November-December 2016 • Vol. 25/No. 6418

Bonnie Nickasch, DNP, APNP, FNP-BC, is Assistant Professor and Director, DNP Family Nurse Practitioner Emphasis, University of Wisconsin Oshkosh, Oshkosh, WI; and Family Nurse Practitioner, ThedaCare Physician Services, Appleton, WI. Suzanne Marnocha, PhD, RN, CCRN, is Professor, Assistant Dean, and Pre-Licensure Director, University of Wisconsin Oshkosh, Oshkosh, WI. Lisa Grebe, BSN, RN, is Registered Nurse, ThedaCare Regional Medical Center, Appleton, WI. Heather Scheelk, BSN, RN, is Registered Nurse, Intensive Care Unit, ThedaCare Regional Medical Center-Neenah, Neenah, WI. Colette Kuehl, BSN, RN, is Dialysis Nurse, Purity Dialysis Center, Watertown, WI.

‘What Do I Do Next?’ Nurses’ Confusion and Uncertainty with ECG Monitoring

T elemetry monitoring is usedon many hospital units.Goodridge, Furst, Herrick, Song, and Tipton (2013) identified a need for increased education/train- ing in cardiac monitoring for the medical-surgical nurse who often needs to interpret cardiac rhythms outside a cardiac-specific unit. A nurse’s ability to interpret a cardiac rhythm quickly and correctly is vital to initiating appropriate interven- tions and key to patient safety. Nurses often report confusion

and uncertainty due to their lack of knowledge related to electrocardio- graphy (ECG) rhythm identifica- tion and intervention. Many hospi- tal leaders have attempted to close the knowledge gap, but no specific evidence supported the amount and type of training, or how often training is needed (Costanzo, Ehr – hardt, & Gormley, 2013; Forfa, 2013; Tai, Cattermole, Mak, Graham, & Rainer 2012). Further – more, gaps in registered nurse (RN) telemetry training and retraining identified within facilities have led to patient safety concerns (Pecci, 2012; U.S. Department of Veteran Affairs, 2010).

Purpose The purpose of this qualitative

study was twofold: to identify RNs’ perceived knowledge of and ability to respond to dysrhythmias to iden- tify possible areas for improvement, and to identify the type and amount of education needed by

RNs to be proficient with ECG rhythm analysis and patient treat- ment (eliminate confusion and uncertainty).

Review of Literature A review of the literature was

completed in the following databas- es for 2012-2016: CINAHL, Health Source Nursing, Medline, Ovid, and PubMed. Search terms included elec- trocardiography, ECG, EKG, telemetry, and dysrhythmia. The search then was narrowed by using the addi- tional search terms accuracy, compe- tence, proficiency, teaching, and train- ing. Very little research was available

regarding evidence-based practices designed for telemetry monitoring by medical-surgical nurses. Thus, authors reviewed studies in other practice areas and also included

earlier literature. In 2004, the American Heart Association (AHA) recognized this lack of information by publishing detailed standards of care for telemetry use (Drew et al., 2004). The AHA recommended ECG rhythm orientation for all nurses who have any exposure, even infrequent, to telemetry mon- itoring by didactic and return demonstration. Instruction should be based on a list of concepts under- stood by nurses with significant exposure to ECG monitoring. However, no specific recommenda- tions were offered for nurses who do not have significant exposure to telemetry monitoring (e.g., med- ical-surgical nurses). Essentially, the AHA recommended leaders of each hospital determine what the mini- mum ECG proficiency should be for all nurses. This lack of specific rec- ommendation by the AHA could

Research for PracticeResearch for Practice

Bonnie Nickasch, Suzanne Marnocha, Lisa Grebe, Heather Scheelk, Colette Kuehl

The prevalence of telemetry monitoring is increasing on medical- surgical units, but no evidence-based guidelines standardize nurs- ing education. Research indicates nurses feel uncertain and report a lack of knowledge when caring for patients with telemetry moni- toring.

November-December 2016 • Vol. 25/No. 6 419

create confusion and increase the likelihood that nurses, especially nurses with minimal exposure to telemetry monitoring, will not receive appropriate education or policy guidance. Notably, the AHA has not updated this manual despite significant increases in telemetry usage. Advanced cardiac life support

(ACLS) is the only education that defines a standard of knowledge for ECG interpretation for nurses car- ing for adult patients (AHA, 2016). Because telemetry monitoring is used widely, a national standard should be set for minimum ECG rhythm identification and treat- ment proficiency among nurses to ensure patient safety. Costanzo and colleagues (2013)

published results from their long- standing education consortium focused on dysrhythmia education. Nursing educators from 14 hospitals designed and offered a 24-hour instructor-led, computer-based ECG training program over 2 weeks for all newly hired nurses with no previous ECG education. Content included basic anatomy and physiology, nor- mal and abnormal rhy thms, and ventricular pacing with appropriate intervention. After completing the program, participants took a 50- question standardized test of general ECG knowledge, rhythm identifica- tion, and interventions. Because the test was developed by the re – searchers, it was given for 2 months with the standard consortium exam- ination that had known reliability data. Item analysis was completed after 2 months and two questions were revised for clarity. Ninety-nine percent (N=215) of participants achieved a score of 85% or better in no more than two attempts. Re – searchers did not try to determine if the increase in base knowledge trans – lated to better psychomotor per- formance; they also did not investi- gate how long the increased knowl- edge lasted without repeat educa- tion. Tai and colleagues (2012) con-

ducted a prospective study evaluat- ing nurse confidence levels when initiating defibrillation. Nurses from the Emergency Department at a

teaching hospital in Hong Kong attended an educational session on defibrillation skills and identifica- tion of rhythms in cardiac arrest. Comparing pre-test and post-test scores, authors found no change in ECG rhythm identification but noted increased nurse confidence as well as improved decision making and psychomotor performance on defibrillation. Authors did not address how long the improve- ments lasted and when nurses should be re-educated. In a study by Forfa (2013), a clin-

ical educator identified a lack of ECG rhythm recognition, interpre- tation, and rhythm management by nephrology RNs and subsequently developed a review course. Fourteen RNs completed the review course before taking a required annual rhythm recognition course in which they were categorized as competent, additional practice needed, or needs remediation. Scores from the 2011 and 2012 annual rhythm recogni- tion course were compared to evalu- ate impact of the 2012 review course. Though improvements in scores were seen in 2012, 35.7% (n=5) of nurses still required remedi- ation. This suggested annual reviews and tests may be helpful but may not ensure continued competence. A gap exists in the literature con-

cerning nurses’ perceived proficien- cy in ECG rhythm analysis and intervention. None of the reviewed articles evaluated these variables or offered data to inform the current study. In particular, literature con- cerning nurses who do not use the education on a daily basis was lack- ing.

Sample Selection The study site was a 157-bed

Midwestern hospital. The research team used a purposive sample of 11 RNs from the hospital’s medical- surgical (n=6) and cardiac step- down units (n=5). All RNs who had completed orientation were invited to participate. Managers placed signs related to the study in com- mon work areas to encourage staff participation. All staff were offered time away from the unit or paid if

not on duty so they could partici- pate. This approach increased the diversity of response as staff with diverse opinions or experiences could self-select for participation. After 11 interviews were completed, researchers believed data saturation occurred and no more RNs were interviewed.

Ethics This study received Institutional

Review Board approval from the University of Wisconsin Oshkosh and the hospital in which the study was conducted. All potential partic- ipants were informed of the study purpose and requirements, as well as the voluntary nature of their involvement, before providing con- sent. Participants were informed their answers would help guide development of a new ECG educa- tion program. They were compen- sated for their time by the hospital by being relieved during their paid shifts or being paid to come to the hospital when not scheduled to work. Only aggregate results were shared with hospital leaders.

Methods and Design The literature was used as a basis

for the seven-question semi-struc- tured interview guide used in this descriptive qualitative study. Inter – views were completed by two doc- torally prepared nurse researchers with experience in qualitative research. Then-BSN students (now RN authors) took notes during the interviews. Each participant com- pleted an informed consent and demographic questionnaire, and answered the semi-structured ques- tions (see Table 1). Researchers asked participants to be frank and honest in their responses. Participants were ensured all information would be held in strict confidence, and they were free to withdraw from the study at any time. The interviews occurred in a private room adjacent to the hospital library.

Analysis Spiegelberg’s (1975) techniques

of intuiting, analyzing, and describ-

‘What Do I Do Next?’ Nurses’ Confusion and Uncertainty with ECG Monitoring

November-December 2016 • Vol. 25/No. 6420

ing were used for data analysis. This technique allowed researchers to uncover emerging themes, patterns, and insights. All interviews were audio-recorded and transcribed ver- batim for consistent review and data analysis. Recordings and tran- scribed text were reviewed once by the entire team and twice by the two doctorally prepared researchers. Data were coded, concepts defined, and emerging themes identified. The research team focused on con- firmability when discussing the emerging themes. After determin- ing the major overarching theme and sub-themes, members complet- ed an additional literature search to determine if emerging themes were congruent with past studies.

Trustworthiness The trustworthiness of this study

was established through ensuring credibility, dependability, conform – ability, and transferability (Lincoln & Guba, 1985). Organi zational leaders noted RNs on the study units had verbalized concerns related to safely caring for patients with telemetry monitoring. Researchers established credibility via informal conversa- tions and feedback sessions follow- ing presentations at state and national nursing conferences. Credi – bility was evident when RNs attend- ing state and national nursing con- ferences confirmed study findings resonated with their own thoughts, feelings, and experiences. Several RNs identified situations in which staff in their agencies verbalized dis- comfort with telemetry monitoring due to infrequent exposure and unclear behavioral expectations. Dependability was demonstrated

through the researcher’s reflective appraisal of the project. Themes were grounded in the interviews and literature. Although there was congruence, limitations to this study included a small sample size and representation of a single geo- graphic location. To increase de – pendability, this study should be replicated in other similar units within the Midwest and beyond. Regarding confirmability, one of

the doctorally prepared authors has 38 years of intensive care experi-

ence and has been an ACLS instruc- tor for over 20 years. This author has heard descriptions of clinical RNs in the hospital and remotely calling telemetry technicians and intensive care RNs with questions about rhythm interpretation and actions for a patient’s dysrhythmia. Additionally, the author presented study findings at a national research conference and received RNs’ feed- back indicating results were similar to issues in their hospitals. Com – mon concerns involved having infrequent exposure to ECG moni- toring and feeling uncertain and uncomfortable. To enhance the transferability of

current study results, researchers have included the semi-structured interview guide (see Table 1). They also have described sample selec- tion, research team composition, and data analysis. However, the per- son who wishes to transfer the results to a different context or set- ting is responsible for judging how sensible the transfer would be.

Findings/Discussions The main overarching theme

was Confusion and uncertainty: What should I do next? to reflect nurses’ feelings in caring for patients receiv- ing telemetry monitoring. Re – searchers also identified three gen- eral subthemes regarding RNs’ use of telemetry in treating hospitalized patients: (a) Use it or lose it, (b)

Losing my independence: Relying on unlicensed telemetry technicians, and (c) Help! I am out of my comfort zone.

Overarching Theme Nurses reported confusion and

uncertainty in caring for patients with telemetry monitoring. Two nurses who were considered clinical resources and self-identified as nurse leaders were not comfortable with ECG analysis or what to do when the telemetry technician called to report a rhythm change. As one resource nurse stated,

We don’t even look at the strips to determine what the rhythm is … I will flat out ask (the telemetry tech- nician) is this something I should call the doctor for? … because they (telemetry technicians) know more than I do … it is usually not an RN sitting in there, but I trust them a lot more than I would trust myself to know what the heck they are talking about, because they see it every day.

A second resource nurse noted, “Yeah, if somebody would come to me … and say this patient had whatever abnormal rhythm … I would honestly not know the answer … my first thing would be to call the doctor because I don’t know.” Another clinical RN com-

Questions 1. Please share what specific education you believe is necessary to be proficient

in ECG cardiac rhythm analysis and treatment. 2. How often and what type of education would help to maintain your proficiency? 3. How many times a year on average do you care for a patient with ECG

monitoring (telemetry)? 4. Please share situations about cardiac rhythm analysis and patient treatment

that make nursing care more difficult. 5. Describe step-by-step what you would do if you receive a phone call from the

telemetry technician about a patient experiencing cardiac rhythm problems. 6. Please share what you would do if you have a question about a rhythm

analysis or patient treatment. 7. Please share any suggestions you might have to improve the ECG monitoring

and patient treatment processes here.

TABLE 1. Semi-Structured Interview Guide

Research for Practice

November-December 2016 • Vol. 25/No. 6 421

mented, “The paper may say that we are (proficient) but I know I for one, and I know there are others, we’re just not confident in it.” Though some nurses mentioned ACLS education and training increased their confidence, they did not believe extra training every 2 years was sufficient to maintain their sense of proficiency. One nurse stated, “It really was a waste of time for me because once I left the classroom, I never saw it again.” Another nurse agreed, “The biggest thing to me is consistently using it in order to be proficient.”

Subtheme 1: Use it or Lose it The most common explanation

for uncertainty was the need for information to be used often or it would be forgotten. Even though some nurses were pleased their organizations sent them through ACLS, they believed they did not retain the knowledge because they did not use it often enough. One RN stated, “For me, I feel like, if you don’t use your skills, you lose your skills.” This use it or lose it theme appeared in all interviews. Every nurse expressed a desire for more education, more frequent use, or both to maintain proficiency. One nurse stated, “The class was fine, but to be proficient, you have to use it, and on my unit, we never use it.” Another nurse speaking about ACLS noted, “It’s just that when you walk out of there, and then don’t see it again for a long a period of time, I think that’s where things get forgot- ten.” This perception may have con-

tributed to nurses’ anxiety and worry. One nurse commented, “It’s like not being a cardiac nurse … it’s like, let’s go, let’s get them off the floor, because I don’t want some- thing to go wrong … oh my God, they’re not gone yet.” Another nurse seemed even more anxious, stating, “I just feel like nursing is getting so … they’re stretching us too thin and no amount of teaching is going to help, unless you use it on a multiple- day basis.” This nurse displayed characteristics of anxiety during this portion of the interview, tapping her leg and speaking quickly.

Subtheme 2: Losing My Independence: Relying on Unlicensed Telemetry Technicians This lack of knowledge likely was

the basis for nurses’ belief they were unable to work independently. Nurses described lack of knowledge and confidence in how to read the rhythms. Additionally, they often were uncertain of a rhythm’s seri- ousness and what to do when called by the telemetry technician with information about an abnormal rhythm. This insecurity led RNs to ask telemetry technicians for guid- ance on what to do next, and for help in differentiating the rhythm as serious or relatively benign. For example, as one nurse indicated when the telemetry technician calls, “I will flat out say – is this something I should call the doctor for?” A nurse stated, “I trust them (the telemetry technician) a lot more than I would trust myself to know what the heck they’re talking about … they see it every day.” Another nurse said, “Granted they’re not professional people, but technically they know more than I do, and I’m a professional person.”

Subtheme 3: Help: I Am Out of My Comfort Zone The sense of fear and panic in

the nurses’ statements was unmis- takable. One RN explained her dis- comfort when caring for a patient with a dysrhythmia: “Not being a cardiac nurse, the minute RNs (on medical-surgical unit) hear the patient should go, it’s like, let’s just go, let’s get them off the floor, because I don’t want something to go wrong.” Similarly, another nurse stated, “It makes me nervous when they sit there (patients) … some- times, it’s … a little too long for my liking.” When describing her dis- comfort with dysrhythmias, anoth- er nurse said, “I don’t even feel comfortable enough knowing what would be considered, you know, extremely lethal.” These statements emphasized the need for increased education and training for all nurs- es working with telemetry monitor- ing. Nurses suggested working in small groups to discuss and think

critically about potential and past cases. They also indicated regularly scheduled hands-on experience in the telemetry room (e.g., 1 hour per month) and annual computer- based and instructor-led training would be beneficial. Finally, one participant suggested rotating with intensive care nurses would be valu- able.

Nursing Implications This study identified confusion

and uncertainty as notable factors in ECG rhythm analysis and inter- vention by medical-surgical and cardiac step-down RNs. Findings in – dicated nurses believe they require more frequent training and expo- sure in these two areas. Authors sug- gest policies and procedures must be developed to assist nurses in responding to dysrhythmias appro- priately, quickly, and confidently. This is congruent with AHA’s rec- ommendation that agencies should specify the desired steps medical- surgical RNs should take with rhythm changes in monitored patients (Drew et al., 2004). To increase RN knowledge, per-

ceived proficiency, and comfort in caring for patients with telemetry monitoring, nurses in the study sug- gested several modes of education be used (e.g., online, paper and pencil, case-based scenarios, hands-on expe- rience with ECG rhythm strips). To reduce reliance on unlicensed per- sonnel, a list of resource contacts should be developed so RNs can obtain assistance quickly (e.g., inten- sive care RN, cardiac RN, house supervisor). Evidence-based hospital standards must be developed and disseminated to all nurses, to include a hierarchy of resources for nurse consultation and a step-wise process for assessment. A format for report- ing the dysrhythmia to the provider could be developed to ensure com- plete, concise communication. A laminated card listing this step-wise process could be attached to the back of the RN’s name badge as a quick reference. Color-coded, lami- nated reference sheets also could be stored in each patient room. In the event of a dysrhythmia, these tools

‘What Do I Do Next?’ Nurses’ Confusion and Uncertainty with ECG Monitoring

November-December 2016 • Vol. 25/No. 6422

could ensure response consistency.

Limitations In this qualitative study, a small

number of informed participants shared their personal narratives. Their answers reflected their own experiences within their own envi- ronments. Moreover, the study measured only participants’ percep- tions of proficiency related to ECG rhythm identification, rather than using an objective measure of knowledge.

Recommendations for Future Research Future research is needed to

determine the amount of education needed to help RNs feel comfortable and proficient in ECG monitoring. Additionally, perceived knowledge and tested knowledge may not be the same. Future studies could focus on the optimal mode and frequen- cy of ECG training. This content area could be studied with a larger, more diverse sample. Further re – search could investigate the effec- tiveness of case studies, as suggested by several participants, and the components necessary to create a significant learning experience from a case study.

Conclusion Participants in this study report-

ed confusion and uncertainty re – garding caring for patients with ECG monitoring. They perceived these feelings to be due to lack of frequent exposure to monitored patients and/or education regarding their appropriate treatment. To increase comfort and proficiency, participants recommended case reviews, more frequent online learning, hands-on experience, and specific step-by-step guidelines.

REFERENCES American Heart Association (AHA). (2016).

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Costanzo, A.J., Ehrhardt, B., & Gormley, D.K. (2013).  Changing the rhythm of dys- rhythmia education through blended learning. Journal for Nurses in Pro – fessional Development, 29(6), 305-308.

Drew, B.J., Califf, R.M., Funk, M., Kaufman, E.S., Krucoff, M.W., Laks, M.M., … Van Hare, G.F. (2004). Practice standards for electrocardiographic monitoring in hospi- tal settings: An American Heart Assoc – iation Scientific Statement from the

Research for Practice

Participants in this study reported confusion and uncertainty re garding caring for patients with

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Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young: Endorsed by the International Society of Computerized Electrocardiology and the American Association of Critical-Care Nurses. Circulation, 110(17), 2721-2746.

Forfa, M.J. (2013). Advancing nursing practice in rhythm recognition with an e-learning educational program. Nephrology Nurs – ing Journal, 40(2), 159-163.

Goodridge, E., Furst, C., Herrick, J., Song, J., & Tipton, P.H. (2013). Accuracy of car- diac rhythm interpretation by medical- surgical nurses. Journal of Nurses in Professional Development, 29(1), 35-40.

Lincoln, Y.S., & Guba, E.G. (1985). Naturalistic inquiry. Beverly Hills, CA: Sage Publica – tions.

Pecci, A.W. (2012). VA finds large gaps in RN telemetry training, retraining. Health – Leaders Media.  Retrieved from http:// www.healthleadersmedia.com/nurse- leaders/va-finds-large-gaps-rn-teleme try-training-retraining

Spiegelberg, H. (1975). Doing phenomenolo- gy. Dordrecht, NL: Martinus Niijhoff.

Tai, C.K., Cattermole, G.N., Mak, P.S., Graham, C.A., & Rainer, T.H. (2012). Nurse-initiated defibrillation: Are nurses confident enough? Emergency Medicine Journal, 29(1), 24-27.

U.S. Department of Veterans Affairs, Office of Inspector General. (2010).  Healthcare inspection: Telemetry monitoring issues, VA Eastern Colorado Health Care System, Denver, Colorado (VA Office of Inspector General Report No. 09-01047- 69). Retrieved from  http://www.va.gov/ oig/54/reports/VAOIG-09-01047-69.pdf

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