Clinical Project: ECG Interpretation for Improved Patient Outcomes

This clinical project investigates the significance of ECG interpretation in the emergency department, particularly for managing arrhythmia patients. The project identifies challenges in ECG interpretation among nurses, such as inadequate training and limited practical application of theoretical knowledge. It highlights the importance of accurate ECG interpretation for timely management of life-threatening arrhythmias and improved patient outcomes. The literature review explores strategies to enhance ECG interpretation skills, including innovative teaching methods like flipped classrooms and the potential use of 3D apps. The project emphasizes the need for continuous professional development and the implementation of standardized practices to improve nurses' competence in ECG monitoring, ultimately leading to better patient care and reduced mortality rates. Desklib provides access to similar solved assignments and study resources for students.

Running head: CLINICAL PROJECT IN NURSING
Clinical project in nursing
Name of the student:
Name of the University:
Author’s note

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Introduction:
Electrocardiogram (ECG) monitoring is a common investigative procedure implemented
in the emergency department (ED) to aid diagnosis and prognosis of patient. It is an important
diagnostic procedure to facilitate promotes diagnosis and management of patient with acute
myocardial infarction and arrhythmia. ECG interpretation is dependent on knowledge and skills
relevant to the procedure and this knowledge helps in providing safe and quality care to patient
(Morris & Body, 2017). Werner, Kander and Axelsson (2016) supports that a medical team with
good ECG interpretation skills can reduce risk for patient and this would reduce the time taken to
achieve coronary perfusion and save resources. Hence, how well emergency staffs can interpret
ECG determines the quality of care and recovery for patient. The main purpose of this clinical
project is to conduct a literature review on the importance of ECG interpretation in ED and
evaluate the importance of ECG interpretation for patient outcomes. This topic has been chosen
because I aim to become a competent emergency nurse and learning skills related to ECG
interpretation will help me to fulfil my career development goals. As I am to be a competent
nurse delivering holistic care, this clinical project will develop my knowledge about ECG
interpretation particularly in arrhythmia patient, so that I can provide high quality and holistic
patient care. Interpretation of ECG finding can help in maintaining continuity of care too.
The main objectives of this clinical project are as follows:
 To evaluate the importance of ECG reading in emergency department
 To learn about the interpretation of ECG finding arrhythmia patient
 To understand the patter of changes in ECG reading

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 To develop skills related to documentation of assessment finding and evaluate current
skills in documentation process
Description of the issue:
During my clinical practice experience, I experienced challenges in interpreting ECG
readings and this affected my ability to manage deteriorating health condition of patient. I
realized that I do not have competence to understand and interpret ECG reading use this to plan
patient care. This is a common issue not only for me, but also for other ambulatory nurse. A
study investigating about ECG interpretation skills in ambulatory nurse revealed that knowledge
related to ECG interpretation is low among nurses and there were at least 14% of the nurse who
even failed to recognize a ventricular fibrillation. Hence, inability to recognize arrhythmia can
have significant impact on patient outcome. The study findings revealed that only 46% of the
samples were able to recognize ECG indicating myocardial infarction thus significantly
influencing patient survival rate (Werner, Kander & Axelsson, 2016). Nickasch et al. (2016)
argues that misinterpretation of ECG reading can lead to mistaken diagnosis, cardiac
arrhythmias, mismanagement of patients and unnecessary laboratory test. Hence, as poor
interpretation of ECG reading can lead to burden of care, poor patient outcomes and unnecessary
challenges in care, developing knowledge related to ECG interpretation is vital.
Feelings:
Based on my past exposure to the emergency department, inability to recognize
arrhythmia in patient was very demotivating experience for me. Though I wanted to provide
holistic care to patient, however inability to identify the pattern of waves and diagnose problem
for patients delayed care process and I was dependent on my seniors and physicians to take the

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right course of action. However, as I aim to become a competent nurse, I want to enhance my
knowledge related to ECG interpretation process. Hence, using the principles of evidence based
practice, my goal is to develop knowledge regarding ECG interpretation by conducting review of
literature and finding out the factors that influence ECG interpretation and evaluating the
benefits of ECG interpretation skills in management of patient with arrhythmia.
Literature review (Analysis of the issue):
The literature review on the clinical project topi would help to understand the reason
behind poor ECG interpretation and understand the impact of increasing knowledge related to
ECG interpretation process. The review of different research papers gave knowledge regarding
the following aspects of the clinical project topic:
Challenges associated with ECG interpretation:
To identify the strategies needed to improve ECG interpretation skills in emergency
department, identifying the challenges experiences by nurse in ECG interpretation is important.
This will help to identify areas in which nurses need more practice exposure for their skill and
professional development. The review of the study by McGrath and Sampson (2018) revealed
that very few emergency nurses are able to review, interpret and act on ECG findings because
they lack knowledge and confidence about interpreting results due to poor training. Another
study by supports Celikkan et al. (2013) that nursing students are often uncomfortable in
applying theoretical knowledge from classroom during clinical practice because they get limited
opportunities for practice ECG interpretation. These findings gives the implication that one of
the major reason for poor confidence and knowledge regarding ECG interpretation is that
nursing students do not get the chance to practically apply the knowledge about ECG and they

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lack practical exposure in confidently interpreting ECG reports of patient. This findings suggest
that there are limitations in current methods following in nursing education program related to
teaching ECG interpretation and there is a need to adapt innovative teaching methods so that
learning and acquisition of knowledge related to ECG interpretation becomes easier for
emergency nurses.
Importance of ECG interpretation for the management of arrhythmias:
The study by Ruhwanya, Tarimo and Ndile (2018) indicates that knowledge and skills
related to ECG interpretation is vital for management of life threatening arrhythmias. Arrhythmia
is a medical condition associated with abnormal heart rhythms because of poor heart conduction
and reduction in cardiac output thus having an impact on the tissue perfusion process (Acharya et
al., 2017). Initial screening of arrhythmias is mainly done by ECG and the information obtained
from the ECG provide nurse with idea regarding electro cardiac record of patient. Through
knowledge and understanding regarding different aspects of ECG such as heart rate, interval
measurement and regularity of rhythm support nurses in identify and managing arrhythmia.
Ruhwanya, Tarimo and Ndile (2018) gave the evidence that nurses have the responsibility to
gather ECG data of patient and notify the physician for taking treatment decisions. However, the
evidence indicates that nurse have low level of knowledge and skills related to ECG
interpretation and arrhythmia. This finding gives the implication to increase participation of
nurse in clinical practice development programme so that they can master the skills to manage
life threatening arrhythmias. Another significant finding of this research is that it demonstrated
that nurse have good theoretical knowledge regarding ECG, however they lack the skills to apply
the knowledge appropriately in clinical setting. It gives the implication to increase nursing
education in the area of ECG interpretation.

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The research literature by Begg et al. (2016) revealed the importance of ECG
interpretation skills for management of arrhythmia by showing that link between ECG related
knowledge and arrhythmia management. ECG is the first line of investigation for patient with
arrhythmia and accurate interpretation of ECG report facilitates subsequent management of
patient. The study revealed great variation in interpretation of ECG findings based on experience
of staffs. This evidence suggests the need to take training in ECG interpretation to prevent the
rate of mortality associated with cardiovascular disease.
Strategies taken by nurse to develop ECG interpretation skills:
The main contribution of the research by McGrath and Sampson (2018)
Electrocardiograms is that it gave a five-step approach to interpret ECG findings. The five steps
focussed on monitoring heart rate, heart rhythm, QRS duration, presence and absence of P-wave
and PR interval on ECG graph. To follow the five steps, firstly, the nurse should be aware about
the ECG graphs. The first step is to calculate the heart rate by reading from left to right of the
rhythm strop and then followed by analysis of QRS complex, PR interval and P-waves. The
significance of this research paper is that it effectively describes different areas of the ECG graph
and the method to calculate heart rhythm and other parameters. The five step approach also
defines areas where taking normal reading would be difficult. Hence, this article can be utilized
in education and training program for nurse so that they can easily understand the practice steps
needed to interpret ECG. The five step approach can be incorporated in training and education
programmes for nurse so that emergency nurse can systematically assess cardiac rhythms and
detect abnormalities in rhythm in a timely manner. This would help in providing timely
treatment too and ensure that emergency nurses are well-equipped to provide the best care to
patient.

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In-hospital cardiac arrest is a major reason for mortality rate in patient and nurse’s ability
and competence in identifying arrhythmia is important to reduce the mortality rate associated
with cardiac arrest in hospitals. Hernández-Padilla et al. (2016) gave evidence regarding the
effectiveness of two teaching methods in improving student’s competence in ECG interpretation.
The study used randomized controlled method to randomly allocate nursing students to
traditional instructor led classroom and a flipped classroom group. The flipper classroom group
received training regarding ECG interpretation by delivering instruction online with the use of
visual aid and the traditional classroom group received teaching using traditional teaching
approach. The statistical analysis of outcomes related to knowledge, skills and efficacy in ECG
interpretation revealed that flipped classroom method is more effective than traditional teaching
methods. Ruhwanya, Tarimo and Ndile (2018) have indicated that nurses have good theoretical
knowledge about ECG, however they fail to apply theory in practice. Hence, the findings
presented by Hernández-Padilla et al. (2016) can be used to increase practical application of
ECG knowledge in clinical setting. Flipped classroom teaching can expose nurse to real
scenarios or videos where ECG interpretation is utilized for management of arrhythmia. This
teaching method can facilitate acquisition of information and knowledge related to ECG reading
for nurses.
Although diagnostic test like ECG and other vital test are part of nursing curricula,
however still emergency nurse lack competence in ECG interpretation. There are certain areas
where they find themselves stuck. The search for literature on ways to increase knowledge
regarding ECG interpretation for nurse revealed that the contribution of new technology in
increasing nurse’s confidence in competently identify ECG rhythms and any abnormal rhythms
to effectively manage arrhythmia. Holthaus and Wright (2017) gave insight into the significant

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of 3D app in teaching nursing students about ECG rhythm interpretation. The main rationale for
including 3D app in teaching process was that it facilitates active learning in students by
providing richer experience to students by the use of 3D graphics and high-definition audio and
video. It also increases the scope of providing students with plentiful practice opportunities
(Nielsen, Brandt & Swensen, 2016). The 3D app was explored to teach ECG rhythm
interpretation to nursing students. Undergraduate nursing students were provided 3D app
learning session by providing iPads with 3D apps. The students were given orientation regarding
the ways to use the app and they had to complete a posttest after the learning session intervention
(Holthaus and Wright 2017). However, the technology cannot be applied currently because the
research demonstrated both positive and negative outcomes for nurses thus suggesting the need
to conduct future research to consider the use of this technology. Validating the 3D technology
for evidence based teaching is necessary to ensure that nurse can extract benefit from such
technology.
The study by Funk et al. (2017) focuses on implementation of appropriate practice
standards to improve ECG monitoring. The study evaluated the impact of implementation of
American Heart Association (AHA) practice standards for ECG monitoring nurse knowledge,
quality of care and patient outcomes. The intervention consisted of a two-step process involving
online ECG monitoring program and the second step involved teaching strategies to sustain
change in practice. Nurse’s knowledge was tested by the use of 20-item online questions on ECG
monitoring and arrhythmia. The quality of care was assessed by accuracy of electrode placement,
rhythm interpretation, and identification of cardiac events and monitoring use of ST-segment.
Furthermore, patient outcomes were examined by measure mortality rate and in-hospital
myocardial infarction event in hospital. The overall analysis of outcomes obtained post the

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intervention revealed that nurse’s knowledge related to ECG monitoring significantly improved
after the intervention. However, one weakness was that the findings were not obtained for a long
term period. The quality of care also improved and in case of patient outcome, only rate of in-
hospital myocardial infarction rate decline significantly. This study gives insight regarding the
potential of online ECG education and strategies to sustain changes as a strategy to increase
competence in ECG interpretation. Hence, presence of appropriate standards for ECG
monitoring can further enhance the ECG monitoring process in hospitals. Support of health
administrators can help to take adequate training and increase skills related to ECG
interpretation.
Apart from online teaching method, review of research studies also suggest the role of
cardiac arrhythmia simulation on increasing nursing student’s knowledge acquisition related to
ECG interpretation for management of arrhythmias. Tubaishat and Tawalbeh (2015) evaluated
the effect of simulation based teaching on acquisition of ECG interpretation by the use of
randomized controlled study design. Nursing students in the study were randomly allocated to
experimental group attending simulation scenarios and control group receiving traditional lecture
on the process. The utility of the simulation based training was understood from the fact that
simulation significantly increases knowledge of cardiac arrhythmia and skills needed to effective
manage patient. Hence, simulation can be used as a strategy to enhance knowledge related to
ECH interpretation and effective management of patients with arrhythmia.
Evaluation and action plan:
On reflecting on the evidence obtained for cause of poor ECG interpretation among nurse
and strategies to improve knowledge regarding ECG interpretation, it can be said that lack of

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exposure to practice and poor attention to application of theory into practice is the reason for
nurse’s inability to correctly interpret ECG reading and identify arrhythmia in patient. The utility
of this clinical project is that it has enhanced my knowledge regarding the strategies that I can
adapt to improve competence in relation to ECG interpretation.
The activities done in the clinical project introduced me to new teaching techniques in
which I can participate to develop skills related to ECG and arrhythmia management. These
include online education, flipped classroom teaching, 3D app application and simulation. I think
online education and flipped classroom teaching are relevant to my practice issue because I do
have theoretical knowledge, but I fail to interpret the waves. Hence, online teaching tools can
enrich my learning experience and develop my interest in ECG analysis. However, I thing I will
face challenges in using 3D app because the quality of learning will depend on the content of
app. Unless the 3D app is validated for use in my practice, I cannot use it. Furthermore, it cannot
address the challenges that are encountered due to changes in different setting. I think online
sources and simulation is the best method for me to enhance my learning and professional
development. However, one challenge in this area is that how to come out if I am stuck at certain
point. Hence, my plan for the future is to contact a mentor who has many years of experience in
ECG interpretation. His knowledge and expertise can help me to overcome all barriers
encountered while taking training on ECG interpretation.
Conclusion:
The clinical project focused on understanding the importance of ECG interpretation skills
for nurse and finding the best steps needed to increase learning and knowledge acquisition in
relation to ECG interpretation. As poor exposure to practice is a reason for poor confidence of

10CLINICAL PROJECT IN NURSING
nurse in analysing ECG report, the literature review revealed the importance of new teaching
modalities such as online mode, flipped classroom and simulation to enhance learning
experience. It is recommended that nursing students be supported to increase their skills in ECG
interpretation and arrhythmia management by providing online education as well as simulation
experience with the support of a mentor.

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References:
Acharya, U. R., Fujita, H., Lih, O. S., Hagiwara, Y., Tan, J. H., & Adam, M. (2017). Automated
detection of arrhythmias using different intervals of tachycardia ECG segments with
convolutional neural network. Information sciences, 405, 81-90.
Begg, G., Willan, K., Tyndall, K., Pepper, C., & Tayebjee, M. (2016). Electrocardiogram
interpretation and arrhythmia management: a primary and secondary care survey. Br J
Gen Pract, 66(646), e291-e296.
Celikkan, U., Senuzun, F., Sari, D., & Sahin, Y. G. (2013). Interactive videoconference
supported teaching in undergraduate nursing: A case study for ECG. Journal of
Educational Technology & Society, 16(1), 286-294.
Funk, M., Fennie, K. P., Stephens, K. E., May, J. L., Winkler, C. G., Drew, B. J., ... & Currie, L.
(2017). Association of implementation of practice standards for electrocardiographic
monitoring with nurses’ knowledge, quality of care, and patient outcomes: findings from
the Practical Use of the Latest Standards of Electrocardiography (PULSE)
Trial. Circulation: Cardiovascular Quality and Outcomes, 10(2), e003132.
Hernández-Padilla, J. M., Granero-Molina, J., Rosales, R., Sao-Romao-Preto, L., Füge, K., &
Fernández-Sola, C. (2016). Effects of two teaching interventions on nursing students’
acquisition of competence in ECG interpretation. Resuscitation, 106, e52.
Holthaus, A., & Wright, V. H. (2017). A 3D App for Teaching Nursing Students ECG Rhythm
Interpretation. Nursing Education Perspectives, 38(3), 152-153.

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McGrath, A., & Sampson, M. (2018). Electrocardiograms: a guide to rhythm recognition for
emergency nurses. Emergency Nurse, 26(1).
Morris, N., & Body, R. (2017). 5 A study analysing the diagnostic performance of ECG
interpretation for 30-day major cardiac events in the emergency department. Emerg Med
J, 34(12), A864-A864.
Nickasch, B., Marnocha, S., Grebe, L., Scheelk, H., & Kuehl, C. (2016). 'What do I do
next?'Nurses' confusion and uncertainty with ECG monitoring. Medsurg Nursing, 25(6),
418.
Nielsen, B. L., Brandt, H., & Swensen, H. (2016). Augmented Reality in science education–
affordances for student learning. Retrieved from: https://oda-
hioa.archive.knowledgearc.net/bitstream/handle/10642/4939/2399-11653-1-PB.pdf?
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Ruhwanya, D. I., Tarimo, E. A., & Ndile, M. (2018). Life threatening arrhythmias: Knowledge
and skills among nurses working in critical care settings at Muhimbili National Hospital,
Dar es Salaam, Tanzania. Tanzania Journal of Health Research, 20(2).
Tubaishat, A., & Tawalbeh, L. I. (2015). Effect of cardiac arrhythmia simulation on nursing
students’ knowledge acquisition and retention. Western journal of nursing
research, 37(9), 1160-1174.
Werner, K., Kander, K., & Axelsson, C. (2016). Electrocardiogram interpretation skills among
ambulance nurses. European Journal of Cardiovascular Nursing, 15(4), 262-268.