Description of Knowledge and Skill of Nurses to Interpret Basic ECG

in The Hos

ital

Nissa Aruming Sila

, Nursala

and M. Yusuf Asegaf2

Faculty of Nursing Universitas Airlangga, Kampus C Mulyorejo, Surabaya, Indonesia

Docter - Lecture, Cardiology Dept, Universitas Airlangga Hospital

Keywords: ECG Interpretation, Nursing.

Abstract: Heartdisease is the third cause of the death worldwide. The American Heart Association reported that 405.309

Americans died because of cardiovascular disease in 2008, and about 785.000 Americans got coronary attack

for the first time every year. Screening for early detection of cardiovascular disease is an appropriate step in

reducing mortality. Electrocardiogram(ECG) data are critical in formulating management strategies of

patients with heart disease. The purpose of this study was to determine the level of knowledge and skill of

nurses to interpreting ECG rhythms. This study used a descriptive method. Data were collected by

questionnaire of knowledge and questionnaire of ECG interpretation from 69 ward nurses. Dataanalysis

showed that 76% of nurses had an average level of knowledge on ECG and 24% of them had below that level

Sufficient knowledge of ECG is not supported by the skill to interpret ECG examination. Increasingthe

knowledge and skill of basic ECG interpretation of ward nurses is important. Improving the knowledge and

skill of ward nurses to interpret ECG rhythms could improve the response time to manage patients with

cardiovascular disease so that all procedure could be faster, right and accurate.

1 BACKGROUND

Heart disease is a third disease that causes death

worldwide. Early detection of heart disease is a right

step to decrease that mortality (Fakhriet al., 2017).

Electrocardiogram (ECG) is an essential strategy in

the management to determine the next treatment in a

patient handling with cardiology diagnosis. It was

estimated as the best sign compared to the increase in

serum levels (Zimmerman, Beuhler and Kerns, 2012).

It is a diagnostic device that is still affordable for

society compared to the other high technology device

to detect the abnormalities of the heart (Fent et al.,

2016). The ability of the nurse in the ECG

interpretation was still low. Their ability was only

limited to the measurement and quite low in the

interpretation (Zhang and Hsu, 2013).

Every year one of six died in the world was

caused by cardiovascular disease. The American

Heart Association reported that 405.309 Americans

were dead due to cardiovascular disease on 2008 and

it was estimated that there would be 785.000

Americans got coronary attack for the first time every

year, 470.000 got a recurrent attack, and 195.000 got

first myocardial infarction without symptoms

(Muhlestein et al., 2015). The cardiovascular disease

nowadays has reached the first position of the cause

of the death in Indonesia. Around 25% of all the

deaths caused by the cardiovascular abnormalities.

The result of Riskesdas 2013 showed that the

prevalence of several cardiovascular diseases such as

hypertension (based on blood pressure measurement),

was quite high, which was 31.7%, while heart disease

was 7.2% and stroke was 8.3% for every 1000

citizens (Badan Penelitian dan Pengembangan

Kesehatan, 2013).

Most of the STEMI death occurred in the first 1-

2 hours. There are a lot of obstacles to identifying the

initial recognition of STEMI, including the lack of the

patient ability to recognize that they get an ischemia

or the paramedic ability to detect the myocardial

infarct on the ECG result (Muhlestein et al.,

2015).Universitas Airlangga Hospital as a health

service has 100 visits on the heart case each day or

20% of the total outpatients and has almost 700

regularly patient visits with the main problem on the

heart every month.

The nurse has to have 99% ability in detecting the

ECG signal when the patient is in the lethal

arrhythmia or the other disturbance that threatens

244

Sila, N., Nursalam, . and Asegaf, M.

Description of Knowledge and Skill of Nurses to Interpret Basic ECG In The Hospital.

DOI: 10.5220/0008323302440249

In Proceedings of the 9th International Nursing Conference (INC 2018), pages 244-249

ISBN: 978-989-758-336-0

their lives. In contrary, the ability of the nurse in

detecting the presence of ischemia or infarct based on

the ECG result was below 50% (Zimmerman,

Beuhler and Kerns, 2012). There were a lot of efforts

performed to improve the nurse ability in the ECG

interpretation. In fact, not all of the health service

aware of the importance of improving the nurse

ability to decrease the mortality level due to the slow

handling (Zhang and Hsu, 2013). There were a lot of

methods developed to simplify the ECG

interpretation, such as the automatic reading machine,

mobile ECG, or computerized ECG. But, those

methods did not improve the ability of the paramedics

in interpreting the ECG (Bojsen et al., 2015).

The benefit of using ECG is diverse, such as

identifying the arrhythmia or dysrhythmia, the

coronary disease, the cardiomyopathy, the metabolic

disease and the side effect of drugs. From all the

benefits of ECG aforementioned, its main role is to

identify the presence of arrhythmia or dysrhythmia. It

means that by only using the morphology of ECG, the

diagnosis of the patient could be strengthened. And

for the other benefits, it should be supported by the

other supporting examination, such as patient clinical

condition and so on (Nazmah, 2015). Based on those

benefits, nurses, as a health service provider who are

always alongside the patient, their ability in observing

the ECG morphological change is important to have

a fast response time and a good service quality

(Nazmah, 2014). The knowledge of the nurse to

interpret the ECG could improve the service quality,

like on nursing care to the patients or the

determination the result criteria on delivering the

nursing care (Xue and Farrell, 2014).

Universitas Airlangga Hospital as an educational

hospital in which the knowledge development should

be equal and optimal was expected on having nurses

with a good ability level on interpreting basic ECG.

When there is an abnormality found on the ECG

result at the care units, the handling response, in this

case, could be faster and the service quality could

increase.

Based on the explanation mentioned above, this

study was aimed to obtain the description of the

ability of nurse of Universitas Airlangga Hospital in

interpreting the basic ECG.

2 METHODS

This study used a descriptive design, which aims to

know description of knowladge and Ability

Interpreting The Basic ECG of Nurse. A sampling

method used in this study was a total sampling

method. 69 ward nurses already met the inclusion and

exclusion criteria that have been set by the researcher.

The data collecting instrument used were nurse

knowledge level instrument towards ECG and ability

and pace of nurse instrument in interpreting the ECG.

The instrumen have been tested for validity and

reliability with corrected total correlation > r table

(0.632), alpha cronbach knowladge = 0.892, and

alpha cronbach Ability Interpreting Basic ECG =

0.911). Questionnaire Data is analyzed descriptively.

Data is presented in the form of frequency

distribution and proportion / percentage.

3 RESULTS

Based the study that has been performed to 69

inpatient nurses of UniversitasAirlangga Hospital, it

was obtained the demography data distribution as

shown in Table 1.

Table 1 Description of demography data of respondent.

Characteristics Frequency

erson

)

Percentage

(

)

1 Age (Years)

20 – 25

26 – 30

31 – 35

> 35

17,4

62,3

17,4

2,9

2 Gender

Male

Female

14,5

85,5

3 Working Duration

1-3 tahun

3-5 tahun

>5 tahun

69,6

24,6

5,8

4 Last Education

D3 Nurse

S1 Ners

(

Bachelor

)

15,9

84,1

5 Employee Status

Hospital

Honorary

Employee

University

Honorary

Employee

Government

Employee

78,3

5,8

15,9

Undergoing the nurse knowledge questionnaire

about ECG, the researcher could get the data as

shown in Table 2.

Table 2: Description of knowledge about ecg of nurse.

o Knowledge Level Frequency

(Person)

Percentage

(%)

Description of Knowledge and Skill of Nurses to Interpret Basic ECG In The Hospital

245

1 Good

Sufficient

Not Sufficient

75,3

24,6

Table 3: Description of ability interpreting the basic ecg of

nurse.

o Characteristics Frequency

(Person)

ersentase

(%)

1 Rhythm

True

False

44,93

55,07

2 Frequency

True

False

11,59

88,41

3 Pacemaker Source

True

False

40,57

59,43

4 Axis

True

False

11,59

88,41

5 Extrasystole

True

False

4,34

95,66

6 Block

True

False

7,25

92.75

7 Heart Muscle

Enlargement

True

False

4.34

95.66

8 Coronary Heart

Disease

True

False

4,34

95,66

9 Overall

Interpretation

True

False

100

4 DISCUSSION

4.1 Demography Age

Based on the result of this study, it was obtained the

data that most of the nurses were on the early adult

period which was 55 nurses (79.7%), 12 nurses were

on the final adolescent phase (17.4%), and 2 nurses

were on the final adult phase (2.9%). The nurse at the

Universitas Airlangga Hospital has relatively same

age and quite young.

Age is an item affecting the growth and

development of human physiology. It also affects

one’s process of thinking. With the increase of

someone age, the process of thinking would be more

critical gradually in adult phase. In the early adult

phase, one’s focus would be emphasized on the job

and surrounding socialization. In this age level,

someone would spur themselves on competition and

productivity. They would use their decent motoric

ability in learning to master new skills and use their

mental ability to remember things that have been

learned before, analogical reasoning, and creative

thinking and was supported by the efficient physical

ability so that they could compete in their

environment (Zhang and Hsu, 2013).

The result of the previous study also showed that

in the early adult phase, a nurse would be encouraged

and takes part in the competition with their colleagues

to show their productivity in their work (Wu, 2012).

Most of the nurses in Universitas Airlangga

Hospital were on the early adult phase, so it was

implied that that condition could be a big benefit to

improve the nursing service. At that state, they have

high spirit competitiveness towards their colleagues.

Thus, it was expected that this optimal

competitiveness atmosphere could bring betterment

to the nursing service.

4.2 Gender

Based on the result of this study, it was obtained that

most of the nurse was female, which was 59 nurses

(85.5%), and the rest were male (14.5%). Overall, the

total of nurses in UniversitasAirlangga Hospital in all

service units was female. This result was suitable with

the previous study, which stated that the number of a

male nurse (44.3%) was less than a female nurse

(56.7%).

This was assumed that the nurse job was preferred

by female than it was by male. The nurse job is indeed

the basic science as mother instinct so that female is

more interested in this job. Even from the school or

university, this field was dominated by the female.

Even, in fact, there are a lot of nursing activities that

need a male nurse to fulfill the basic need of the

patient, as an example in the unit that has patients who

lose their consciousness and mobility and were

helped completely by the nurse and the other sensitive

need performed by the opposite sex.

4.3 Working Duration

Most of the nurses had the working experience

duration for 1-3 years, which was 48 nurses (69.6%),

and the other nurses that had the working experience

duration for 3-5 years were 17 nurses (24.6%), and

more than 5 years were 4 nurses (5.8%). The nurses

at Universitas Airlangga Hospital had relatively

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

246

minimal experience and most of them were fresh

graduates. The duration of the nurses working

affected their knowledge and skills. The longer their

duration of work, the better their quality or

performance in the nursing care. The working

experience would increase their expertise and skills in

the working. With that amount of time, the

knowledge and skills of the nurse were sharpened

with several cases that they handled (Varvaroussis et

al., 2014).

The nurses at Universitas Airlangga Hospital had

the adequate knowledge, but not with the ECG

interpretation ability. This was caused by the fact that

they still had minimal experience but obtained more

knowledge from the university or autodidact study.

4.4 Last Education

Based on the result of this study, it was obtained the

data that the majority of the last education was a

Bachelor of nursing (S1 Ners), which was 58 nurses

(84.1%) and Vocational of Nursing (D3 Nursing) was

11 nurses (15.9%). According to the Nursing

Constitution No. 38 2014 in Indonesia, the

professional nurse is bachelor of nursing (S1 Ners),

and D3 was a vocational education.

The Bachelor of Nursing (S1 Ners) has a scholarly

competency compared to the vocational nursing (D3

Nursing). The high number of nurse with the last

education of bachelor of nursing was expected to

increase their knowledge that also could improve

their performance in the nursing care. The

educational level of most of the nurses at Universitas

Airlangga Hospital was a benefit in delivering

optimal service.

4.5 Employee Status

Based on the result of this study, it was obtained the

data that most of the nurses at UniversitasAirlangga

Hospital had an employee status as honorary hospital

employee, which was 54 nurses (78.3%), the

honoraryuniversity employee was 4 nurses (5.8%)

and government employee was 11 nurses (15.9%).

The majority of the nurses at UniversitasAirlangga

Hospital had status as an honorary hospital employee,

not only in the inpatient unit but also in every service

unit.

The employee status is not defined as a standard

in obtaining the opportunity to gain knowledge or

skills.

4.6 The Nurse Knowledge about ECG

The knowledge is a result of knowing and it occurred

after someone performed sensing to a specific object.

The sensing occurred through the human senses;

vision, hearing, smell, touch, and taste. Most of the

knowledge was obtained through eyes and ears. The

knowledge or cognitive is an important domain to

form an over behavior (Zhang and Hsu, 2013).

The majority of nurse knowledge level in this

study as sufficient were 51 nurses (75.3%) and not

sufficient of 17 nurses (24.6%). The knowledge of the

inpatient unit nurses at Universitas Airlangga

Hospital could be said as fairly good. But, there were

still some nurses who could not interpret the ECG

result.

This caused worries on the nurse ability at

analyzing the result of ECG. It was worried that the

nurse could not recognize the change of condition on

the heart. This could not only happen in the

emergency unit and intensive unit, but also in the

inpatient unit. The better knowledge of the nurse in

interpreting the ECG result would simplify the

monitoring and management of the patient during

their stay in the inpatient unit so that the change of

condition of ECG in the emergency condition could

get an intensive handling immediately.

The lack of knowledge level might arise due to the

lack of curriculum during school and the skills on

interpreting the ECG result could be learned from

training. The data at Universitas Airlangga Hospital

said that only 1 of 97 (1.03%) had been certified at

ECG training.

The effect of ECG training to nursing knowledge

in interpreting ECG on the previous training showed

that there was a difference of the nurse knowledge

score average before and after ECG training with a p

value of 0.001 (p<0.005) (Raupach et al., 2016).

4.7 The Ability of The Nurse on

Interpreting the Basic ECG

The ability of the nurses was based on their

knowledge, but when someone has good knowledge,

it was not always accompanied by good skills. In the

previous study, it was found a correlation between the

education level and knowledge, and affected the skills

on ECG (Zhang and Hsu, 2013).

Description of Knowledge and Skill of Nurses to Interpret Basic ECG In The Hospital

247

4.8 Rhythm

The result of this study showed that 31 nurses

(44.93%) could interpret the ECG rhythm correctly,

and the rest still could not interpret the ECG rhythm

correctly. The rhythm is a method to identify the

electricity produced by the pacemaker source whether

it is regular or there is an abnormality that makes the

distance between the electric waves of the heart

irregular. The nurse ability was fairly good in

identifying the rhythm appearing in the ECG result so

that they could give the right management if there is

a disturbance on the heart rhythm.

4.9 Frequency

The result of this study showed that 8 nurses

(11.59%) could calculate the frequency of the

patient’s heart through ECG correctly, while 61

nurses (88.41%) was not able to calculate the ECG

frequency correctly.

The heart rate in every minute is one of the

indicators of heart workload. The ability to calculate

the heart frequency through the ECG was less owned

by the nurses. But, this could be performed by

conducting an easier physical examination on the

patient so that the response time is faster.

4.10 Pacemaker Source

The result of this study showed that 28 nurses

(40.57%) could determine the pacemaker source from

the ECG correctly, while 41 nurses (59.43%) could

not determine the pacemaker source from the ECG

correctly.

The normal pacemaker source on the human heart

was placed at SA Node. If the SA Node could not

bring up and produce impulse, then the ECG result

would be changed. This change still could not be

detected by some nurses so that the type of action

could not be determined for the next step.

4.11 Axis

The result of this study showed that 8 nurses

(11.59%) could determine the heart axis from the

ECG correctly, while 61 nurses (88.41%) could not

determine the heart axis from the ECG correctly.

The heart axis is an image of the heart position or

the electricity path behaves. If a patient’s axis were

disturbed, there would be a wave abnormality on the

ECG image. If the patient’s heart axis could not be

determined, there could be a wrong interpretation

when reading the ECG result. It could be read as

abnormal ECG while in fact, it is the normal one.

4.12 Extrasystole

The result of this study showed that 3 nurses (4.34%)

could determine the presence of extrasystole from the

ECG correctly, while 66 nurses (95.66%) could not

determine the presence of extrasystole from the ECG

correctly.

The presence of extrasystole on the ECG result is

an early sign that there is an abnormality in the heart

electricity. If this extrasystole was ignored and

without intensive handling could lead to an

arrhythmia that threatens the life of the patient.

4.13 Block

The result of this study showed that 5 nurses (7.25%)

could determine the presence of blockfrom the ECG

correctly, while 64 nurses (92.75%) could not

determine the presence of block from the ECG

correctly.

The knowledge about the block is crucial to be

known by the nurse to identify the presence of

impulse conduction interference in the conduction

path. When the nurse could detect a block faster, then

the help to the patient with conduction interference

could be optimal.

4.14 Heart Muscle Enlargement

The result of this study showed that 3 nurses (4.34%)

could determine the presence of heart muscle

enlargement from the ECG correctly, while 66 nurses

(95.66%) could not determine the presence of heart

muscle enlargement from the ECG correctly.

The method used to determine the presence of

heart muscle enlargement is not only by using ECG.

There are a lot of other examination that could be

used. ECG is one of the simple methods to observe

the presence of heart enlargement and could be

treated if the heart workload is too big.

4.15 Coronary Heart Disease

The result of this study showed that 3 nurses (4.34%)

could determine the presence of coronary heart

disease from the ECG correctly, while 66 nurses

(95.66%) could not determine the presence of

coronary heart disease from the ECG correctly.

The ECG examination was used for early

detection and evaluation on the presence of heart

attack on the patient. When in the ECG image was

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

248

found the presence of heart attack, ischemia or infarct

to be treated. After treating, the evaluation of the

treatment result is also by using ECG examination.

4.16 Overall Interpretation

The result of this study showed that no one could

conclude the overall ECG result correctly. This was

caused by the lack of nurse knowledge about reading

the ECG result so that in the end, there was no correct

overall interpretation.

The nurse relatively relied on the ECG

interpretation result from the device compared to

reading the ECG result directly. Some previous

studies stated that the error level of device reading

was relatively big because the device could not verify

the physical condition or patient complaints.

5 CONCLUSIONS

Knowledge possessed by the nurse to the ECG

interpretation was quite good, but it was not

accompanied by the ability to interpret the ECG

result.

Nurse at UniversitasAirlangga Hospital need an

opportunity to improve their ability and skills in

interpreting the ECG result, considering the potential

of UniversitasAirlangga Hospital nurse was good.

The combination of the young age as the eagerness to

learn and thrive is still high, a good education level as

the intelligence level is high, the short working

experience as they want more skills and high

opportunity to study because they are in the education

environment, which is UniversitasAirlangga.

The method selection in improving the ability and

skills in interpreting the basic ECG is important as an

effective form in the service and learning time. The

increase in the ability and skills of the nurse in

interpreting the ECG result is expected to improve the

service and response time to the patients with heart

disease in UniversitasAirlangga Hospital.

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