RAJIV GANDHI UNIVERSITY OF

HEALTH SCIENCES

SYNOPSIS ON

THE M.SC.(N) DISSERTATION

A STUDY TO ASSESS THE EFFECTIVENESS OF SELF

INSTRUCTIONAL MODULE ON KNOWLEDGE OF

ELECTROCARDIOGRAM AMONG STAFF NURSES IN A

SELECTED HOSPITAL IN MANGALORE

Submitted By:Ms. Anitha Paul

1st year M.Sc. Nursing student,

Srinivas Institute of Nursing

Sciences,

Valachil Padavu, Arkula,

Mangalore – 574 143.

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.

ANNEXURE – II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

1. NAME OF THE CANDIDATE

AND ADDRESS

(IN BLOCK LETTERS)

MS. ANITHA PAUL

1st YEAR M. Sc. (NURSING)

MEDICAL SURGICAL NURSING

SRINIVAS INSTITUTE OF NURSING

SCIENCES,

VALACHIL PADAVU, ARKULA,

MANGALORE – 574 143.

2. NAME OF THE INSTITUTION

SRINIVAS INSTITUTE OF NURSING

SCIENCES,

VALACHIL PADAVU, ARKULA,

MANGALORE – 574 143.

3. COURSE OF STUDY

SUBJECT

M.Sc. NURSING

MEDICAL SURGICAL NURSING

4. DATE OF ADMISSION 01-06-20115. TITLE OF THE TOPIC.

A STUDY TO ASSESS THE EFFECTIVENESS OF SELF

INSTRUCTIONAL MODULE ON KNOWLEDGE OF

ELECTROCARDIOGRAM AMONG STAFF NURSES IN

A SELECTED HOSPITAL IN MANGALORE

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6.

6.1

BRIEF RESUME OF INTENDED WORK

Introduction

“The most beautiful things in the world cannot be seen with the eyes, but

can only felt with the human heart”.

- Nursing journal of India

The heart is a hollow, cone-shaped organ approximately the size of an

adult’s fist, weighing less than 0.450 Kgs. Cardiac muscle cells possess an

inherent characteristic of self-excitation, which enables them to initiate and

transmit impulses. The SA node, located at the junction of the superior venacava

and right atrium act as the normal pacemaker of the heart generating an impulse

60-100 times per minute. This impulse travels across the atria via the internodal

pathways to the atrioventricular (AV) node. It then passes through the bundle of

His at the atrioventricular junction and continues down the interventricular

septum through the right and left bundle branches and out to the purkinje fibers.1

Electrocardiography (ECG or EKG from the German

Elektrokardiogramm) is a transthoracic interpretation of the electrical activity of

the heart over a period of time, as detected by electrodes attached to the outer

surface of the skin and recorded by a device external to the body. The etymology

of the word is derived from the Greek word ‘electro’, because it is related to

electrical activity, ‘kardio’, for heart, and ‘graph’, a Greek root meaning

"to write".2

Fig 1:ECG wave

An initial breakthrough came when Willem Einthoven, working in Leiden,

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Netherlands, used the string galvanometer that he invented in 1903. Einthoven

assigned the letters P, Q, R, S and T to the various deflections, naming of the

waves in the ECG and described the electrocardiographic features of a number of

cardiovascular disorders. In 1924, he was awarded the Nobel Prize in Medicine

for his discovery. 2

Epidemiologists in India and international agencies such as the World

Health Organization (WHO) have been sounding an alarm on the rapidly rising

burden of cardiovascular disease (CVD) for the past 15 years. The reported

prevalence of coronary heart disease (CHD) in adult has risen four-fold in 40

years and even in rural areas the prevalence has doubled over the past 30 years. In

2005, 53% of the deaths were on account of chronic diseases and 29% were due

to cardiovascular diseases alone. It is estimated that by 2020, CVD will be the

largest cause of disability and death in India.3

With the epidemiologic transition, the CVD burden continues to rise in

developing countries including India. The projected rise in disease burden due to

CVD is expected to make it the prime contributor of total mortality and

morbidity. Almost 2.6 million Indians are predicted to die due to coronary heart

disease (CHD), which constitutes 54.1% of all CVD deaths in India by 2020.

Additionally, CHD in Indians has been shown to occur prematurely, that is,

at least a decade or two earlier than their counterparts in developed countries.

Demographic and health transitions, gene-environmental interactions and early

life influences of fetal malnutrition are the likely causes of increased CVD burden

in India.4

Need For The Study

Cardiovascular disease is the leading cause of death and disability in the

United States. Over 64 million people have some type of cardiovascular disease.

Coronary heart disease is responsible for 1 in 5 deaths in the United States.

The economic costs of CVD, both direct and indirect, to the nation are estimated

at $368 billion annually.1

Coronary heart disease is becoming more common in the developing

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world such that in India, cardiovascular disease (CVD) is the leading cause of

death.5 The deaths due to CVD in India were 32% of all deaths in 2007 and are

expected to rise from 1.17 million in 1990 and 1.59 million in 2000 to 2.03

million in 2010 6. Although a relatively new epidemic in India, it has quickly

become a major health issue with deaths due to CVD expected to double during

1985–2015 7. Mortality estimates due to CVD vary widely by state, ranging from

10% in Meghalaya to 49% in Punjab (percentage of all deaths). Goa (42%),

Tamil Nadu (36%) and Andhra Pradesh (31%) have the highest CVD related

mortality estimates.8 State-wise differences are correlated with prevalence of

specific dietary risk factors in the states. Moderate physical exercise is associated

with reduced incidence of CVD in India (those who exercise have less than half

the risk of those who don't).7

The ECG is an essential tool in evaluating the heart rhythm.

Electrocardiography detects and amplifies the very small electrical potential

changes between different points on the surface of the body as the myocardial

cells depolarize and repolarize, causing the heart to contract. The same electrical

impulses spread outward from the heart to the skin, where they can be detected by

electrodes attached to the skin. The ECG displays the electrical action of the

heart. The ECG is the gold standard for noninvasive diagnosis of cardiac

arrhythmias and conduction abnormalities and useful tool in evaluating the

function of implanted devices such as pacemaker and implanted defibrillators.9

According to Drew BB, the critical care nurses should learn how to use ST

segment monitoring to detect acute ischemia, which is often asymptomatic in

patients with acute coronary symptom. ECG monitoring is becoming more

common in both in-patient and out-patient care settings. Nurses have significant

diagnostic influences in areas of cardiac rhythm monitoring and dysarrhytmia

identification. It is essential that nurses who care patients at risk for cardiac

dysarrhytmia have a thorough understanding of accurate electrode placement.10

Monitoring the routines of critical care nurses has indicated that nurses do

not select leads according to diagnosis (or history of coronary disease).

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A survey was conducted on769 ICU in 2009 by AACN. The results revealed that

53% of the nurses stated that routine leads (standard lead choice) were used to

monitor patients regardless of the diagnosis.11

A qualitative study was conducted on arrhythmia knowledge with the

objective to identify and describe critical care nurse’s perception of arrhythmia

knowledge. The sample consisted of 70 critical care nurses who worked in acute

care settings where they read ECG data and made treatment decisions. The data

collection method included 5 focus groups which were conducted over a period of

12 months. Group size ranged from 4 to 8 participants. The result showed a

deficit in nurse’s ability to recognize and identify specific arrhythmia, including

heart block, aberrant conduction and tachyarrhythmia.12

A descriptive study was conducted in North West America among nurses

on interpreting 12 lead ECG for acute ST-elevation of myocardial infarction. The

objective of the study was to assess the nurse’s knowledge of interpreting ECG.

The sample consisted of 75 nurses who were given asset of 6 patients and asked

to identify the presence or absence of ischemia and were unable to determine

the correct leads, location and amplitude of ST-segment elevation. For 3

non-ischemia ECG’s 37(49%) of the nurses identified them as a normal ECG,

47 (63%) determined that an early repolarization pattern was ischemic and

34 (45%) indicated that a left bundle branch block pattern was ischemic.

These results not only identify educational opportunities but also provide

important information for researchers implementing clinical trials.13

  Nurses will continue to need ongoing education and mentoring in correct

application of ECG leads and principles of monitoring. Audits of nursing practice

should include physical placement of electrodes and lead selection. The results

from audits will highlight improvement in practice and ongoing educational

needs. Involvement of staff nurses in the audit process is an excellent method of

highlighting evidence-based practice at the bedside.11

Nurses play a critical role in arrhythmia identification and management at

the bedside. On the basis of the nurse’s interpretation of the electrocardiographic

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(ECG) monitor recording, the nurse may simply gather more data, notify the

physician who makes treatment decisions based on the rhythm interpretation of

the nurse, or institute pharmacologic and counter shock therapies consistent with

unit-specific protocols. Therefore understanding the nurse’s perception of

arrhythmia knowledge, and ultimately, developing tools to evaluate this

knowledge, and competence in the recognition of ECG rhythms, are of critical

importance to nursing.12 So the investigator felt the need to conduct the study on

this group.

Review of Literature

An experimental study was conducted on nurse’s ability to identify

anatomic location and leads on 12-lead electrocardiograms with ST elevation in

myocardial infarction in United States, 2010. The objective of the study was to

determine the nurse’s knowledge to identify the presence of ST elevation in

myocardial infarction (STEMI), selection and location of leads. The sample

consisted of 75 nurses from the emergency department, coronary care unit and the

progressive care. The nurse’s were given 6 patient scenarios (3 STEMI and

3 non - STEMI) and a corresponding 12-lead ECG. This was followed by a

brief in-service education on ECG by hand held tool. The nurse then interpret the

same six ECGs (in a different order) using the hand held tool. The results showed

that identification of STEMI location improved when the tool was used. Lead

identification improved in 2 of the 3 STEMI scenarios.14

A study was conducted to determine the proficiency of ICU nurse’s and

emergency room (ER) nurses in performing ECG procedure and nursing

management in selected hospitals in Iligan city, Philippines in 2010.The objective

of the study was to assess the knowledge on fundamentals of ECG, including 12

lead placement, nursing management and the basic interpretation of rhythm strips.

The sample consisted of 66 ICU and ER nurses and data were collected by using

questionnaire. The results revealed that the overall total average score yielded a

mean proficiency of 58.02% of the respondents which was below the expected

range of 75%.

This showed the insufficiency of ICU and ER nurses on the knowledge

and skill on ECG. The study concluded that skill enhancement program and

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continuing education should be provided to both ICU and ER nurses to render

quality nursing care to the patients.15

A study was conducted on Cardiac Surgical Nurse’s in North America

regarding the use of Atrial Electrograms to Improve Diagnosis of Arrhythmia in

2010. The objective of the study was to determine whether use of atrial

electrograms significantly improves nurse’s ability to diagnose cardiac

arrhythmias. A sample of 282 nurses completed a test consisting of 5

electrocardiographic rhythms for which use of atrial electrograms might improve

interpretation. A standardized educational session on obtaining and interpreting

atrial electrograms was given to 165 nurses who had not previously received such

education. In a second test, the same rhythms were provided along with atrial

electrograms to 261 nurses. The results showed that use of atrial electrograms

significantly increased overall arrhythmia interpretation scores.16

A descriptive study was conducted to evaluate the nurse’s current

knowledge related to electrocardiographic (ECG) monitoring. The objective of

the study was to determine the nurse’s knowledge on ECG monitoring. The

sample consisted of 1739 nurses working on adult cardiac units in 17 hospitals

(15 in the US, 1 in Canada, 1 in Hong Kong) from September 2008 to June 2009.

The results had shown that nurses had the highest mean score (52; SD ± 6) on the

essentials of ECG monitoring and had the lowest mean score (36; SD± 23) on

ischemia monitoring. The study concluded that nurse’s knowledge about ECG

monitoring can be improved and education should particularly target less

experienced nurses.17

A prospective study was conducted to determine the accuracy of

diagnosing atrial fibrillation on ECG by primary care practitioners and

interpreting diagnostic software in England, 2007. The objective of the study was

to assess the accuracy of general practitioners and practice nurses in the use of

different types of ECG to diagnose atrial fibrillation. The sample consisted of 49

general practitioners and 49 practice nurses who were given 2595 patients.

The results showed that general practitioners detected 79 out of 99 cases of atrial

fibrillation on a 12 lead ECG. The practice nurses misinterpreted 114 out of 1355

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6.4

6.5

cases of sinus arrhythmia as atrial fibrillation. The study concluded that many

primary care professionals cannot accurately detect atrial fibrillation on an

electrocardiogram.18

An experimental study was conducted to assess the effectiveness of

planned teaching programme among GNM students on ECG in West Bengal in

2002. A sample of 30 final year GNM students were selected by lottery method

and data were collected by questionnaire and observation checklist. The results

shown that sum of the mean knowledge scores of students were 26.23 in pretest

and 73.66 in post-test, the ‘t’ value was 26.86.The findings suggested that the

planned teaching programme had effect on the knowledge of GNM students.19

Statement of the Problem

A study to assess the effectiveness of self instructional module on

knowledge of electrocardiogram among staff nurses in a selected hospital in

Mangalore.

Objectives of the Study

Objectives of the study are to

To assess the pre-test knowledge of staff nurses regarding

electrocardiogram.

To develop and evaluate the effectiveness of self instructional module.

To find out association between the selected socio demographic variables

of staff nurses with their pre-test knowledge scores on electrocardiogram.

Operational Definitions

Effectiveness :

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6.7

Effectiveness refers to improvement in the post-test scores of nurses after

the administration of self instructional module on electrocardiogram

which is measured and expressed in terms of knowledge scores.

Self Instructional Module :

Self instructional module refers to a booklet which covers the information

and instructions regarding anatomy and physiology of heart, recording and

interpretation of normal and abnormal ECG to enhance the knowledge of

staff nurses regarding electrocardiogram.

Knowledge :

Knowledge refers to the awareness of staff nurses on electrocardiogram.

Electrocardiogram :

The electrocardiogram is a graphical record of the electrical impulses that

are generated by depolarization and depolarization of the myocardium.

Staff Nurses :

Staff nurses refers to those qualified registered nurses working in a

selected hospital in Mangalore.

Assumptions

Staff nurses may not have adequate knowledge regarding

electrocardiogram.

Self instructional module will enhance the knowledge of staff nurses on

electrocardiogram.

The knowledge may vary according to the selected demographic variables.

Delimitations

The study will be limited to:

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7.1

7.2

Staff nurses who are working in a selected hospital in Mangalore.

Gain in knowledge scores.

Assessment of effectiveness of SIM on recording of 12-lead ECG and

interpretation of selected arrhythmias.

50 staff nurses.

Hypotheses

H1:- There will be a significant difference between the post-test knowledge

scores and pre-test knowledge scores of electrocardiogram.

H2:- There will be a significant association between the mean pre- test

knowledge score on electrocardiogram and the selected demographic

variables.

MATERIALS AND METHODS

Source of DataThe data will be collected from staff nurses who fulfill the inclusion

criteria and are willing to participate.

Research Design

The research design selected for this study is pre- experimental, one

group pre test post test design

O1 X O2

(DAY 1) (DAY 1) (DAY 7)

O1 - Pre Test

O2 - Post Test

X - Administration of SIM.

SCHEMATIC OUTLINE OF RESEARCH DESIGN

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DESIGNPre-experimental one group pre-test post-test design

POPULATION

Staff Nurses

SAMPLE TECHNIQUENon-probability purposive

sampling

FINDING, DISCUSSION AND CONCLUSION

STUDY SAMPLE50 Staff nurses working

in a selected hospital

STUDY SETTING Selected hospital in

Mangalore

TOOLSelf administered closed

ended structured questionnaire

Frequency & Percentage of socio -

demographic variables

Mean, Standard deviation and percentage of knowledge on

ECG

Paired’t’ test for significance of difference between the pre

test & post test scores.Chi-square test for association

between pretest and socio demographic variables

VARIABLES

DEPENDENT

Knowledge on ECG

INDEPENDENT SIM on ECG

ATTRIBUTES Gender, age, experience, qualification, in-service

education on ECG

ANALYSIS

Setting

The study will be conducted in a selected hospital in Mangalore.

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7.3

7.4

7.57.5.1

7.5.2

7.5.3

7.5.4

7.5.5

PopulationThe population selected for this study will be staff nurses working in a

selected hospital in Mangalore.

Method of Data CollectionSampling Procedure

Sampling procedure will be non probability purposive sampling.

Sample Size

The data will be collected from 50 staff nurses who meet the inclusion

criteria.

Inclusion Criteria

Staff nurses working in medical-surgical wards.

Both male and female staff nurses.

50 staff nurses

Exclusion Criteria

Staff nurses who were:

Not willing to participate in the study.

Not available at the time of data collection.

Instrument Used

Instrument used for the study is closed ended knowledge questionnaire.

The questionnaire is divided into two sections.

Section A :- Demographic variables including gender, age, experience,

qualification, in-service education on ECG.

Section B :- A structured knowledge questionnaire is used to assess the

knowledge of staff nurses on electrocardiogram.

Data collection method

Data will be collected after obtaining permission from the concerned

authorities of the selected hospital in Mangalore. The investigator selects 50 staff

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7.6

7.7.1

7.7.2

nurses through non-probability purposive sampling. The objectives of the study

will be explained to the participants and a formal written consent will be taken

from the subjects. Investigator will introduce herself to the participants and then

the closed ended knowledge questionnaire is administered. After 30 minutes the

questionnaire will be collected back and a well designed SIM on

electrocardiogram will be distributed to the sample. After 7days the post-test will

be conducted by using the same questionnaire.

Data Analysis PlanBased on the objectives data analysis will be done using descriptive and

inferential statistics. Findings will be presented in the form of tables and figures.

Descriptive statistics

To describe the demographic variables and level of knowledge, frequency,

percentage, mean and standard deviation will be used.

Inferential statistics

1. The Chi-square test will be used to find the association of mean pre-test

knowledge scores with selected demographic variables.

2. Paired ‘t’ test will be used to assess the effectiveness of self instructional

module.

Does the study require any investigation or intervention to be conducted on

patient or other human or animals? If it so please describe briefly.

No. This study does not involve any investigation or intervention.

However a self instructional module will be given to the staff nurse’s on

knowledge of electrocardiogram. The study does not involve any injury,

injections or harm to the subjects.

Has ethical clearance been obtained from your institution in case of 7.7.1?

Yes. Ethical clearance will be obtained from the ethical committee of the college

of nursing prior to the conduction of study. Administrative permission will be

obtained from the concerned authorities of the hospital. Written consent will be

obtained from the staff nurses and confidentiality will be maintained.

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