|Year : 2020 | Volume
| Issue : 2 | Page : 185-192
To assess the effectiveness of simulation teaching of defibrillation on the knowledge and skill of nurses working in the critical care unit of a Tertiary Care Teaching Institute: Prospective, randomised study
Devanshi Chowdhary1, L Gopichandran2, Rakesh Garg3, Dalim Kumar Baidya3
1 Registered Nurse, Department of Anesthesiology, AIIMS, New Delhi, India
2 Associate Professor, College of Nursing, Department of Anesthesiology, AIIMS, New Delhi, India
3 Professor, Department of Anesthesiology, AIIMS, New Delhi, India
|Date of Submission||09-Apr-2020|
|Date of Decision||02-Sep-2020|
|Date of Acceptance||12-Oct-2020|
|Date of Web Publication||19-Feb-2021|
Ms. Devanshi Chowdhary
M.Sc Nursing Student, College of Nursing, AIIMS
Source of Support: None, Conflict of Interest: None
Rapid defibrillation is a life-saving treatment for pulseless ventricular tachycardia and ventricular fibrillation which are the most common cardiac cause of sudden death. Simulation teaching has been shown as an effective teaching method for nurses. The present study was conducted to assess the effectiveness of planned simulation teaching regarding defibrillation on the knowledge and skill of nurses working in the critical care unit and emergency department of a tertiary care hospital. A randomised control design was used in which 100 nurses from the emergency department and critical care unit were randomly assigned to the experimental and control group. Baseline knowledge and skill were assessed using an investigator developed defibrillation knowledge assessment questionnaire and defibrillation skill assessment checklist, respectively. Simulation teaching was given in the experimental group. The simulation teaching was provided in the clinical area in a group of 3–4 nurses. Post-test 1 was taken immediately after the simulation teaching in the experimental group. Post-test 2 was taken after 1 month of enrolment in the study in both the groups with the same tool. A significant improvement in knowledge and skill was observed in the experimental group. A significant association of pre-test knowledge with gender, age, educational qualification, education program attended, experience with defibrillation and of the post-test knowledge with gender, nature of work, experience with defibrillation, educational qualification and age were found. A significant association of pre-test skill with nature of work and post-test skill with gender and nature of work was also found. A significant moderate positive correlation (r = 0.42) was found between the knowledge and skill on nurses. Simulation teaching is an effective method for increasing knowledge and skill among nurses. The present study has further opened up new avenues into nurse-led defibrillation initiatives in India.
Keywords: Defibrillation, effectiveness, knowledge, nurses, simulation teaching, skill
|How to cite this article:|
Chowdhary D, Gopichandran L, Garg R, Baidya DK. To assess the effectiveness of simulation teaching of defibrillation on the knowledge and skill of nurses working in the critical care unit of a Tertiary Care Teaching Institute: Prospective, randomised study. Indian J Cont Nsg Edn 2020;21:185-92
|How to cite this URL:|
Chowdhary D, Gopichandran L, Garg R, Baidya DK. To assess the effectiveness of simulation teaching of defibrillation on the knowledge and skill of nurses working in the critical care unit of a Tertiary Care Teaching Institute: Prospective, randomised study. Indian J Cont Nsg Edn [serial online] 2020 [cited 2021 Feb 28];21:185-92. Available from: https://www.ijcne.org/text.asp?2020/21/2/185/309858
| Introduction|| |
The sudden cardiac death can be described as a death occurring within a short interval of time generally less than an hour, from the time of onset of symptoms, in a person with known or unknown cardiac disease. Death due to sudden cardiac arrest is most commonly caused by VT degenerating to VF. Early delivery of shock with a defibrillator – cardiopulmonary resuscitation (CPR) and defibrillation within 3–5 min of collapse produce the rates of survival as high as 49%–75%. According to the Advanced Cardiac Life Support (ACLS) VF/pulseless VT algorithm outlined by the American Heart Association, defibrillation is one of the primary intervention for pulseless VT and VF. It has been reported that with every minute of delay of defibrillation from a witnessed cardiac arrest, there is a drop in the survival rate to about 7%–10%. It is known that the time taken for defibrillating a patient in cardiac arrest is directly related to the survival, presence of neurological deficits and the quality of life after the cardiac arrest.,
Various studies have found that simulation teaching is effective in various domains such as knowledge, critical thinking ability, learner satisfaction and confidence. Simulation teaching has also been used in teaching CPR and has been found superior to the traditional teaching using a PowerPoint presentation and demonstration on a static mannequin. A cross-sectional study (Kerala, India) to evaluate the current practices and knowledge on Basic Life Support and ACLS principles among health-care professionals revealed there were major lacunae in the knowledge of the health-care professionals for which urgent attention was needed. The present study found that very few respondents could identify rhythms such as VF VT and only about one-third could respond to pulseless electrical activity. Another study (India, Nasik) on 80 nurses working in critical care intensive care units (ICU's) that assessed the knowledge of ICU nurses regarding the use of defibrillator found that only 24% had good knowledge, 54% had average knowledge while 23% had poor knowledge. Demonstration programs on automated external defibrillator and manual defibrillator among nursing students have showed decreased time required to defibrillate and increase confidence among nursing students when practiced on the mannequin and have also yielded positive results in performing CPR immediately. A randomised control trial on the effectiveness of simulation among nurses to improve retention of resuscitation priorities in-hospital cardiac arrest showed a statistically significant (P = 0.001) decrease in the median time interval to start chest compressions (P = 0.001) and time taken for defibrillation with the increase in the frequency of the in situ program. A study to see the effectiveness of simulated demonstration on the knowledge and practice regarding defibrillation technique in Mumbai, India, found that there was a significant increase in knowledge and practice scores of the nurses regarding defibrillation after simulation teaching. In another prospective cohort study (Hong Kong, China) on the ability of nurses to identify ventricular fibrillation (VF) and ventricular tachycardia (VT) rhythms on an electrocardiogram (ECG) and thereby do subsequent defibrillation on their own, it was found that there was a significant improvement (P = 0.014) in taking decision of defibrillation. The intervention also increased the confidence of 67% of the nurses in handling patients with VF or VT.
Most often, nurses are the first respondents to any physiological changes in the vital parameters of the patient in the hospital. Hence, knowledge and skill among nursing professionals would aid in early defibrillation for cardiac arrest victims for optimal survival. However, the nurses are trained in diverse ways for such an essential life-saving procedure. Hence, appropriate knowledge and training of CPR including early defibrillation remain as the most important for nursing personnel.
The primary objective of the study was to assess the effect of simulation teaching on the skill and the knowledge of nurses, whereas the secondary objectives of the study were to find out the correlation of knowledge and skill and the association of knowledge and skill with the demographic variables of nurses.
| Methods|| |
This study was done among nursing professionals working in the critical care unit of a tertiary care teaching institute. The present study was approved by the Institutional Ethics Committee (Ethics reference no: IECPG-106/22.03.2017), and informed consent was obtained before enrolment, and confidentiality of the participants were maintained. Staff nurses designated as nursing officers or senior nursing officers present during the time of data collection, working in the emergency department and critical care units, and having at least 2 years of clinical experience in the clinical area were enrolled in the study. Nurses who had attended a course on CPR and/or defibrillation in any structured training programme within the previous 6 months and nurses working in paediatric and neonatal critical care units were excluded from the study.
Based on a similar study, the sample size was calculated using the G*Power version 220.127.116.11, applying a two-tailed test with 5% margin of error, 95% confidence level, an effect size was calculated as 0.475 which provides a sample size of 60. After considering a 20% non-response rate, a total sample size of 72 participants was estimated. To keep the sample size in round off figure and considering the rule of thumb, 50 participants in each experimental and control group were taken.
The nurses who met the inclusion criteria were recruited in the study and randomly assigned to either the experimental or control group through a computer-generated list of random numbers and allocation concealment using sequentially numbered opaque sealed, envelope technique. The baseline knowledge and skill of the nurses in both the experimental and control group were assessed. The nurses were assessed on their knowledge to identify rhythms, knowledge regarding defibrillator and defibrillation with a defibrillation knowledge assessment questionnaire. The skill of defibrillation was assessed with a checklist formed as per the guidelines of the Indian Resuscitation Council, with the help of a mannequin (having software of rhythm and option of defibrillation) and the defibrillator (whichever was present in the respective clinical areas). The nurses were asked to demonstrate the procedure of defibrillation based on a given scenario on the screen.
- Control group: The nurses in the control group received no intervention. A baseline assessment was taken by pre-test in the control group on the same day of enrolment in the study, post-test was done at 1 month. After the post-test, at 1 month, the control group was provided with a copy of the study material with a simulated demonstration on the process of defibrillation in view of ethical concerns and to reduce contamination during the study period
- Experimental group: A baseline assessment was done in the experimental group by a pre-test, after which they received a simulation teaching with the help of a PowerPoint presentation and a medium-fidelity simulated demonstration in a group of 3–4 nurses in their respective clinical area. The mannequin was equipped with rhythm software which enabled the monitor with the mannequin to show rhythms (pre-decided by the researcher), and for subsequent defibrillation on the mannequin. The nurses were evaluated according to the defibrillation skill assessment checklist. The simulation teaching was given on the same day of enrolment in the study. The experimental group was assessed for knowledge and skill immediately after the simulation teaching in post-test-1 and at 1 month in post-test-2.
The tools used for data collection were as follows: Demographic datasheet, defibrillation knowledge assessment questionnaire and defibrillation skill assessment tool. The tools were developed after extensive literature review. The content validity of the tools (defibrillation knowledge assessment questionnaire and defibrillation skill assessment checklist) was established based on the evaluations from five medical experts and five nursing experts. The content validity index for the defibrillation knowledge assessment questionnaire and defibrillation skill assessment checklist was 0.81 and 0.79, respectively. Suggested changes, including any ambiguity in language, were incorporated. Changes were made based on the comments received. The reliability of the defibrillation knowledge assessment questionnaire (Cronbach's alpha - 0.80) was done by the test-retest reliability and the reliability of the defibrillation skill assessment tool (Cronbach's alpha – 0.76) was done by inter-rater reliability. After the content validity and reliability, the tools were piloted on five nurses and found feasible.
Validity of the educational intervention
The lecture material was validated by experts, and validity was established. The intervention was tried out on five nurses working in High Dependency Unit (HDU). It took approximately 15 min to administer the intervention. A defibrillation knowledge assessment questionnaire was used to assess the knowledge of study participants in assessing shockable rhythm and on defibrillation. It consisted of two parts, the first part consisted of 10 ECG rhythms with a given scenario (related to cardiac arrest scenarios formed by the team of five experts and tested on five participants to reach the final set of assessment tool) to assess whether the given rhythm was shockable. The second part consisted of 15 multiple choice questions (prepared by five subject experts and revised as per comment for any ambiguity) on defibrillation. A defibrillation skill assessment checklist consisting of 16 steps was used to assess the pre- and post-skill scores of nurses in the defibrillation technique.
The pre-test and the post-test assessment was done in the clinical area. The data were collected during the duty hours of the nurses (preferably the evening hours, due to the lighter workload during the evening shift) the researcher carried the mannequin to the respective clinical area, all the nurses willing to participate and within the inclusion criteria were taken and were randomly assigned into experimental and control group, a baseline assessment was done in both the groups after which a simulated demonstration of about 15 min was done in the experimental group. Bias and contamination were avoided as the experimental group was given intervention in a closed room inside the clinical area, and the control group was reassured on a simulated demonstration and a copy of the study material after 1 month. The pre-test and the post-test skill assessment and knowledge assessment were done by the researcher. To increase the reliability of the assessment done by the researcher, the researcher also underwent ACLS training before the start of the data collection.
The analysis was performed using StataCorp. 2015. Stata Statistical Software: Release 14. College Station, TX: StataCorp LP. Descriptive statistics (mean, standard deviation, percentage and frequency) were used to describe the demographic characteristics of nurses, Fishers exact and Chi-square, the test was used to compare the demographic variables of the experimental and control group. An independent t-test was used for intergroup comparisons, while the paired t-test was used for intragroup comparisons. The independent t-test was used to find the association between the knowledge and practice scores of staff nurses with the selected demographic variables. ANOVA followed by Bonferroni test was used to find out the association between demographic variables having more than three categories and knowledge and practice scores of staff nurses. Pearson's correlation co-efficient was used to find the correlation between knowledge and skill score of nurses. The level of significance was taken as 0.05.
| Results|| |
The schematic presentation of the study design is developed in the CONSORT diagram [Figure 1]. A total of 100 nurses working in the critical care unit or emergency department were found to be eligible to participate in the study. The demographic characteristics of the study participants are depicted in [Table 1]. Both the groups were found to be comparable (by Fisher's exact test and Chi-square test) in all the demographic domains [Table 1].
|Table 1: Comparison of demographic characteristics of nurses between control group and experimental group|
Click here to view
Effectiveness on knowledge and skill
At the pre-test, both the groups were comparable in relation to knowledge and skill. However, there was a significant increase (P = 0.0001) in the knowledge on shockable rhythm and knowledge on defibrillation in the experimental group [Table 2] and [Table 3] A statistically significant increase (P = 0.0001) was noted in the skill score of nurses in the experimental group while no improvement was found in the control group [Table 4] and [Table 5].
|Table 2: Comparison of knowledge of nurses regarding defibrillation between the control group and experimental group|
Click here to view
|Table 3: Comparison of knowledge of nurses regarding defibrillation within the control group and experimental group|
Click here to view
|Table 4: Comparison of skill in defibrillation of nurses between the control group and experimental group (n=100)|
Click here to view
|Table 5: Comparison of skill in defibrillation of nurses within the control group and experimental group (n=100)|
Click here to view
Association of knowledge and skill with demographic variables
A significant association of pre-test knowledge score with gender (P = 0.007), age (P = 0.037), educational qualification (P = 0.009), education program attended (P = 0.042) and experience of providing defibrillation (P = 0.008) was found among nurses (n = 100). A significant association of post-test 2 knowledge was found with gender (P = 0.008), nature of work (P = 0.011), experience of providing defibrillation (P = 0.047), educational qualification (P = 0.022) and age (P = 0.031) [Table 6].
|Table 6: Association between knowledge of nurses regarding defibrillation with selected demographic variable|
Click here to view
There was a statistically significant association of pre-test skill scores with the nature of work (P = 0.040). A significant association of post-test 2 skill was found with gender (P = 0.009) and the nature of work (P = 0.011) [Table 7]. There is a significant (P = 0.038) weak negative correlation (r = -0.212) of pre-test knowledge of the nurses with their years of experience. A significant (P = 0.008) weak negative correlation (r = -0.264) was also found between post-test 2 (1 month) knowledge score and experience [Table 8].
|Table 7: Association between skill of nurses in defibrillation with selected demographic variable|
Click here to view
|Table 8: Correlation of experience with knowledge and skill of nurses (n=100)|
Click here to view
Correlation of knowledge with skill
There was a highly significant moderate positive correlation (r = 0.42; P = 0.0001) between knowledge and skill scores of nurses [Table 9].
| Discussion|| |
The simulation teaching was effective in increasing the knowledge and skill of the nurses in defibrillation. In the present study, there was a significant improvement (P = 0.0001) in the mean knowledge and skill of the staff nurses immediately after the simulation teaching on defibrillation.
The study findings are in line with a previously published study involving nurse-led defibrillation., In the present study, 79% of the nurses (n = 100) knew that VF and pulseless VT were shockable rhythms. This could be because of the fact that the setting where the study was conducted was critical care areas, and such rhythms were commonly encountered. These findings are in contrast to a previous study done among health-care professionals (57.7% nurses) which reported 33.6% of the participants responded only to VF as a shockable rhythm while 28.9% responded only to pulseless VTs as a shockable rhythm. This contrast can be attributed to the heterogeneous sample used in the cited study. In the present study, simulation teaching was found to be effective in increasing the skill of nurses in defibrillation. A similar finding was reported in a study done among nursing students, where after demonstration, most of the student nurses were able to place paddles correctly and also initiate CPR immediately after defibrillation. Simulation teaching has also been shown to have particularly large effects in the psychomotor domain,, improving learners' competence and confidence and can herby increase patient safety and reduce health care costs in the long run. Systematic reviews have also shown that the use of simulation in education significantly improves knowledge, skills and self-confidence which is in line with the present study.
In the present study (pre-test), there is a significant association of knowledge of nurses with gender and educational qualification. Another study also reported a significant association of knowledge with gender (P < 0.05) and professional education (P < 0.05). The present study showed a significant association between educational programs attended and the knowledge of nurses regarding defibrillation. It is reported that the nurses who underwent previous training had significantly (P = 0.001) higher mean scores than untrained nurses and a significant association of knowledge with age (P = 0.03) and male gender (P = 0.007), was also found, which is similar to the present study. However, these study findings are contradictory to a study done by Lima et al. which found no association between demographic variables and knowledge of CPR in health-care professionals. The sample of the study comprised physicians, medical and nursing students which could be the reason for contradictory findings. Other authors also found no significant association of knowledge of the nurses regarding defibrillation with the demographic variables. This contradictory finding could be attributed to small sample size (n = 50) of the cited study.
In the present study, a highly significant (P = 0.0001) moderate positive correlation was found between pre-test knowledge and skill score of nurses. This is supported by a reported study on the effect of teaching program on knowledge and skills regarding automatic external defibrillation among nurses working in the emergency unit which found a significant (P < 0.05) positive correlation between the total score of nurses' knowledge related to skills of (CPR) Cardio Pulmonary Resuscitation and total skills after teaching program (r = 0.183 and 0.783), respectively. The study findings are also supported by another study among nurses working in the emergency department in secondary and tertiary public hospitals where a moderate (P = 0.01) positive correlation (r = 0.38) was found between triage knowledge and triage skill. Another study also reported a significant (P = 0.012) positive correlation (r = 0.432) between the knowledge and skill of the nurses in cardiopulmonary resuscitation. Teaching defibrillation with simulation teaching was thus found to increase knowledge and the ability to handle defibrillation.
| Conclusion|| |
Simulation teaching is an effective method for increasing knowledge and skill among nurses. The present study supports that nurses can efficiently be taught the procedure of defibrillation which will help them to increase their confidence and take prompt decisions in case of any emergency when encountered with a patient with VF or pulseless VT. This skill is of utmost importance for the nurses as it proves to be a life-saving skill in the hands of nurses.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Koplan BA, Stevenson WG. Ventricular tachycardia and sudden cardiac death. Mayo Clin Proc 2009;84:289-97.
Ibrahim WH. Recent advances and controversies in adult cardiopulmonary resuscitation. Postgrad Med J 2007;83:649-54.
Hansen CM, Kragholm K, Granger CB, Pearson DA, Tyson C, Monk L, et al
. The role of bystanders, first responders, and emergency medical service providers in timely defibrillation and related outcomes after out-of-hospital cardiac arrest: Results from a statewide registry. Resuscitation 2015;96:303-9.
Valenzuela TD, Roe DJ, Nichol G, Clark LL, Spaite DW, Hardman RG. Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. N Engl J Med 2000;343:1206-9.
Cant RP, Cooper SJ. Simulation-based learning in nurse education: Systematic review. J Adv Nurs 2010;66:3-15.
Tawalbeh LI, Tubaishat A. Effect of simulation on knowledge of advanced cardiac life support, knowledge retention, and confidence of nursing students in Jordan. J Nurs Educ 2014;53:38-44.
Nambiar M, Nedungalaparambil NM, Aslesh OP. Is current training in basic and advanced cardiac life support (BLS & ACLS) effective? A study of BLS & ACLS knowledge amongst healthcare professionals of North-Kerala. World J Emerg Med 2016;7:263-9.
Laxman MG. Study of knowledge of staff nurses regarding use of defibrillators in intensive care units. Ind J Basic Appl Res;2014;4(1): 298-306.
Liu JJ, Gui L, Chen ZM, Xu KY, Li Y, Zhang J, et al. Effectiveness of combining manual external defibrillator and automated external defibrillator training for third-year nurse students. Int J Nurs Sci. 2015 Mar 1;2(1):105-9.
Sullivan NJ, Duval-Arnould J, Twilley M, Smith SP, Aksamit D, Boone-Guercio P, et al
. Simulation exercise to improve retention of cardiopulmonary resuscitation priorities for in-hospital cardiac arrests: A randomized controlled trial. Resuscitation 2015;86:6-13.
Gupta V, Dias R. Effectiveness of simulated demonstration regarding defibrillation technique on knowledge and practices among nurses. Int J Sci. 2014;3(6):720-7.
Tai CK, Cattermole GN, Mak PS, Graham CA, Rainer TH. Nurse-initiated defibrillation: Are nurses confident enough? Emerg Med J 2012;29:24-7.
Garg R, Ahmed SM, Kapoor MC, Rao SC, Mishra BB, Kalandoor MV, et al
. Comprehensive cardiopulmonary life support (CCLS) for cardiopulmonary resuscitation by trained paramedics and medics inside the hospital. Indian J Anaesth 2017;61:883-94.
] [Full text]
Kim J, Park JH, Shin S. Effectiveness of simulation-based nursing education depending on fidelity: A meta-analysis. BMC Med Educ 2016;16:152.
Al-Elq AH. Simulation-based medical teaching and learning. J Fam Community Med 2010;17:35-40.
] [Full text]
Alanazi AA, Nicholson N, Thomas S. The use of simulation training to improve knowledge, skills, and confidence among healthcare students: a systematic review. Internet J Allied Health Sci Pract. 2017;15(3):2.
Lima SG, Macedo LA, Vidal Mde L, Sá MP. Permanent Education in BLS and ACLS: Impact on the knowledge of nursing professionals. Arq Bras Cardiol 2009;93:582-8, 630-6.
Safaa A, Zienab M, Hosam A, Mona M, Mogeda M. Effect of an educational program on nurses' knowledge and practice regarding defibrillation and cardioversion. Assiut Sci Nurs J 2019;7:24-31.
Hend A, Amany A, Omibrahem E. Effect of cardiopulmonary resuscitation training program on nurses knowledge and practice. Life Sci J 2012;9:3494-503.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]