Assessment of Nurses Competency during emergency ...neelain.edu.sd/mmacpanel/includes/magazines/pdf/1_12_5.pdf · khidir Mustafa EL nimeiri and Prof. Ahmed Bolad AL Neelain University,

NMJ November 2013 الثاني عشر العدد –ة مجلة النيلين الطبي

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2013 Al Neelain Medical Journal vol.3 No. 12 ISSN 1858-627

Assessment of Nurses Competency during emergency Management of Patients with

Acute Myocardial Infarction

Hassanat Elbashir Mohamed Mustafa, Prof Sideeg Ebraheim khalil, Prof. Mustafa

khidir Mustafa EL nimeiri and Prof. Ahmed Bolad

AL Neelain University, Faculty of Medicine and Faculty of Nursing Sciences and Alshaab

Hospital

ABSTRACT

Background: Nursing care is of utmost importance in survival of a patient with

myocardial infarction. The competence of the nurse in charge is very crucial in such

patient care. This study aimed at assessment of nurses‘ competence in management

of patients presenting with myocardial infarction at five Hospitals in Khartoum

State. Materials and Methods: Relevant data were collected by standardized

structured questionnaire from 139 nurses (participants) caring from patients in the

cardiac care units (CCU) and emergency departments. Results: The study enrolled

139 nurses (females 84% and males 16%); with various qualification degrees master

10 %, Bachelor 67% and diploma 23% randomly selected from the already

mentioned departments. About 55% of the participants had level of knowledge in

management of acute myocardial infarction below average while 42% of the study

sample had attitude below average. Moreover, 58% of the participants had below

average skill. By testing the factors that affect the competence components it

appeared that training, management guidelines, qualification, experience in nursing

and number of years expended in CCU and emergency department had got

significant effect.Conclusion: It was concluded from this study that the level of the

nurse competence in the management of patients with acute myocardial infarction

depends on the advanced level of training and setting of clear guidelines for

management.

Keywords: Myocardial infarction, Nursing, CCU

INTRODUCTION


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Cardiovascular disease remains a major healthcare problem and one of the most consumers of

the public health resources. Ischaemic heart diseases (IHD) remain the commonest cause of

death all over the world. As in statistical reports of the World Health Organization (WHO);

2011, the rate of death per 100,000 due to coronary artery diseases in Yemen was 238.5,

Sudan; 212.0, Bangladesh; 203.7, Libya; 199.3 and Jordan; 162.5[1]

.While 114.000 people

in UK are admitted to hospital with acute coronary syndrome (ACS) annually [2

ACS is

composed of unstable angina (UA), non ST-segment elevation myocardial infarction

(NSTEMI) and ST- segment elevation myocardial infarction (STEMI) [3, 4, and 5]

. An acute

myocardial infarction (AMI) is an emergency situation requiring immediate diagnosis and

treatment; it is caused by complete blocked of the coronary artery due to a thrombus

attached to a ruptured plaque. In some instance acute myocardial infarction (AMI) occurs due

to physiologic stress [5,6,15].

Also there are a number of risk factors known to predispose to the

AMI . It is important that the patients presenting with acute myocardial infarction treated

promptly‘ [3, 7].

So initial therapy should focus on stabilizing the patient's condition, relieving

ischemic pain and providing antithrombotic; [8, 9, 10].

Some complications may occur immediately following the heart attack or may need a

time to develop [11].

The goals of care are to master any potential life-threatening

complications for instance ventricular fibrillation and to minimize the time to reperfusion. [12]

In the USA was reported that the incidence rates of STEMI decreased between 1997 and

2005 from 121 to 77; in some instances the management of acute myocardial infarction

continues to undergo major changes. Good practice should be based on sound evidence.

According to measurement criteria of American Association of Critical-Care Nurses

(AACN) acquires and maintains current knowledge and competency in the care of acutely

and critically ill patients. The nurse participates in ongoing learning activities to acquire and

refine the knowledge and skills needed to care and seeks learning opportunities that reflect

evidence-based practice in order to maintain clinical skills and competencies. So the nurse

engages in a self-assessment and formal performance appraisal on a regular basis own

nursing practice in relation to professional practice standards, institutional guidelines, rules,

and regulations to identifying areas of strength as well as areas where professional

development would be beneficial[13,14].

The word competency is wider meaning. ―According to Australian nursing and

midwifery Council (ANMC) ; national competency standers.‖ competence was described as

combination of skills, knowledge, attitudes, values and abilities that underpin effective

and/or superior performance in a profession/occupational area. Also it was being described

in the clinical practice as what an individual is able to do by ―Ottawa conference‗s

recommendations 2010‖ .Miller pyramid has been used over the last twenty years as a

framework to assessing clinical practice competence . This pyramid consists of these items

(knows, know how, show and does) .They use many tools for the competence assessment,

but Self-assessment has been reported as the most common form of competence

assessment. Evidence about the effectiveness of self-assessment in the assessment of

competence and cost-effectiveness .It assists nurses to maintain and improve their practice

by identifying strengths and an area that may need to be further developed and gives

individuals conscious control over practice accompanied by a decrease in quality of

care.(1,2)


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The overall aim of this study is to assess the knowledge attitude and skills of the

nurses who work at CCU and ER during emergency management for patients with acute

myocardial infarction . In order to identify the gaps regard nursing care and to search for

solutions with expertise and policy makers to construct plans and strategies to fill the gaps

and to fulfillment high quality nursing care.

Justification:

Critical illness requires life-saving intervention and application of high technology

medicine and intensive nursing within a specialist critical care unit. An acute

myocardial infarction (AMI) is an emergency situation requiring immediate diagnosis

and treatment

Nursing competence has become a controversial issue in healthcare settings around

the world, as it affects many aspects of the nursing profession, including education,

practice and management. These are five stages of competence which include,

novice, advanced beginner, competent, proficient and expert (3)

MATERIALS AND METHODS

Research Design: This study was a descriptive hospital based one.

Study setting: The study was conducted in five hospitals in Khartoum State (Khartoum,

Alshab, Khartoum North, Ahmed Gasium and Omdurman) in a period from 2012 to 2013 at

Cardiac Care Units and emergency departments.

Study population: Any nurse working in the CCU and emergency departments in these

hospitals had an equal chance to be enrolled in the study.

The study population includes only nursing staff who work at public teaching hospitals at

Khartoum state; it is covers 139 of nurses from both gender (females 84% and males 16%);

with various qualification degrees (master 10.%, Bachelor 67% and diploma 23%) included

the Nurses whose experience was more than three months and any nurses with experience

of less than that period.

The Study sample and sampling: The study enrolled 139 nurses from the study population

by random sampling. The study included only nurses whose experiences were more than

three months in these departments.

Data collection:

Data were collected by standardized structured questionnaire in direct interviewing of the

participants.

The study variables included qualification, nursing experience and period of work, training,

knowledge: about definition of acute coronary syndrome (ACS), components of ACS, initial

management of acute myocardial infarction, thrombolytic agents, and defibrillators. Skill

assessment included monitoring criteria, administration of thrombolytic agents, defibrillation


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and use of protocol and guidelines. The attitude included the nurse action when bleeding or

allergic reaction occurs.

The questionnaire consisted of 48 questions that covered the following domain;

demographic data, knowledge, attitude and how to practice. Most questions were multiple

choice, each question item scoring from very poor to very good modified based on multiple

Likert scale [17].

Pre- testing: The questionnaire was pre- tested twice before the conducting the survey and

all corrections and changes were done. The questionnaire also reviewed by expert for

information quality and legitimacy then necessary corrections were made. The internal

consistency of this questionnaire also was tested using Cronbach‘s alpha test which is the

most common test used to measure the internal consistency. This test follows certain steps

using SSPS software program. The volunteers who assisted in data collection were

adequately trained.

Data Analysis: The raw data were collected, cleaned and coded. SPSS version 19 statistical

computer software program was used for the data analysis; and excel microsoft program

used for graphs.[71]

The analysis reflects the competency among the study population. Firstly

assesses each variable of knowledge, attitude and skill individually, and then compute these

variables to give core level of these three items. Lastly we compare between them using

person chi-square test and spearman correlation, t-test and ANOVAs test. Data was

presented in figures which included level of knowledge, skill and attitude and tables

included cross tabulations and linear regression relationship.

Ethical considerations: Permission to carry out this study was granted by the Ethics and

Research Committee of the College of Medical and Health Sciences at AL Neelain

University. Also agreement was granted after written consents from authorities in the

ministry of health, hospitals, CCU and emergency departments All participants provided

verbal consent prior to beginning of the interview after thorough explanation of what the

study was all about by the interviewers and full information's of nurses' staff & their

agreement.

RESULTS

Competency of the nurses

Table (1) Level of the study sample competency regard emergency care of patient

with acute myocardial infarction (n=139)

s of competency Level below average Level at average and above Total

knowledge Account 77 62 139

% 55.4% 44.6% 100 %

Attitude Account 58 51 109


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% 41.7% 36.7 % 78.4%

Skill Account 80 56 136

% 57.6% 40.3% 97.9

Miss=21.6%

Table (2): Competency of the study population regard emergency care of patient with

acute myocardial infarction

One-Sample Test

Items N Mean Std.

Deviation

Std.

Error

t df Sig. (2-

tailed)

knowledge 139 16.9065 7.93807 .67330 25.1 138 .000

Attitude 109 8.3486 1.70715 .16352 51.1 108 .000

Skill 136 13.6103 3.36028 .28814 47.2 135 .000

Table (3): Competency of the study population regard emergency care of patient with

acute myocardial infarction

Non-parametric test

Items Chi-Square df Asymp. Sig.

knowledge 87.748 33 .000

Attitude 94.250 16 .000

Skill 50.606 8 .000

The one-way ANOVA test


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Table (4): Level of the study population competency regards management of acute

myocardial infarction versus. of advance life support training (ALS)

Training of ALS

Factors N Mean Std.

Deviation

Std.

Error

df F Sig.

knowledge Yes 30 20.2000 7.69415 1.40475 1 6.866 .010

No 109 16.0000 7.79601 .74672 137

Total 139 16.9065 7.93807 .67330 138

Skill Yes 30 14.8333 3.10820 .56748 1 5.260 .023

No 106 13.2642 3.36169 .32652 134

Total 136 13.6103 3.36028 .28814 135

Attitude Yes 24 8.5000 1.66812 .34050 1 .240 .625

No 85 8.3059 1.72533 .18714 107

Total 109 8.3486 1.70715 .16352 108

.

Table (5): Levels of competency of the study population versus uses of protocol and

guidelines


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Availability of protocol and guidelines

Levels N Mean Std.

Deviation

Std.

Error

df F Sig.

knowledge Yes 51 20.3725 7.42956 1.04035 1 17.16

.000

No 88 14.8977 7.55674 .80555 137

Total 139 16.906 7.93807 .67330 138

Skill Yes 49 14.734 3.44465 .49209 1 9.09

.003

No 87 12.977 3.15851 .33863 134

Total 136 13.610 3.36028 .28814 135

Attitude Yes 33 9.0606 1.49874 .26090 1 8.83 .004

No 76 8.0395 1.70834 .19596 107

Total 109 8.3486 1.70715 .16352 108

Table (6): Competency of the study populations about emergency care of AMI regard

streptokinase training

Training about streptokinase

Levels N Mean Std.

Deviatio

n

Std.

Error

df F Sig.

knowledge Yes 21 22.38

1

5.89471 1.2863

3

1 12.77

.000

No 11

8

15.93

2

7.87697 .72513 137

Tota

l

13

9

16.90

7

7.93807 .67330 138

Skill Yes 21 14.66

7

2.93825 .64118 1 2.48

.118

No 11 13.41 3.40789 .31779 134


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5 7

Tota

l

13

6

13.61

0

3.36028 .28814 135

Attitude Yes 15 9.000 1.36277 .35187 1 2.57 .112

No 94 8.245 1.73940 .17941 107

Tota

l

10

9

8.349 1.70715 .16352 108

Table (7); Level of competency among the study population versus qualification.

Effect of qualification on competency of nurses

Factors N Mean Std.

Deviation

Std.

Error

df F Sig.

knowledge Master 14 8.5000 3.13172 .83699 2 3.55 .032

B.Sc 93 7.5591 2.47361 .25650 136

Diploma 32 6.4375 2.82771 .49987 138

Total 139 7.3957 2.67468 .22686 2

Skill Master 13 14.000

0

3.55903 .98710 133 1.20 .305

B.Sc 91 13.835

2

3.11721 .32677 135

Diploma 32 12.812

5

3.89737 .68896 2

Total 136 13.610

3

3.36028 .28814 106 .322 .725

Attitude Master 11 8.3636 1.91169 .57640 108

B.Sc 72 8.4306 1.61704 .19057 2

Diploma 26 8.1154 1.90425 .37345 136

Total 109 8.3486 1.70715 .16352 138


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Table (8) : Competency of the study population versus period of the work at CCU and ED.

Competency and Years of work at CCU

Factors N Mean Std.

Deviation

Std.

Error

df F Sig.

knowledge < 1 37 15.3784 9.00725 1.48078 3 2.25

.087

1-2 30 17.4667 7.38934 1.34910

3-4 18 21.4444 7.31817 1.72491 111

4+ 30 16.5333 8.70090 1.58856

Total 115 17.1739 8.41496 .78470 114

Skill < 1 37 13.4324 4.33680 .71297 1.20

.353

1-2 30 13.8667 3.25612 .59448 3

3-4 16 15.3125 2.67628 .66907 108

4+ 29 13.7586 2.92349 .54288

Total 112 13.9018 3.51563 .33220 111

Attitude < 1 33 8.0909 1.87689 .32673

1.20

.313

.

1-2 29 8.6552 1.79833 .33394 3

3-4 17 8.8235 1.13111 .27433 104

4+ 29 8.1034 1.67641 .31130


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Total 108 8.3611 1.71010 .16455 107

Table (9): Level of competency of the study population versus nursing experience

Level of competency and nursing experience /years

Items N Mean Std.

Deviation

Std.

Error

df F Sig.

knowledge <3 6 5.333 1.751 .715 3

134

137

4.58 .004

3 -5 2 5.500 2.121 1.500

6 -8 13 5.539 2.402 .666

9+ 117 7.744 2.637 .244

Total 138 7.399 2.684 .229


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Skill <3 6 11.833 2.639 1.078 3

131

134

2.22 .089

3 -5 2 14.000 4.243 3.000

6 -8 13 11.769 3.346 .928

9+ 114 13.912 3.343 .313

Total 135 13.615 3.372 .290

Attitude <3 4 6.500 1.000 .500 3

105

108

2.24 .088

3 -5 1 10.000 . .

6 -8 7 7.857 2.340 .885

9+ 97 8.443 1.646 .167

Total 109 8.348 1.707 .164

DISCUSSION

These results showed that the majority of the study population had below average

competence in knowledge (55%) attitude (42%) and skill (58%).

By one way-ANOVAs test; to compare different factors that can influence the items

of competence such as training, protocol and guidelines, qualification, experience in nursing

and number of years expended in critical care unit (CCU) and emergency departments the

result showed that; there was significant effect of training on the level of knowledge and skill,

but insignificant effect on the attitude (P values.010, .o23, .625) [(table 4]

.


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The advanced life support training has been emphasized by American heart

association guidelines 2010, for cardiopulmonary resuscitation; the evaluation and

management of acute coronary syndromes (ACS). They are intended to define the scope of

training for healthcare providers who manage patients with suspected or definite acute

myocardial infarction within the first hours after onset of symptoms. The healthcare providers

managing the individual patients are best suited to determine the most appropriate treatment

strategy [24].

The effect of training about streptokinase on the competency was highly significantly

on knowledge (p value .000), but insignificant effect on skill and attitude (p value .118,.112 );

this may indicate that they are some errors in the training program. But the effect of uses of

protocol and guidelines; had significant effect on all aspects of competence (p values .000,

.003, .004) [table 5,6].

The quality of medical care is largely contingent on educating health personnel to

provide continuous comprehensive care that is rooted in the concepts of the chronic care

model and promotes self-management. Adherence to clinical practice guidelines and the

reduction of unwarranted variability in medical practice were very important.

Adherence to guidelines recommended therapies improved in-hospital outcomes; for

mortality 2.2% vs. 3.9%, P=0.0008, for recurrent ischemia 13.7% vs. 20.4%, P=0<0.0001) [26]

There was significant differences of the level of knowledge versus qualification and

insignificant between skill attitude among the s study population respectively (p values .032,

.725, .305) this clear in linear representation; the level of knowledge was high and slightly

raise of the level of skill and fall of the level of attitude among nurses who hold master

degree while attitude slightly high among the nurses with bachelor degree. [table 7].

So the low

effect of qualification on the skill and attitude related to that; most of study population (80%)

their specialties differs than scope of care which they given. Most of their specialties are

pediatrics, maternity and community this means there is mal displacement.

Also there were insignificant differences on the levels of competence regarding period

of work at CCU and emergency department respectively (p value .087, .353, .087,.353) . This

was related to the low average of years of working at CCU and ED among the study

population (1.8 year, std .deviation . 1.08) .However there were (92.8%) their worked

period blow the average only 6.2% who worked above the average . This means all the staff

of CCU are junior and the number of expert staff are low ; When you look at linear

relationship you can see the competency starts to raise exponentially up to 3-4 years of

work then starts to decline again . This reflects the competency independent on the years of

work only and it was not enough to raise the competency of the staff unless there was

updating of knowledge. So international they constructed that renewed the license of work

every 5 years. [table 8]

There was significant difference between the nursing experience and the level of

knowledge ( p values .004), while the differences were insignificant with skill and attitude P

value (088,.089). The skill and attitude level were fluctuating on linear relationship. Also the

average experience of most nurses who were working there was 1.3 years (Std. deviation

.467), however 67.6% of the nurses staff their nursing experience below the average, this


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means the nurses who work at CCU and emergency department have no enough experience

to take responsibility of care for the patients with acute myocardial infarction.

A similar study was carried out by Riitta-Liisa in 2012 at University of Turku,

Finland; to evaluate competence between graduating nursing students and nurses in intensive

and critical care nursing was self-rated as good by 69%, as excellent by 25% and as moderate

by 6%. However, graduating nursing students‘ knowledge and skills for working in intensive

and critical care were poor. The students‘ self-ratings of their knowledge and skill base were

also significantly lower than nurses‘ ratings. However, both groups reported the same attitude

and value base, which was excellent. So the level of the nurses‘ competence was better than

our nurses [27].

Study limitation

There are Limitations to assess others environmental factors that can affect the quality of

nursing care and performance.

Limitation to assess nature of the training and protocol which used

Suggestions for further research

According to the results study the following suggestions for further researches are

proposed to assess the factors interfere with nursing competence during critical care should

be studied further

To study how basic nursing competence develops during clinical practice in CCU And

ED.

To study how basic nursing competence develops during orientation programs.

Also suggestions of further interventional research to improving environmental work and

enhance quality care.

Conclusion

So the core competency of the study population was poor and there was low effect of

nursing experience, qualification, years of work at CCU or ED, protocol and training. Also

most of the study population had low nursing experience, in addition to lack of training,

protocol and guidelines for management patients with acute myocardial infarction.

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Assessment of Nurses Competency during emergency ...neelain.edu.sd/mmacpanel/includes/magazines/pdf/1_12_5.pdf · khidir Mustafa EL nimeiri and Prof. Ahmed Bolad AL Neelain University,