A significant challenge when developing nursing proficiency in cardiac rhythm interpretation is to instill demonstrable competencies that will translate into safe practice. This point is aptly described by Toth and Ritchey (1984), who stated in their sentinel article on nursing knowledge development, “Although basic knowledge does not guarantee safe practice, safe practice cannot exist without basic knowledge” (p. 275). The term cardiac rhythm response was first identified as an important phenomenon for nursing practice, science, and research in 1989 (Drew, 1989). This substantive area of nursing comprises a significant component of professional development curriculum and although best practices have been slowly developed over the years, there are no clear guidelines as to what constitutes differing competency levels. Nurses who are involved in developing practicing nurses who care for monitored patients need to be able to target specific levels of competency to tailor staff development interventions.
Nursing professional development practitioners have long been confronted with difficulty in defining what constitutes competency in nursing practice (Church, 2016). In 1984, Alspach defined competency as an attribute described as adequacy or capability to manage a real-life task or situation. As Alspach pointed out, most traditional educational programs were based on what recognized content experts considered the best practice for a given situation, rather than observations of actual clinical performance. This observation still holds true today. The application of Alspach's position toward competency development requires that arrhythmia competencies originate from the experiences, observations, and validation of actual bedside practitioners. Historically, arrhythmia knowledge has been measured by what the content experts considered the ideal or theoretical notion of arrhythmia knowledge. Often, these content experts have been practicing for long periods of time and find it difficult to recall what it was like in the early stages of electrocardiographic (ECG) knowledge acquisition. Benner's (1984) classic research on novice to expert substantiates that expert nurses develop intuition based on repetitive experiences with similar patient situations and are no longer reliant on rule recognition for clinical judgment. Additionally, she pointed out that the expert nurse is not the best suited for breaking down information for a beginner. Hence, nursing professional development practitioners may have difficulty identifying with the needs of the novice or advanced beginner who is attempting to learn rhythm interpretation.
Existing literature on ECG lead placement and arrhythmia knowledge indicates that practice is substandard and competency must be elevated (DiLibero, DeSanto-Madyea, & O'Dongohue, 2016; Funk et al., 2017; Goodridge, Furst, Herrick, Song, & Tipton, 2013; Keller & Raines, 2005). Additionally, in the American Heart Association Scientific Statement on Practice Standards for Electrocardiographic Monitoring in Hospital Settings, the experts propose that hospital clinical leadership should determine what staff proficiencies are required in cardiac monitoring in each specific unit setting (Drew et al., 2004). In a recent update to these standards, the American Heart Association noted that staff educational competencies and standards continue to be inadequate (Sandau et al., 2017). This, in turn, raises the question of how competency standards should be formulated and how compliance can be determined. Given that the Joint Commission and other regulatory agencies require documentation of competencies at all levels of nursing care, the development of delineated categories of arrhythmia competency for acute care nurses would provide a useful starting point for shaping best practices in the care of ECG-monitored patients.
Currently, three nationally recognized methods exist for assessing acute care knowledge that include an arrhythmia component: the Basic Knowledge Assessment Tool (BKAT) for Critical Care Nursing, Advanced Cardiac Life Support provider testing, and the American Association of Critical Care Nurses' Critical Care Registered Nurse Certification (CCRN). Whereas these examinations screen for a basic knowledge level, they do not constitute an in-depth assessment of arrhythmia competency. Additionally, there are many institution-specific examinations administered at the completion of arrhythmia courses that assess knowledge acquisition; however, these are not routinely used for determining competency levels. The AACN Essentials of Critical Care Orientation has a component of basic ECG interpretation, which states it is used to build competency, yet it does not clearly differentiate between levels of competency. Without a uniform definition of what constitutes arrhythmia competency, existing institutional-specific assessment tools cannot effectively assess this dimension. Currently, there is not a nationally recognized, evidence-based mechanism for defining levels of arrhythmia competency.
This research sought to build on previous work that investigated levels of arrhythmia recognition of nurses working in critical care settings using the Keller Arrhythmia Rating Tool (KART) (Keller, 1997; Keller & Raines, 2005). One aim was to refine the instrument to quantitatively categorize which types of rhythm responses comprise basic, intermediate, and advanced levels of arrhythmia interpretation. The second aim was to link the ability to interpret ECG rhythms to competency. For the purposes of this study basic, intermediate, and advanced levels of competency are defined as the nurse's ability to integrate the arrhythmia knowledge needed to interpret a range of cardiac ECG rhythm responses that are encountered in clinical practice. This new version of the tool was renamed the Cardiac Arrhythmia Recognition Tool (CART). The sample was expanded to include other acute care areas where nurses work with monitored patients. Nurses were also asked to rate the difficulty level required to interpret each strip on a scale of 1 (easy) to 5 (difficult). If a nurse rated a strip easy but incorrectly identified the rhythm, that indicated a gap in knowledge. The CART could then be used to assist nursing professional development practitioners in creating a curriculum that addressed the learners' needs and in subsequently developing a plan for competency advancement.
In the previous study (Keller & Raines, 2005), the original version of the KART subscales of basic, intermediate, and advanced knowledge were extrapolated from focus group interviews of critical care nurses. The items were ordered from basic to advanced knowledge based on the participants' opinions. Furthermore, the focus group sessions assisted in the identification of three subscales. The strips and items were placed in order of difficulty, from basic to advanced, based on the combined ratings of focus groups. The first 12 items were universally rated as basic knowledge by focus group participants. The last 20 items were rated more than basic and became categorized as either intermediate or advanced based on analysis of focus group data.
The initial tool (prior to modification) was a 32-item instrument where the items were ordered by level of difficulty in alignment with the findings from the focus group. Seventy-three critical care nurses volunteered in this initial phase (Keller, 1997). On that instrument, the participant's responses were quantitatively analyzed using SPSS®, and each item was placed in a category (beginner, intermediate, or advanced) based on percentage of correct and incorrect responses, which did not always align with the focus group findings (Keller & Raines, 2005). This first set of reliability statistics for the subscales revealed low internal consistency, with a Cronbach's alpha of .45 for the basic scale, .64 for the intermediate subscale, and .80 for the advanced subscale. Reliability of the total scale was .82. The alphas for the advanced subscale and the overall instrument indicated good internal consistency reliability. However, the alphas for the basic and intermediate sub-scales were below acceptable range, and further study was needed to refine the basic and intermediate scales.
After analyzing the initial rhythm strips, it was determined that the quality of some of the tracings was problematic. For example, one of the initial strips was on the border between normal sinus rhythm and sinus tachycardia depending on which method was used to determine rate, and in some strips, the p-wave was not clearly recognizable. These strips were replaced with more clearly defined representations of the arrhythmias. In the initial tool, a strip denoted sinus rhythm with a left bundle branch block in V1. However, there were no strips depicting a sinus rhythm with a right bundle branch block, so it was decided to add a sinus rhythm with a right bundle branch block in V1 to the tool.
Subsequently, after replacing the nondiscriminating ECG rhythm strips, the new 33-item evaluation tool was again administered to acute care nurses (N = 85). Institutional review board approval was obtained, and the researchers were given permission to recruit participants at a regional nursing conference and obtained 33 completed tools. Additionally, permission was obtained to complete the sample from three hospitals in the southeastern United States. A cover letter with an informed consent statement was attached to the CART and placed in a self-addressed envelope. Consent was implied by completing the CART and returning the sealed envelope. No identifying information was collected except type of unit worked, years of nursing and ECG monitoring experience, and whether the respondent was an advanced cardiac life support provider, a CCRN, or a certified emergency nurse board certified. These nurses represented a range of acute care backgrounds. Work settings included general intensive care units (n = 30), cardiovascular intensive care (n = 8), coronary care (n = 8), emergency department (n = 9) trauma (n = 7), surgical intensive care (n = 6), postanesthesia care (n = 4), telemetry (n = 3), step-down unit (n = 2), and catheterization laboratory (n = 1). Seven participants did not provide this information. The majority of the nurses (85%) had completed advanced cardiac life support training. Thirty-seven nurses were critical care board certified CCRNs, and four emergency department nurses were credentialed as certified emergency nurses.
Nurses were asked to write their strip interpretation on a line below the strip. All strips were copies from actual cardiac tracings and 6 seconds in length. Additionally, nurses were asked to rate the level of difficulty that was required to interpret each strip on a scale of 1 to 5. The description of the continuum was that a 1 indicated an easy or basic level of competency was required to interpret the strip, 2 indicated somewhat easy/basic, 3 indicated intermediate, 4 indicated more than intermediate but not difficult or advanced, and 5 indicated a difficult or advanced level of competency. On the final two items, nurses were asked to draw the correct lead placement on a torso for a lead V1 and lead II. The torso depicted clavicles and ribs to use as landmarks. The five electrode placements were to be indicated by drawing a circle and labeling the color of the wire attached to the site where the nurse would place the electrode on a person. They were also asked to indicate where the positive electrode was located by drawing in a plus sign in V1 and lead II.
The first step in the analysis involved ranking the items according to the number of correct and incorrect responses. A numerical value of zero was assigned to each incorrect response and a numerical value of one was assigned to each correct response so that summary statistics could be calculated. This ordering enabled each CART item to be placed into one of three groups based on the percentage of correct and incorrect responses. The 12 CART items with the highest percentage of correct responses were designated as basic knowledge. The intermediate group fell into the middle percentiles and consisted of nine CART items. The remaining 12 CART items that were most often answered incorrectly became the advanced group (Table 1). The alignment between the items and the level (basic, intermediate, or advanced) for the previous KART and the current CART was 91%, with differences only in correctly interpreting atrial fibrillation, premature atrial contraction, and ventricular tachycardia. In the current version, 96% of respondents correctly identified atrial fibrillation, which moved the item from intermediate up to the basic category. Premature atrial contraction was correctly identified 63.5% of the time, which moved the item down to the intermediate category. Ventricular tachycardia was identified correctly 95% of the time, which changed it from intermediate to basic. All other items on the two versions remained in the same category. The reliability as measured through internal consistency for the individual skill levels improved from the previous version, with beginner and intermediate arrhythmia recognition improving to .72 and .71, respectively, and the advanced component was .73. The finalized CART consisted of 33 items, with an overall Cronbach's alpha of .84. Both versions demonstrated a positive correlation between years of practice with monitored patients and higher scores. The logical conclusion is that experienced nurses possess a higher level of knowledge when compared overall to other acute care nurses, which adds to the discriminate validity of the CART.
Cart Items by Percent Correct, Competency Category, and Perceived Level of Difficulty for Incorrect Items
The CART data provided some insightful results. Table 1 lists the ECG rhythm strips on the CART, the items competency category (Basic, Intermediate, and Advanced), and the respondent's perceived level of difficulty, which reports only on the items incorrectly identified. For example, torsade de pointe was correctly identified by 67% of the respondents, which placed it in the intermediate category. Of interest is that 63% of the nurses who answered this item incorrectly had rated the item as having an easy level of difficulty. The nurses thought the rhythm was an easy one to recognize, but they were unable to correctly identify the item. Responses such as this indicate large knowledge gaps that should drive educational interventions.
The items that were most often correctly identified and categorized as basic were normal sinus rhythm, sinus bradycardia, sinus tachycardia, atrial fibrillation, 4:1 atrial flutter, junctional rhythm, unifocal premature ventricular contractions, multifocal premature ventricular contractions, ventricular tachycardia, ventricular fibrillation, asystole, and an atrial-ventricular paced rhythm. The intermediate category consisted of all levels of heart block, torsades de pointes, idioventricular rhythm, ventricular bigeminy, atrial tachycardia, and premature atrial contractions. The items that were most often answered incorrectly were the bundle branch blocks, several supraventricular tachycardias, premature junctional contraction, lead placement, atrial fibrillation with aberrancy, and Wolff-Parkinson-White in atrial fibrillation (WPW A-Fib). Participants thought that several of the advanced rhythms (that they incorrectly identified) should be categorized as basic to somewhat basic (Table 1). Atrial fibrillation with aberrant conduction was correctly identified by only 9.4% of the nurses; the most common written in response was atrial fibrillation with a premature ventricular contraction. This would indicate that although the strip was marked as a V1 lead, the nurses were not familiar with the rSR (right bundle branch block) configuration of an aberrant beat. The majority of the respondents named the wide beat as ventricular. This disparity in knowledge extended to sinus rhythm with a right bundle branch block in a V1 lead. This rhythm was incorrectly identified by 44.7% of the nurses and placed in the advanced level; however, 43% of the nurses who got it wrong rated the item as basic to somewhat basic. Another area that stood out was the inability of the participants to identify a premature junctional contraction. Only 13% correctly identified the rhythm; however, 77% of the nurses identified this rhythm as a basic to somewhat basic competency level. The item that was consistently missed was WPW in A-Fib, and 68% of the nurses who got it wrong thought the rhythm was easy to interpret. This item was most often identified as ventricular tachycardia even though the rhythm was clearly irregular.
This research resulted in the refinement of the CART, a tool that demonstrates good reliability and internal consistency between basic, intermediate, and advanced arrhythmia recognition levels. These various levels of interpretation ability offer a starting point in distinguishing competency levels. Upon further refinement, the CART could also be used by nursing professional development practitioners to target when additional education is required. The need for educational endeavors to close existing gaps between assessment and practice is evident. For example, areas identified by the CART that need further scrutiny were the failure of less experienced nurses to easily recognize and differentiate premature atrial contractions, ventricular couplets, and heart blocks, as well as proper electrode placement for lead V1. Additionally, knowledge of bundle branch blocks was weak for approximately half of the nurses, which has implications for lead placement knowledge pertaining to aberrancy versus ectopy in wide QRS tachycardia. Coronary care nurses' first documented aberrant conduction in lead V1 was in 1974 (Gozensky & Thorne, 1974). Forty-five years later, this remains an educational challenge in practice. These areas of weakness affect educational interventions and how we define best practice standards for arrhythmia interpretation. To improve this deficit of knowledge in the clinical setting, nursing leadership needs to recognize the value of increasing practice knowledge and holding individuals to an established standard of competency.
Of interest is how the CART quantitative findings support earlier qualitative findings (Keller & Raines, 2005). The advanced scale remains the same, with two exceptions and one addition. Premature atrial contractions (PACs) and ventricular couplets were qualitatively categorized as basic. However, using the CART, only 63.5% of the nurses correctly identified PACs, ranking this rhythm as intermediate. This was not surprising to the educators conducting this research given that their experiences in teaching PACs to novices has consistently indicated that nurses new to ECG interpretation have difficulty identifying this rhythm, particularly when the early p-wave is not clearly seen. Only 52.9% of the nurses correctly identified ventricular couplets, placing this arrhythmia at the advanced level. One unexpected finding was that couplets were identified as advanced on both versions of the instrument. A premature junctional contraction was qualitatively placed as intermediate but quantitatively remained an advanced item, with only 15% of nurses correctly identifying this cardiac rhythm. Another critical finding was the lack of recognition for WPW in A-fib. Although this rhythm is not commonly encountered in practice, it is imperative that it is recognized. The description coined by Mary Conover (2002) of FBI (fast, broad, irregular) is an easy way to describe and remember this lethal rhythm. There is mention of this rhythm in the Guideline for the Management of Adult Patients With Supraventricular Tachycardia (Page et al., 2015) algorithm in the American Heart Association's Advanced Cardiac Life Support curriculum. We recommend that more information about this rhythm be presented to providers.
The purpose of this study was to refine the CART and to investigate arrhythmia recognition competency of nurses who care for ECG-monitored patients. The empirical findings may not be generalizable outside this setting. The small sample was a convenience sample, which could bias the initial competency levels of the respondents on the higher end. Nurses with a higher level of knowledge might be more inclined to complete the CART as a convenience sample than nurses with less ability; thus, general competencies might be lower than those reported in this article. All the respondents came from hospitals within a contained geographical area and may not reflect those in other regions. There were few participants from step-down and cardiac catheterization laboratory units. The majority of the responders were intensive care unit nurses. As this instrument is modified to a computer-based format, further testing will be needed with a more diverse sample.
The CART's overall ability to screen for advanced competency would be useful in identifying and validating unit experts. This expert group may not be the best for breaking down steps for rhythm interpretation for novices; however, they are important resources for confirming interpretations and interventions. If clear competency levels are defined, practice expectations and clinical conversations may be facilitated. These informal unit-based experts could then assume a more formalized role to ensure a safer level of practice within units.
Nurses at the front line are caring for more complex patients in greater numbers with increasing responsibilities that can hinder time and resources to support knowledge development. Thus, this hectic climate in the clinical care setting is a potential roadblock to advancing arrhythmia knowledge. Nursing professional development practitioners need to partner with their colleagues at the bedside in order to fine tune and develop best practices that target varying competency levels. Rather than being satisfied with minimal competency in cardiac rhythm responses, nurse educators are challenged to establish differing levels of accountability. Starting at the undergraduate level, academic nurse educators' expectations should be to teach the basics and prepare nurses for the realities of the practice arena (McIntosh, Duske, Anderson, & Hill, 2008). The intermediate and advanced levels of knowledge could then be taught in the clinical practice setting. The development and refinement of the CART and the identification of competency levels are important steps toward supporting arrhythmia knowledge as an established substantive structure within nursing.
Introduction to foundational knowledge for arrhythmia practices needs to begin while in the academic setting and continue into the service setting. The process of learning about cardiac rhythm responses and developing competency standards needs to be defined and evaluated by nursing education and administration, based on the expectations and realities of clinical practice and further research. This stance would further define parameters for best practice nursing care in the setting of ECG-monitored patients. Beginning the conversation among nursing professional development practitioners as to what constitutes arrhythmia competency is a pivotal step in that direction.
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Cart Items by Percent Correct, Competency Category, and Perceived Level of Difficulty for Incorrect Items
|Arrhythmia||% Correct||Category||% Perceived Level of Difficulty (LOD) When Incorrecta|
|Normal sinus rhythm||97.6||Basic||0||0||0||-||100|
|Atrial-ventricular paced rhythm 100% capture||96.5||Basic||100||0||0||0||-|
|Unifocal premature ventricular contractions||96.5||Basic||50||50||0||-||-|
|Multifocal premature ventricular contractions||90.6||Basic||72||0||0||14||14|
|4:1 atrial flutter||89.4||Basic||38||38||13||-||13|
|Third degree complete heart block at the ventricular level||84.7||Intermediate||25||8||8||42||17|
|First degree atrial-ventricular block||80||Intermediate||39||31||8||23||-|
|Third degree complete heart block at the junctional level||74.1||Intermediate||22||17||33||22||6|
|Torsades de pointes||67.1||Intermediate||63||13||17||8||0|
|Premature atrial contractions||63.5||Intermediate||21||21||31||10||17|
|Sinus with right bundle branch block (V1 lead)||44.7||Advanced||23||23||21||21||13|
|Sinus rhythm with left bundle branch block||40||Advanced||18||33||13||22||13|
|Supraventricular tachycardia with right bundle branch block (V1 lead)||37.6||Advanced||13||28||23||21||15|
|2:1 atrial flutter||37.6||Advanced||31||33||22||7||7|
|Second degree atrial-ventricular block Mobitz II||34.1||Advanced||20||22||20||18||20|
|Electrode placement for lead II monitoring||28.2||Advanced||33||4||17||10||35|
|Electrode placement for lead MCL1 or V1 monitoring||20||Advanced||16||11||11||20||42|
|Premature junctional contractions||15.3||Advanced||48||30||12||7||5|
|Atrial tachycardia with block||14.1||Advanced||25||30||20||10||15|
|Atrial fibrillation with aberrant conduction||9.4||Advanced||40||23||17||9||11|
|Wolff-Parkinson-White in atrial fibrillation||0||Advanced||68||13||9||4||5|