ORIGINAL RESEARCH

Heart rhythms at the bedside: cardiology unit nursing team's knowledge

Michael Jonathan Rodrigues Machado^I; Marcio Roberto Paes ^II; Anna Carolina Gaspar Ribeiro^III ; Maria Luiza Hexsel Segui^IV ; Tatiana Brusamarello^V

^I Nurse. Nursing Intern at the Clinical Hospital of the Federal University of Paraná. Curitiba, Paraná, Brazil. E-mail: michaeljrmachado@hotmail.com
^II Nurse. PhD in Nursing. Professor, Department of Nursing, Federal University of Paraná. Curitiba, Paraná, Brazil. E-mail: marropa@ufpr.br
^III Nurse. Master in Nursing. Professor of the Multidisciplinary Internship Program of the Clinical Hospital. Curitiba, Paraná, Brazil. E-mail: carol_03gsp@hotmail.com
^IV Nurse. Master in Nursing. Coordinator of Multidisciplinary Internship Program of the Clinical Hospital. Curitiba, Paraná, Brazil. E-mail: gugasegui@hotmail.com
^V Nurse. PhD student in Nursing by the Graduate Program in Nursing, Federal University of Paraná. Curitiba, Paraná, Brazil. E-mail: brusamarello.tatiana@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2017.16137

ABSTRACT

Objective: to examine the cardiology unit nursing team's knowledge of cardiac rhythm disorders. Methods: in this qualitative, descriptive study of 17 nurses of a cardiology unit of a university hospital in Curitiba, Paraná, Brazil, data were collected from July to December 2014, by semi-structured interviews, and analyzed by content analysis. The project was approved by the Research Ethics Committee (protocol No. 34720014.1.0000.0096). Results: nursing technicians' recognition of cardiac rhythms displayed on the cardiograph monitor was deficient; the participants cited actions in response to electrocardiographic alterations and the importance of knowledge on the subject; and they reported deficient professional training. Conclusion: nursing technicians' knowledge about changes in cardiac rhythm in the care context was found to be insufficient as a result of deficient professional training.

Keywords: Nursing; cardiovascular nursing; nursing care; cardiology

In the context of hospital admissions, cardiovascular care must count on medium and high complexity services, state-of-the-art technology and highly qualified health professionals to care for patients with acute or chronic cardiovascular morbidities^1-3.

Thus, the nursing team in environments with such specificities, maintaining its assistance characteristics to promote patient care, aiming at the maintenance and recovering of human health, must be qualified to recognize signs and symptoms, as well as for the handling and accurate reading of healthcare equipment and technologies in health services^4,5.

The improvement of technological equipment is continuous and dynamic and also requires that the qualification of professionals evolves in the same intensity and scope. However, professional training in the area of cardiology nursing has been deficient, mainly for professionals at the secondary level (auxiliary and nursing technicians). This situation is also aggravated by the lack of continuing education programs offered by health institutions, which becomes an implicit barrier in this context and that may interfere in the quality of care developed by the nursing team ^5,6.

Considering the epidemiological impact of cardiovascular diseases in Brazil and in the world, and the responsibility of the nursing team of cardiology services for the continuous observation, perception and communication of changes in heart rhythm in the monitor, the question that guided this work arises: what is the knowledge of nursing professionals working in a cardiac unit on heart rhythm of patients at the bedside?

Therefore, the purpose of this study was to analyze the knowledge of the nursing team of a cardiac unit on changes in heart rhythm.

LITETRATURE REVIEW

Cardiovascular diseases account for almost 30% of deaths in Brazil, being considered the main cause of death in this population. Cardiovascular diseases were ranked in 2007 as the third cause of hospital admissions by the Unified Health System (SUS), mainly in large urban centers ^1,2.

The main cardiovascular diseases that lead people to be hospitalized in hospital cardiac units are: coronary diseases (acute myocardial infarction, angina pectoris), cardiac conduction disorders and heart failure ¹.

Thus, public policies have been instituted with a view to improving cardiovascular care and based on the epidemiological profile of the population with higher risk of suffering cardiac diseases. These policies aim to reduce mortality and provide survival conditions for patients with quality and safety for their recovery. These improvements are due to technological advances in health, in scientific knowledge and also due to the investment in training of health professionals in the medium and high complexity cardiovascular care offered to the population³.

Some studies on the knowledge of the nursing team regarding the monitoring of patients in cardiology services have concluded that there is still a lack of scientific rationale for nurses and greater qualification of the nursing team in their work^5,7.

METHODOLOGY

This is a descriptive study of a qualitative approach, carried out from July to December 2014, in a cardiac unit of a teaching hospital in Curitiba, Paraná.

Participants were nursing professionals, who work in the cardiology intensive care unit and coronary unit (nurses, nursing assistants and technicians). Inclusion criteria were: performing nursing care for severe cardiac patients and having been working in the cardiology unit for at least one year. Exclusion criteria was being on vacation or leave at the time of data collection.

From a total of 23 nursing professionals working in the cardiac unit, 18 met the inclusion criteria and 17 accepted to participate in the study, being: three nurses, three nursing technicians and 11 nursing assistants. The time of performance in the cardiac unit of these workers ranged from 1 to 13 years.

During the recruitment, all the professionals received information about the research, the objectives and the method to be used. The data collection was done through a semi-structured interview, recorded in audio and occurred in a private and confidential place. As a guide for data collection, the following question was used: what is your knowledge about the heart rhythms visualized on the bedside cardiograph monitor?

After each professional accepted to participate in the research, they signed the Free and Informed Consent Term (TCLE). All ethical precepts were fulfilled according to Resolution 466/2012 of the National Health Council (CNS). The research was approved by the Research Ethics Committee of the Clinical Hospital of the Federal University of Paraná (UFPR), under the protocol number 34720014.1.0000.0096.

The data were treated according to content analysis, of thematic-categorial type⁸, through the phases of pre-analysis, exploration of the material, treatment of results obtained and interpretation. The pre-analysis consists of familiarizing with the material by listening and transcribing recorded interviews and floating readings. In the exploration of the material, the raw data are stoned by the cuts of the topics of interest and relevance to the study. At the stage of treatment of the obtained results and interpretation, the most relevant data were articulated with theory, in which the researcher proposes inferences for the final interpretation and construction of the categories.

Participants were nominated according to the initial letter of their professional category: (A) nursing assistant, (T) nursing technician and (N) nurse, followed by an Arabic number regardless of interview order.

RESULTS AND DISCUSSION

From the analysis of the data, four categories emerged, namely: Recognition of cardiac rhythms in the cardiograph monitor; Conducts in face of electrocardiographic alterations; Importance of knowledge about heart rhythms and Deficits in professional training.

Recognition of cardiac rhythms in the cardiograph monitor

Participants' speeches demonstrate the existence of disparities in the recognition of heart rhythms of patients by visualizing the cardiograph monitor. Some nurses reported easily recognizing some changes in heart rhythm tracings on the monitor and identifying what type of change they are. However, most mid-level professionals reported difficulties and lack of knowledge to recognize electrocardiographic changes in the patients monitored.

Yes, I can identify it. I have no difficulties with either the trace or numerical values. I have some difficulties in some specific situations such as a ventricular tachycardia [...] or supraventricular tachycardia, some rhythms such as atrial fibrillation. Flutter, branch block, bradyarrhythmias, extrasystole, bigeminism, we are already familiar with . (N2)

Some things I can see [...] the most common, infarction with supra, patient with a pacemaker, extrasystoles , changes in potassium, we can see it in the patient's path. And patients with complete atrioventricular block. Printed electrocardiogram [...] there are things I am not able to see. (N3)

I cannot see the tracings, but the numbers I can evaluate and see when it's right or not. I know when it is changed through the numbers: heart rate, blood pressure, oxygenation. I do not know anything, I cannot even notice changes, I'm trying to find it out because I'm taking an electrocardiogram course now. I can see when there is something very unusual, but when it is more subtle, I cannot; it is very difficult. (A1)

The numbers yes, but the curves still find it difficult. I can see if there is something different from the curve, I cannot see what it is, I can see and call the doctor. I cannot identify anything by the curve. (A8)

Well, since I do not have much experience in a cardiac intensive care unit, I rely on the numbers. I cannot see changes in the curve, only in the numbers themselves; in the tracings, I cannot. (T3)

High-complex specialist care units, such as cardiology units, must have state-of-the-art equipment for the care of patients with severe cardiopathy. However, it is essential for these services to develop research and interest groups in the area of critical care knowledge, which seeks to improve the technical-scientific aspect of professional expertise, promoting continuous improvement, reflected in the execution of care ⁹. This evidences the importance of the health service to have qualified and skilled personnel for a quality and safe care to the cardiac patient.

With reference to the statements and regarding the low difficulty of the nurses in recognizing electrocardiographic alterations of the patients, it is known that higher education in nursing provides technical-scientific knowledge necessary for the management and performance of nursing care with greater complexity by the nurse. In this way, this professional, because of his/her profile as an educator, is responsible for the continuing education of the other nursing categories, and should be a reference both in formal and in-service education¹⁰.

Thus, nursing professionals must have knowledge and competence to observe, recognize and describe signs and symptoms. However, the speeches of the middle-level participants (nursing assistants and technicians) suggest difficulties in recognizing the signs shown on the monitors. These data become worrisome because the lack of knowledge on the part of the nursing team can interfere in the care provided, thus leading to decreased quality of care and increased risks for the patient^9,10.

The First Guideline of the Brazilian Society of Cardiology on processes and competencies for training in cardiology in Brazil corroborates previous findings by describing that professionals who work directly with cardiac patients should have knowledge about sinus heart rhythm. It complements saying that this professional does not need to identify the specificities of each alteration, since the final diagnosis of the pathology leading to the electrocardiographic change is a function of the cardiologist physician, but the nursing professional must be able to identify changes that may aggravate the patient's health status¹¹.

Conducts in face of electrocardiographic changes

After realizing changes on the monitor, it is essential that the professional takes action correctly and consciously, which in most cases, should be immediate. Among the attitudes taken by the professionals regarding the changes in the electrocardiographic tracing, calling the assistance of other professionals was one of the attitudes mentioned by the participants. The speech of a nursing technician demonstrated that the nurse is considered one of the references in this unit. However, it was verified that there were professionals who reported calling the physician directly.

I often call the nurse when I'm not sure, and then the physician. (T2)

When I see some change [...] I usually tell the nurse. If I realize it's something more serious, I speak directly to the physician. (A3)

I'll let the doctor know. (A8)

Among the skills required for the nurse who works in critical units, leadership is essential in the organization and structuring of the nursing service that seeks to achieve excellence, quality and safe care ^10,12.

Thus, the nurse in cardiology services has in their environment a scenario that requires them to have competence combined with knowledge, skills and positive attitudes to create a bond of trust between the team, the medical group and the patients, who conceive such professional as reference in the service. This was evidenced in a study in which, in health services, nurses demonstrate greater leadership and bonding, there is lower turnover of professionals, fewer conflicts, greater involvement of people in the work process and better use of resources¹².

It should be emphasized that mid-level nursing professionals working in cardiology units should be the focus of nursing managers' attention, since having a qualified team is a vital condition for their performance to be assertive, quality and safe^9,12.

Some participants reported that before communicating a possible change in heart rhythm to nurses or physicians, they check for any interference that may be influencing the reading of the monitor, such as disconnected cables, loose electrodes, and then they check again the monitor reading, to then communicate nurses and physicians:

Well, from my experience I try to see if it is not something related to our nursing area, if there is anything disconnected or some loose electrode [...]. (A4)

First I arrange the electrodes, as sometimes it can be some interference. If I see that it's not something with the monitor or the electrode, then I'll call the physician and the nurse. (T2)

In cardiology services, it is common for the electrodes that are fixed to the patient's chest to take off or even that some of the monitor cables have interference by default or disconnection. This is because patients, due to their clinical condition, can usually present sweating, agitation and because they have conditions of active mobilization in the bed. A study that verified the performance of the team of a coronary unit in relation to equipment alarms found that electrode adjustment was the second most frequent attitude taken by professionals⁵.

Knowledge that the change seen on the monitor may be due to a failure in the system itself is important and should be taken into account. The quality nursing care desired in the cardiac units is also related to the availability of material resources appropriate to the care practice, either they are consumable or permanent. Thus, nurses need to participate in the choice of materials used in care, seeking the primacy of quality with a technical view, which must be a managerial focus for the construction of assertive care strategy⁹.

Another attitude described by the participants was to try to calm the patient and to understand the feelings, fears and anxieties of the patients:

I also talk to the patient to see if he/she is feeling something and to make him/her more relaxed . (A9)

The attitude of the nursing assistant expressed in the last testimony denotes the concern in developing nursing care with effectiveness and objectivity. In this way, the ways of taking care must go beyond technicality, even in a highly technological environment, and return to the smallest meaning of care, which is expressed in thinking, judging, taking care of and translating into caring, affection, diligence and performance. In order to care for people, therefore, attention and interest must be given to their needs, to reflect on all the elements related to the care environment and then to act in favor of the individual¹³.

Nursing care should encompass the needs of the patient as a whole, including their psychological issues. Anxiety can be reduced by proper communication with the patient about their problem. In addition, it is also the responsibility of the nursing staff to be with the patient so that they feel safer, and calm them down so that they feel they are being cared for ^4,13.

Importance of knowledge about heart rhythms

Health professionals working in hospitals assisting critical patients should be alert to signs and symptoms that lead them to anticipate functional changes that patients may present. In this way, the importance of the professional in recognizing electrocardiographic changes in the monitor is highlighted. This is verified in the speech of the participants who expressed that it is essential for the nursing professional to know changes in heart rhythm shown on the monitor at the bedside to provide care with greater efficiency and in a shorter time.

Time is important in some situations. [...] If I see that it is wrong, I need to do something, because often loss of time is harmful for the patient and this time makes the difference . (A4)

It is extremely important. Because it can advance the evolution of the patient's picture because the nursing stays 24 hours at the bedside, so the professional must see the first signs and symptoms . (A5)

The nursing team is present 24 hours a day at the bedside, as mentioned by the last testimony of the nursing assistant, and in many institutions, this team is responsible for comprehensive care to the patient. Therefore, it is imperative that it can properly recognize signals to intervene correctly. Based on this, this professional should recognize anomalous rhythms in the monitor for rapid intervention as an improvement in the quality of intensive care and patient safety^14,15.

In this way, the use of protocols is fundamental for the optimization of care. The creation and implementation of protocols, check-lists or guidelines for the establishment of standards and norms in order to reduce variations and uncertainty in care practice is of the utmost importance. This is because these instruments systematize nursing care, promote greater safety, quality of care provided and have been adopted in health institutions as a strategy to facilitate and control activities developed by professionals¹⁶.

Protocols must be built with the participation of all those involved in the work process, because there is a negative tendency, in the implementation of routines, of assuming a prescriptive and generic character and of being interpreted by the professionals as another bureaucratic activity ¹⁶.

Deficit in professional training

All mid-level participants reported that the training course in nursing superficially approached the cardiology theme, and that knowledge on the theme came from the experience in the care practice:

It was addressed, but I think it needs to be deeper approached, especially us who are in an intensive care unit, because here we see everything and in the course, we learn it, but it is very fast because there is no way, there are so many other things. It is very superficial. (A2)

No. I think because the time is short, they teach only the basic things; there is not a specific subject. I remember that I studied what a heart attack is, what a stroke is, but nothing specific. (T2)

No, neither the assistant nor the technician. I guess they assume it's not important for us to know, I think so. If it wasn't like this, we would have at least one class. I remember that in my course the cardiology subject was taught very superficially [...]. (A10)

Due to the lack of theoretical-practical content of cardiology in the training of nursing assistants/technicians, professionals become familiar with this specialty in day-to-day practice:

I learned right here, with observation day by day and also with colleagues . (A9)

Curricular guidelines for the training of health professionals, including those in nursing, demonstrate that lifelong education is paramount for an excellent professional practice, and it must be committed to the real health needs of the general population^17-19.

Thus, the training of mid-level professionals should prepare them to meet the health needs of the population. Considering the high prevalence of cardiovascular diseases, this theme should be addressed in the training, in order for the future professional to acquire knowledge about electrocardiographic waves of sinus rhythm and interventions in situations of cardiovascular emergency. In addition to day-to-day empirical knowledge, the scientific basis of practice is essential in order to seek continuous updating^18,19.

The world of work is changing, constantly innovating, requiring professionals to pay more attention to such changes. Thus, permanent education programs in the health area have emerged as an effective strategy for the qualification of professionals, especially those in the nursing area. Their importance is unquestionable since they enable professionals to transform care practice^17,19.

Permanent health education policies have promoted changes in the conception and training practices. They have incorporated learning to the habitual life of the institutions, encouraged innovations in educative strategies and extended educational spaces, establishing practice as a source of knowledge in which the professional participates actively in the educational process^17,19.

CONCLUSION

Mid-level participants, most of whom are nursing assistants, have shown insufficient knowledge in the recognition of changes in heart rhythm at the bedside in their daily practice. However, they emphasize the importance of this knowledge for their professional performance.

Results show that knowledge deficit stems from insufficient professional training in cardiology, and that skills have often been acquired in daily care and in the exchange of experiences among team members. In this sense, it is known that basic-level professional training courses address cardiology themes in a superficial manner due to the short duration thereof compared to the great density of subjects to be explained.

Thus, permanent education programs can contribute to the improvement of specificities of nursing care. It is recommended that the managers of the institution, field of study, should promote prior training regarding cardiology care for newly admitted professionals and constant studies on the recognition of signs and symptoms of worsening of the patient's condition and assertive behaviors to attend cardiac emergencies.

A limitation of this study was the method chosen, due to the time available for the development of this research, which restricted the sampling. For this reason, it was possible to portray only the local reality, not being able to involve a sample with greater representativeness and, thus, to make comparisons and generalizations. However, these results were essential for institutional intervention in order to improve nursing care in cardiology.

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