perception about basic

life support/cardio-pulmonary resuscitation coastal South India. Int J Med Pub Health,

146-150.

Isenberg DL, B. R. (2005). Does advanced life support provide benefits to patients?: A literature

review. Prehosp Disaster Med., 265-70.

James Buchan, M. T. (2013). Nurses in advanced roles: a review of acceptability in Portugal. Rev.

Latino-Am. Enfermagem, 38-46.

Jasmeet Soar, J. P. (2015). European Resuscitation Council Guidelines for Resuscitation 2015

Section 3. Adult advanced life support. Resuscitation, 100–147.

Lima, S. G. (2009). Permanent Education in BLS and ACLS: impact on the knowledge of nursing

professionals. Arquivos Brasileiros de Cardiologia, 630-636.

MA, M. (2001). Eficácia do treinamento em suporte avançado de vida nos resultados das manobras

de ressuscitação cardiopulmonar. São Paulo, 130p.

MINISTRY FOR FOREIGN AFFAIRS OF FINLAND. (2014). Country Strategy for Development

Cooperation with Nepal 2013 -2016. Kathmandu: MINISTRY FOR FOREIGN AFFAIRS

OF FINLAND.

Ministry of Health and Population Nepal, Partnership for Maternal, Newborn & Child Health,

WHO, World Bank and Alliance for Health Policy and Systems Research. (2014). Success Factors

for Women’s and Children’s Health : Nepal. Geneva: World Health Organisation.



v


Model A. c. (2011, September 16). Nursing Theories. Retrieved from From Novice to Expert

Patricia E. Benner:

http://currentnursing.com/nursing_theory/Patricia_Benner_From_Novice_to_Expert.html

Nambiar, M. N. (2016). Is current training in basic and advanced cardiac life support (BLS &

ACLS) effective? World Journal of Emergency Medicine, 263–269.

Practice Resource Network. (2008). Should ACLS training be mandatory for critical care and

progressive care nurses? AACN News 25, no. 3: 3-3 1p. Retrieved from AACN News 25.

Sissel I Eikeland Husebø, C. A. (2012). A comparative study of defibrillation and cardiopulmonary

resuscitation performance during simulated cardiac arrest in nursing student teams.

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 20:23.

Stiell IG, B. S. (2012). What is the role of chest compression depth during out-of-hospital cardiac

arrest resuscitation? . Critical Care Medicine, 40:1192–1198.

Subedi, D. R. (2014). Growth of nursing education sector and its effects on professionalization of

nurses in Nepal. IOSR-JNHS, 34-39.

Verplancke, T. P. (2008). ‘Determinants of the quality of basic life support by hospital nurses’,.

Resuscitation, 75-80.

Wikipedia . (2016, December 16). Demographics of Portugal. Retrieved from

https://en.wikipedia.org/wiki/Demographics_of_Portugal

Zaheer H, H. Z. (2009). Awareness about BLS (CPR) among medical students: status and

requirements. J Pak Med Assoc., 57-59.



vi


ANNEX I



vii


ANNEX II

Circle an appropriate answer given in the right column.

PART ONE

Demographic Information

1. Age

2. Gender: 1. Male

2. Female

3. Education 1. Ongoing Certificate Level of Nursing

2. Completed Certificate Level of Nursing

3. Ongoing Bachelor Level of Nursing

4. Completed Bachelor Level of Nursing

5. Specialized course taken (please specify the

area)

4. Economic Condition 1. Affordable for ACLS Training

2. Unaffordable for ACLS Training

5. Work Area (only for working Nurses)

6. Work Experience (only for working

Nurses):

In Months

7. Level of clinical competence Level I :1st year of clinical education (nursing

student)

Level II: newly joined job gaining prior experience in

actual situations



viii


Level III: on the job for 2 to 3 years and able to

develop actions in terms of long-range goals or plans

Level IV: 3-5 years’ experiences

Level V: expert

8. Had you taken the formal ACLS

Training

1. Yes

2. No

9. If yes , when did you take

1. 3 months ago

2. 6 months ago

3. 1 year ago

4. 2 years ago

5. More than 2 years

10. Had you ever performed ACLS

interventions patient with cardiac

arrest?

1. Yes

2. No

11. If yes, how often?

12. If performed after the intervention

condition of patient

Patient

1. Survived

2. Died



ix


PART TWO

Awareness Based Questions

There are three sections: Rhythm Identification, Pharmacology and Application. Take the Rhythm

Identification and Pharmacology and test awareness of their application based on ACLS core

material and algorithms.

Rhythm Identification: This will test the ability to identify the rhythms in the core ALS algorithms

and cases.

1. Please identify the rhythm by selecting the best single answer.

a. Agonal rhythm/asystole

b. Atrial fibrillation

c. Atrial flutter

d. Coarse Ventricular fibrillation

e. Fine ventricular fibrillation

f. Monomorphic ventricular tachycardia

g. Normal sinus rhythm

h. Polymorphic ventricular tachycardia

i. Pulseless electrical activity

j. Reentry supraventricular tachycardia

k. Second-degree AV block ( Mobitz I Wenckebach)

l. Second-degree AV block ( Mobitz II block)

m. Sinus bradycardia

n. Sinus tachycardia

o. Third-degree AV block




x




c. Atrial flutter








k. Second-degree AV block (Mobitz I Wenckebach)

l. Second-degree AV block (Mobitz II block)




3. Please identify the rhythm by selecting the best answer.



c. Atrial flutter
















xi




c. Atrial flutter













5. There is no pulse with this rhythm. Please identify the rhythms by selecting the best single

answer.



c. Atrial flutter








xii









6. Please identify the rhythms by selecting the best single answer.



c. Atrial flutter


















xiii


c. Atrial flutter
















c. Atrial flutter
















xiv




c. Atrial flutter
















c. Atrial flutter










xv







Pharmacology: This section will help to identify your knowledge of ACLS core drugs used.

1. A 57- year-old woman has palpitations, chest discomfort, and tachycardia. The

monitor shows a regular wide- complex QRS at a rate of 180/min. She becomes

diaphoretic, and her blood pressure is 80/60 mm Hg. The next action is to

a. Give amiodarone 300 mg IV push

b. Establish IV access

c. Obtain a 12-lead ECG

d. Perform immediate electrical cardioversion

2. A patient has a rapid irregular wide-complex tachycardia. The ventricular rate is

138/min. He is asymptomatic, with a blood pressure of 100/70 mm Hg. He has a

history of angina. Which of the following actions is recommended?

a. Immediate synchronized cardioversion

b. Giving lidocaine 1 to 1.5 mg IV bolus

c. Seeking expert consultation

d. Giving adenosine 6 mg IV bolus

3. Bradycardia require treatment when

a. The blood pressure is less than 100 mm Hg systolic with or without symptoms.

b. The patient’s 12-lead ECG shows an MI

c. Chest pain or shortness of breath is present

d. The heart rate is less than 60/min with or without symptoms

4. A patient with ST-segment elevation MI has ongoing chest discomfort. Fibrinolytic

therapy has been ordered. Heparin 4000 units IV bolus was administered. Aspirin

was not taken by the patient because he had a history of gastritis treated 5 years

ago. You next action is to

a. Give aspirin 160 to 325 mg chewed immediately.

b. Give 75 mg enteric-coated aspirin orally.

c. Give 325 mg enteric-coated aspiration rectally.

d. Substitute clopidogrel 300 mg loading dose.

5. A patient is in cardiac arrest. Ventricular fibrillation has been refractory to an initial

shock. What is the recommended route for drug administration during CPR?

a. Femoral



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b. Endotracheal

c. External Jugular vein

d. Central line

e. IV or IO

6. You arrive on the scene with the code team. High – quality CPR is in progress. An

AED has previously advised “no shock indicated”. A rhythm check now finds

asystole. After resuming high- quality compressions, your next action is to

a. Place an esophageal- tracheal tube or laryngeal mask airway

b. Gain IV or IO access

c. Attempt endotracheal intubation with minimal interruptions in CPR

d. Call for a pulse check

7. A patient with a possible acute coronary syndrome has ongoing chest discomfort

unresponsive to 3 sublingual nitroglycerin tablets. There are no contraindication,

and 4 mg of morphine sulfate was administered. Shortly afterward, blood pressure

falls to 88/60 mm Hg, and the patient has increased chest discomfort. You should

a. Give an additional 2 mg of morphine sulfate

b. Give normal saline 250 ml to 500 ml fluid bolus

c. Start dopamine at 2mcg/kg per minute and titrate to a systolic blood pressure

reading of 100 mm Hg

d. Give sublingual nitroglycerin 0.4 mg.

8. A patient is in cardiac arrest. Ventricular fibrillation has been refractory to a second

shock. Of the following, which drug and dose should be administered first by the

IV/IO route?

a. Atropine 1 mg

b. Epinephrine 1 mg

c. Sodium bicarbonate 50 mEq

d. Vasopressin 20 units

9. A patient with sinus bradycardia and a heart rate of 42/min has diaphoresis and a

blood pressure of 80/60 mm Hg. What is the initial dose of atropine?

a. 0.5mg

b. 3mg

c. 1mg

d. 0.1md

10. A patient is in pulseless ventricular tachycardia. Two shocks and 1 dose of

epinephrine have been given. Which is the next drug/dose to anticipate to

administer?

a. Amiodarone 150 mg

b. Epinephrine 3mg

c. Amiodarone 300mg



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d. Lidocaine 0.5 mg/kg

e. Vasopressin 40 units

Practical Application

This section will be able to identify a rhythm and then select a treatment or intervention on the

basis of your identification of the rhythm and your knowledge of ACLS drug and treatment

algorithms.

It will help to identify the rhythm and select a treatment or intervention on the basis of your

identification of rhythm and your knowledge of ACLS drugs and treatment algorithms.

1. A patient becomes unresponsive. You are uncertain if a pulse is present with the given

below rhythm. What is your next action?

a. Begin CPR, starting with high-quality chest compressions.

b. Consider causes of pulseless electrical activity.

c. Order transcutaneous pacing.

d. Start an IV and give epinephrine 1 mg IV

e. Start an IV and give atropine 1 mg.

2. You are monitoring a patient. He suddenly has the below rhythm. You ask about symptoms,

and he reports that he has mild palpitations, but otherwise he is clinically stable with

unchanged vital sign. What is your next actions?

a. Give sedation and perform synchronized cardioversion.

b. Give an immediate unsynchronized shock

c. Administer adenosine 6 mg; seek expert consultation.



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d. Give an immediate synchronized shock

e. Administer magnesium sulfate 1 to 2 g IV diluted in 10 ml D5W over 5 to 20 minutes.

3. A patient in the emergency department develops recurrent chest discomfort ( 8/10)

suspicious for ischemia. His monitored rhythms becomes irregular as seen above . Oxygen

is being administered by nasal cannula at 4L/min, and an IV line is in place. Blood pressure

is 160/96 mm Hg. There are no allergies or contraindications to any medication. You would

first order

a. IV nitroglycerin initiated at 10 mcg/min and titrated to patient response

b. Amiodarone 150 mg IV

c. Sublingual nitroglycerine 0.4 mg

d. Lidocaine 1 mg/kg IV infusion 2 mg/min

e. Morphine sulfate 2 to 4 mg IV

4. A patient was in refractory ventricular fibrillation. The third shock has just been

administered. Your team looks to you for instructions. You immediate next order are

a. Give atropine 1 mg IV.

b. Give amiodarone 300 mg IV.

c. Resume high-quality chest compressions.

d. Check the carotid pulse.

e. Perform endotracheal intubation.

5. The patient has been resuscitated from cardiac arrest. During the resuscitation, amiodarone

300 mg was administered. The patient developed severe chest discomfort with diaphoresis,

He is now unresponsive. What is the next indicated action?



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a. Perform immediate synchronized cardioversion.

b. Give lidocaine 1 to 1.5 mg/kg IV.

c. Repeat amiodarone 150 mg IV.

d. Give an immediate unsynchronized high-energy shock (defibrillation dose).

e. Repeat amiodarone 300mg IV.

6. You are monitoring the patient and note the above rhythm on the cardiac monitor. She has

dizziness, and her blood pressure is 80/40 mm Hg. She has an IV in place. What is your

next action?

a. Administer sedation and begin immediate transcutaneous pacing at 80/min

b. Give atropine 0.5 mg IV.

c. Start dopamine at 2 to 10 mcg/kg per minute and titrate to patient response.

d. Give atropine 1 mg IV

e. Start transcutaneous pacing

7. The patient suddenly becomes unconscious and has a weak carotid pulse. Cardiac

monitoring, supplementary oxygen, and IV have been initiated. The code cart with all the

drugs and a transcutaneous pacer are immediately available. Next you would

a. Give atropine 0.5 mg IV.

b. Initiate epinephrine at 2 to 10 mcg/kg per minute

c. Initiate dopamine at 10 20 mcg/kg per minute and to patient response

d. Begin transcutaneous pacing



xx


e. Initiate dopamine at 2 to 10 mcg/kg minute and titrate to patient response.

8. A 35 years –old woman presents to the emergency department with the chief complaint of

palpitation. She has no chest discomfort, shortness of breath. Or light-headedness. Which

of the following is indicated first?

a. Perform vagal maneuvers.

b. Give adenosine 3 mg IV bolus.

c. Give adenosine 12 mg IV slow push (over 1 to 2 minutes).

d. Give metoprolol 5 mg IV and repeat if necessary.

9. You are monitoring a patient with chest discomfort who suddenly becomes unresponsive.

You observe the following rhythms on the monitor. A defibrillator is present. What is your

first action?

a. Establish an IV and give vasopressin 40 units.

b. Establish an IV and give epinephrine 1 mg.

c. Intubate the patient and give epinephrine 2 to 4 mg via the endotracheal tube.

d. Give a single shock.

e. Begin CPR with chest compression for 2 minutes or about 5 cycles of compressions and

ventilations.

10. You arrive on the scene to find a 56 years old diabetic woman with dizziness. She is pale

and diaphoretic. Her blood pressure is 80/60 mm Hg. The cardiac monitor documents the

rhythm above. She is receiving oxygen at 4 L/min by nasal cannula, and an IV has been

established. Your next order is



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a. Atropine 1 mg IV

b. Sublingual nitroglycerine 0.4 mg

c. Dopamine at 2 to 10 mcg/kg per minute

d. Morphine sulfate 4 mg IV

e. Atropine 0.5 mg IV.

Thank You for Participation!!



22


ANNEX III

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