ICU nurses perceptions of potential constraints and anticipated support to practice defibrillation: A qualitative study

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av ail abl e a t w w w . s c i e n c e d i r e c t . c o m

j ou rna l h o m e p a g e : w w w . e l s e v i e r . c o m / i c c n

ORIGINAL

ARTICLE

ICU

nurses’

perceptions

of

potential

constraints

and

anticipated

support

to

practice

deﬁbrillation:

A

qualitative

study

George

C.M.

Hui

a,1

,

Lisa

P.L.

Low

b,∗

,

Iris

S.F.

Lee

c,2 a_Intensive_Care_Unit,_United_Christian_Hospital,_130,_Hip_Wo_Street,_Kwun_Tong,_Hong_Kong

b_The_Nethersole_School_of_Nursing,_Faculty_of_Medicine,_The_Chinese_University_of_Hong_Kong,_Esther_Lee_Building,_Shatin,_N.T.,

HongKong

c_Cardiac_Diagnostic_Laboratory,_Ruttonjee_and_Tang_Siu_Kin_Hospitals,_Queen’s_Road_East_Central,_Wan_Chai,_Hong_Kong

Accepted29April2011 KEYWORDS Nurse-led deﬁbrillation; Intensivecare; Qualitative; HongKong Summary

Aim:Thestudyexaminestheexperienceofintensivecarenursesincaringforpatientsincardiac arrest,andtheirperceptionsofintroducingnurse-leddeﬁbrillation.

Method:Thiswasadescriptive,exploratoryandqualitativestudyatanintensivecareunit(ICU) ofanacuteregionalhospitalinHongKong.Twelveregisterednurseswerepurposefullyselected forinterview.

Results:Althoughalltheparticipantsweretrainedinbasiclifesupport,only50%weretrained inadvancedcardiaclifesupport(ACLS),andthosetrainedinACLSdescribedhavinglimited opportunitiestoapplytheir defibrillationknowledge.Whilst participantsbelievedthatthey were theoreticallypreparedtoinfluence thepatient’s resuscitationoutcomes, newly quali-fiednurseswerereluctanttobeaccountablefordefibrillation.Incontrast,experiencednurses were morewilling to performnurse-led defibrillation.Support frommanagement, coopera-tionbetweennursesanddoctors,regularin-hospital‘real-drill’programmes,sponsorshipfor training,andtheuseofalternativedefibrillationequipmentshouldbeconsideredtoencourage nurse-leddefibrillationinICUsettings.

Conclusion:Nurse-led deﬁbrillationisanapproach ofdelivering prompt careto criticallyill patients,andawayaheadforintensivecarenursinginHongKong.Emphasisonaconsistent policytopromotenurse-leddeﬁbrillationpracticeisneeded.

∗_{Corresponding}_author._Tel.:₊₈₅₂₂₆₀₉_8182;_fax:₊₈₅₂₂₆₀₃_5935.

E-mailaddresses:[email protected](G.C.M.Hui),[email protected](L.P.L.Low),[email protected](I.S.F.Lee).

1_Tel:₊₈₅₂₉₁₅₉_1599. 2_Tel:₊₈₅₂₂₂₉₁_1191.

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Introduction

Sudden cardiac arrest is the most common fatal mani-festation and outcome of heart disease (American Heart Association (AHA),2005a),accountingfor 63.7%of deaths arisingfromcardiovascularcauses.IntheUnitedStates, sud-dencardiacarrestcausesanestimated350,000deathsper year(Capuccietal.,2002).ThegoaloftheAmericanHeart Association (AHA) is therefore to promote basic life sup-port(BLS)andadvancedcardiaclifesupport(ACLS),soas toimprovethesurvivalrateofindividualswithsudden car-diacarrest.InHongKong,5309individualsdiedfromheart diseasein2006,accountingfor14.6%ofthetotalmortality (DepartmentofandHealth,2006).

The main cause of sudden arrest is ventricular tachy-cardia (VT) and ventricular fibrillation (VF) (Powers and Martin,2002).Previousstudieshaveshowndefibrillationas an effective therapy for VF, withthe ability of improving survivalofsuddencardiacarrestifperformedearlywithin fourtofiveminutes(Cooketal.,2003;Kwoketal.,2003). Since1997,theInternationalLiaisonCommitteeon Resus-citation (ILCOR) (Kloeck et al., 1997) has recommended thatresuscitationpersonnelshouldbeauthorized,trained, equippedanddirectedtooperateadefibrillatoriftheir pro-fessionalresponsibilitiesrequirethemtorespondtopersons in cardiac arrest. This recommendation includes all first responders, in both hospital and out-of-hospital settings. Althoughperformingearlydefibrillationwithinthechainof survivalwillensurethehighestpossiblesurvivalrateof in-hospitalcardiacarrest,thelowsurvivalrateofin-hospital suddencardiacarrest(around10—20%)asaresultof resus-citationhasbecomeacauseforconcern(Zafarietal.,2004; Zhengetal.,2001).

Limitedattentionisgiventotheunderstandingofthe sur-vivalrateofin-hospitalsuddencardiacarrestcasesandthe potentialcontributionofnursesincaringforthesepatients inHongKong.WhilstearlierworkintheUnitedKingdom(UK) hasdemonstratedthatin-hospitalsurvivalrates ofcardiac arrestcanbeimprovedbyearlydefibrillationperformedby nurses (Coady, 1999), at the timeof this study nurse-led defibrillationwasnotcurrentlypractisedinHongKong hos-pitals.Giventhechangesintechnologyandtheavailability of newdefibrillators in recentyears, thispaperexamines thepotentialcontributionofintensivecarenurses,aswell astheirpotentialconstraintsandanticipatedsupportinthe introduction of nurse-led defibrillation for improving sur-vival of sudden cardiac arrest patients in an acute care setting.Thisstudyalsohopestohighlighttheconstituents of a policy that should bein placeto promote nurse-led defibrillationforthedeliveryofpromptcaretocriticallyill patientsinHongKong.

Background

SincemostvictimsofsuddencardiacarrestdemonstrateVF, studieshaveshownpoorsurvivalwhenthechainofsurvival is notmet. This indicates thatat the timeof collapse, if earlycardiopulmonaryresuscitation(CPR)anddeﬁbrillation arenotperformed,thechanceofreturningtospontaneous circulationisdiminishedby7—10%perminute(AHA,2005a). Inthecourseofafewminutes,VFwillbecomeasystoleif

treatmentisnotinitiated,cardiovascularshockswillrapidly become irreversible andhypoxic brain damage will occur (AHA, 2005b). Consequently,the intervalbetween sudden cardiacarrestanddefibrillationiscritical,andthe recom-mendedtimeisfourtofiveminutes(Hajbagheryetal.,2005; Loetal.,2003).AccordingtoCusniretal.(2004),thelow survivalrateofin-hospital suddencardiac arrestcouldbe explainedbythetimerequiredtorecognizecardiacarrest, thetimespentwaitingfortheresuscitationresponseteam toinitiatedefibrillationandthetimerequiredtoattachthe defibrillatortodetectthecardiacrhythm.Despite improve-mentinhealthcareprofessionals’knowledgeinidentifying suddencardiacarrestpatientswithpulselessVTorVF,the in-hospitalsurvival rateisstilllowduetothedifficultyin reducing the time from collapse to defibrillation (Herlitz etal.,2005;WeilandFries,2005).

Traditionally,nurses areusually the ﬁrstresponders to suddencardiacarrestwhoinitiateCPR.IntheUnitedStates andItaly,nurseswouldactivatetheresuscitationresponse team, initiate CPR and prepare the equipment for the resuscitationresponseteamtoinitiatemanualdeﬁbrillation (Peberdyetal.,2003;Sandronietal.,2004).InHongKong, themanagement of sudden cardiacarrest resuscitation is similar.

IntheUK,amanualdefibrillationcoursewasintroduced inthedevelopmentofastrategyfornurse-leddefibrillation in a general wardto improve patientoutcomes following cardiac arrest (Coady, 1999). The course covered rhythm recognitionanddefibrillation,withtheobjectiveof train-inga largenumber of nursesand makingdefibrillation an accepted nursing procedure. Of the 98 nurses trained in 1996,nursesinthegeneralwardperformed80%ofthe defib-rillationon 25 patients. Another 149 nurses were trained during1997—1998,butnoincrease wasfound inthe over-allpercentageofnursesperformingdefibrillationfollowing thisperiodoftraining.However,thenumberofpatientsin VTorVFwhoweredefibrillatedbeforethearrivalofthe car-diacarrestteamhadmarkedlyincreasedto46%.Although nurseswere taughthow toperformmanualdefibrillation, theywere reluctant and hesitant about using these skills without supervision. Coady (1999) believed that as more nursesgainedexperienceinsuperviseddefibrillation,they wouldbehighlyconfidenttodefibrillateunsupervised.

Furthermore,studieshaveshownthatwhentrainingwas providedtonurses andphysicians,early CPR canincrease thesurvivalrateofin-hospitalsuddencardiacarrest(Herlitz etal., 2002). However, thereis also evidence to support the problemwith recall of essential CPR knowledge, and thelack of professional responsibility in dealingwiththis issue(MarzooqandLyneham,2009).Astudyfoundthat BLS-trainednurseswithskillsinoperatinganautomatedexternal defibrillator(AED) were expectedto practiceearly defib-rillation using an AED on sudden cardiac arrest patients (Gombotz et al., 2006; Kaye and Mancini,1996). The in-hospitalchain of survival can indeed be strengthened by earlydefibrillationcarriedoutbythefirstresponder(usually thenurse),andbytheperformance/teachingofadvanced lifesupport(Xanthosetal.,2009).

In the local context, manual deﬁbrillators are used tointerpret and recognize cardiac arrhythmias. However, interpretationof cardiacarrhythmias isinsufﬁciently cov-ered in the basic nursing trainingin Hong Kong.As such,

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studies have highlighted the use of AEDs by nurses in responding topatients in sudden cardiac arrests and pro-viding early defibrillation (Gombotz et al., 2006; Mattei etal.,2002;Spearpointetal.,2000).Currently,nopublished dataareavailabletocomparetheuseoftraditionalmanual defibrillatorsversusAEDsinhospitals(InternationalLiaison CommitteeonandResuscitation,2005).Nurse-led defibrilla-tionisbelievedtoimprovethesurvivalrateofpatientswith suddencardiac arrest,enhance nurses’role,and advance nursing practice. Dwyer et al. (2007) highlighted that if nurse-initiated defibrillation is to be accepted, it should beintegratedintoeducationalprogrammestoenhanceskill development.Thisstudyexplorestheperceptionsofnurses onwhetheritwillberealistictoincludetheperformanceof earlydefibrillationincurrentCPRpractices.

Study

design

The purposeofthis study wastoexaminethe experience of ICU nurses in caring for patients with cardiac arrest, andtheirperceptionsofintroducingnurse-leddefibrillation for patientspresenting withVT or VF. Anexploratory and descriptiveresearchdesignusingsemi-structuredinterviews wasadopted.Broad andinteractivequestions wereasked toexploreCPRexperience,existingdefibrillationpractices with regard to the input of nurses, as well as potential constraintsand anticipatedsupportin theintroduction of nurse-leddefibrillationinanacutecaresetting.

Setting

and

participants

The study was conducted at an adult ICU with 20 beds andan emergency admission unitin an acute care hospi-tal in Hong Kong.The nursing staff (n=79) comprised 71 registerednurses, fivenursing officers,twonurse special-istsand oneadvanced practicenurse. Purposivesampling wasusedtoselect12informativenurseswhohadcaredfor patientsincardiacarrestwithVForVT.Theinclusioncriteria were:maleorfemale,currentlyworkingfull-timeandhave beenworkingattheICUforatleastoneyear,experienced in caring for VT or VF patients who needed defibrillation in the ICU within the past two years, and completion of apost-registration CPRtrainingcourse. Table1shows the demographicdataandspecialtytrainingoftheparticipants. AllparticipantshadcompletedBLScertificatetraining.Six (50%)hadobtainedtheACLScertificate,and11(91.6%)had completedtheICUspecialtycertificatetraining.

Data

collection

Data were collected from September to December 2006, after ethicalapproval wasobtained fromthe Surveyand BehavioralResearchEthicsCommitteeoftheUniversityand theHospitalEthicsCommittee.Abrieﬁngsessionwasheld intheICUtoexplainthepurposeofthestudyanddata col-lectionmethodtothenurses.Theimportanceofvoluntary participationwasemphasized.Theresearchercirculateda formandgavethenursesoneweektosignupiftheywished toparticipateinthestudy.Thecompletedformwasputinto thedropbox,whichwasaccessibleonlytotheﬁrstauthor.

However,theinitialresponserate waslow.Another brief-ingsessionwasconductedandanextraweek wasgivento recruittheparticipants.

Eachparticipantsignedaconsentformbeforethe inter-view. A demographic data sheet comprising gender, age, educationbackground, years of nursing experience,years of experienceworking in an ICU and training record was completed.Aninterviewschedulewasdeveloped(Table2) froma review of the literature,and advice wasobtained fromtheICUDepartmentOperationManager,nurse special-ists,AHAACLSinstructorandICUnurses.Allinterviewswere MP3-recorded andeach lasted35—45 minutes.During the interview,theparticipantshadtorecallclinicalexperience andincidentstheyhadexperiencedwhencaringforpatients incardiacarrest,VTor VT,andtheirperceptionsofbeing involvedindeﬁbrillation.Theresearcherwascautiousofthe emotionsanddistressthatcouldpossiblyarisewhen partici-pantssharedtheexperienceofcaringforpatientswhowere distressedasaresultofcardiacarrest.

The credibility of qualitative research is based on the consistency of responses collected over time and on ask-ingdifferentquestionsaboutthesametopictoensurethe equivalenceof theinformation(Morse,1991).Consistency of data collection was guaranteed in the study as only one researcher conductedthe interviews. Trustworthiness ofdatawasmaintainedbyselectivelyapproaching partici-pantstoreadthroughtheirtranscriptsandtocheckthatthe datahadaccuratelycapturedtheirexperience.

Data

analysis

Content analysis was performed to analyse the unstruc-turedinterviewdata(MorseandField,1995).Thestrategy involved preparing and managing the data for analysis, developing categories, and making interpretations of the data. The procedure involved coding the transcripts and entailedaprocessoflinking(ratherthanlabelling)thedata toformabstractideasorsubcategories(MorseandRichards, 2002).As codesweresearched foremergentpatternsand meanings, theywerecollapsedinto explicitsubcategories and categories. All incoming data were checked against the emerging framework that eventually comprised four categories describing thenurses’ experienceof caringfor cardiacarrestpatients,perceivedknowledgeabout manag-ing resuscitation anddeﬁbrillation, current practices that constraineditsimplementation,andwaystosupport nurse-leddeﬁbrillation.

Findings

ResuscitationexperienceinICU

TheICUwasregardedasanadvancedsettingfornursesto takecareofcriticallyillpatients.Well-equipped haemody-namicmonitoringsystemswereavailabletoalertnursesof thepatient’schangingconditionsothatresuscitationcould beperformedpromptly:

ThisICU hasmore patientmonitoringsystems.Wecan quickly detect the patient’s changing condition sothe CPRsuccessratewillbehigher.(N9)

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Table1 Demographicdataandspecialtytrainingofparticipants. Nurse Age Gender ICUwork

experience (years) Rank Education (Nursing) Training ICU specialty Basiclife support Advanced lifesupport N1 26—30 M 7—9 RegisteredNurse Bachelor √ √ √

N2 31—35 F 7—9 RegisteredNurse Certiﬁcate √ √ √ N3 31—35 F 7—9 RegisteredNurse Bachelor √ √

N4 41or above

F Over10 NurseSpecialist Master √ √ √ N5 35—40 F Over10 RegisteredNurse Bachelor √ √

N6 41or above

F Over10 RegisteredNurse Bachelor √ √ N7 26—30 M 4—6 RegisteredNurse Bachelor √ √ N8 31—35 M Over10 RegisteredNurse Bachelor √ √ N9 20—25 M 1—3 RegisteredNurse Bachelor √ N10 41or

above

M Over10 AdvancedPractice Nurse

Bachelor √ √ √

N11 26—30 F 4—6 RegisteredNurse Bachelor √ √ √ N12 26—30 M 4—6 RegisteredNurse Bachelor √ √ √

Althoughallparticipantsdescribedthemselvesasthefirst persontorespondtotheresuscitationscenarios,thisleading rolewasquicklytakenoverbythedoctoronhis/herarrival: Usuallythefirstresponderisthecasein-charge.Thecase in-chargeactsasaleader,coordinatestheCPRprocedure andmonitorstherundown.Whentheyfindasystole,they callforhelpandarrangeothernursestocallthedoctor. (N9)

AlthoughmanpowerwasnotanissueinthisICU, coordi-nationbetweenthenursesshouldbeenhancedtoensurea smootherresuscitationprocedure,particularlyintheinitial criticalseconds.Asforthespeciﬁcroleofnursesin resus-citation,mostparticipantsdescribedroleconfusionin the CPR process. Whilst the patient’s nurse in-charge usually organizedthemanpowerandassignedtaskstoothernurses, confusion arose when inexperienced nurses were unclear abouttheirrolesanddutiesduringresuscitation:

Iﬁnd the CPR processquite confusing. Our nursesare willingtohelpduringCPR,butthey’reunclearaboutthe role they should take. Sometimes nursesfocus onthe circulationandnoonedoes thedocumentation. Some-timesnoonechecksthetime forthenextmedication, orweforgettocallthepatient’srelatives.Ifthedoctor ispresent,he/shewillgivedifferentorders:takeblood

orgivemedication.Thesethingsmakeusquiteconfused. ThisisquiteabigproblemwhenwedoCPR.(N1)

Perceivedknowledgeaboutmanagingresuscitation anddeﬁbrillation

Fifty percent of participants possessed the ACLS certifi-cate,andclaimedtobeknowledgeableandconfidentabout managingresuscitationscenarios.TheACLStraininghad pro-videdthemwithbackgroundknowledgeaboutresuscitation skillsandprotocols,anddevelopedtheirconfidencein han-dlingCPR:

SinceI’vemorebackgroundknowledge,Iknowthe ratio-nale behindwhat Ido(resuscitation) andhowithelps the patient. I’m familiarwith theACLSalgorithm and protocolandit’seasytohandletheCPRscenario.(N10) Whentheparticipantswereaskedabouttheirknowledge of defibrillation,all of them correctly stated the aimsof usingit,thetypesofdefibrillationandpatientswhoneeded tobe defibrillated. ICU nurses’ general knowledge about defibrillationwas therefore satisfactory. As most patients admittedtothe ICUsufferedfromrespiratoryfailure,the participantsmainlyfocusedonrespiratoryratherthan car-diac care. As such, some participants expressed having

Table2 Interviewschedule.

CanyoushareexperiencesofcaringforpatientsinCPR? Canyoushareyourknowledgeaboutdeﬁbrillation?

Tellmeyourexperiences/viewsofcaringforVTorVFpatientswhoneededdefibrillation? Whatwouldyouneedinordertoperformnurse-leddefibrillationinthehospital? Canyouidentifyconstraintsconfrontingyouifnurse-leddefibrillationispracticed?

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insufﬁcientknowledgeincardiaccareandlackedconﬁdence inECGinterpretations:

ICU nurses feel hesitant about performing defibrilla-tion. They’re not confident about ECG interpretation andmanagement.Werarelydealwiththepatients’ car-diacproblems.They’retransferredtotheCCU[cardiac careunit],sowe’reweakincardiaccare.Wedealwith postoperative,renalfailureandneuralcaseshere.(N2) Despitethe completionofadvanced ACLStraining,the performanceofdefibrillationwasstillstronglyperceivedas adoctor’sdutyandthedutiesofnursesweretoassistthem: When the case develops VT or VF, the doctor orders defibrillation.Whydoes thedoctor perform defibrilla-tion?He/shehasobtainedtheACLSlicenseandpractises defibrillationsowellhe/shecandoitnaturally.Thisis theproblemin clinicalpractice. We’vea conceptthat defibrillationisnotdonebynurses.We’rejust responsi-bleforswitchingonthebuttonandconnectingthecable. Whenthedoctorarrives,he/shewillperformit.Thisis thenurses’problem.(N12)

Some participants did challenge this traditional belief of the doctor performing defibrillation and believed that nurses had responsibility to practise timely defibrillation to save the patients’ lives. They described exemplars of ACLS-trainednurseswhowereabletoconfirmshockableVT scenariosanddefibrillatedwithconfidenceinspecial situa-tions.

Constraintsofnurse-leddeﬁbrillation

Themainconstraintsthatpreventedparticipantsfrom want-ingtoimplementnurse-leddefibrillationintheICUincluded limitedexposureandexperienceindefibrillating VTorVF patients,lack of confidenceand fearof makingmistakes. Although they had acquired knowledge of defibrillation practiceaftertheACLS training(i.e.,familiaritywiththe arrhythmiaandtheprotocol),memoryfadedovertimedue tothelackofpractice:

We’llmisssomeinformationifwedon’tpractise system-atically.Althoughwe’veattendedthecourse,we’renot familiar with the steps. We may forget to follow the sequenceofABCD.(N12)

ManyparticipantsstatedthattheincidenceofVTorVF variedeveryyearand,onthewhole,wasconsideredtobe quitelowintheICU:

It’snot the problemoftraining. Trainingprovides the knowledge, but we can’t apply it to the real clinical situation.Trained (ACLS) nursesare scaredwhen they encounterthefirstrealscenariowithoutadoctor’s pres-ence.Althoughwe’vebeentrainedandissuedwiththe certificate,whichisvalidforayear,ittakesalongtime beforewecanmanageadefibrillationscenario.(N4) WhilstthelownumberofcasesmeantthatACLS-trained nurseshadlittlepractice,somenursesdidnotmind‘doing less’asthisguaranteed thatnomistakes wouldbemade, andtherewasnoneedtoshoulderanyresponsibilities:

Nurses claimto have forgotten the knowledge after a fewmonths. Afteralongwait,they loseconfidence.I believeit’sdifficulttopromotenurse-leddefibrillation programmes.Noteverynurseiswillingtotake account-ability.(N4)

Thefearofmakingmistakes,suchasincorrectly manag-ingascenario,makingthewronginterpretationanddoing harmtothepatient,wasreiterated:

I worry about the outcome of the patient and whose responsibility itis.Iworry aboutincorrectlymanaging adeﬁbrillationscenarioandbearingtheresponsibilityif Ihurtothers.(N9)

Unfamiliarity with the patient’s haemodynamic status also added to the participants’ fear of making mistakes. Indeed,familiaritywiththepatient’shaemodynamicstate wasregardedasaprerequisiteforinitiatingdeﬁbrillation:

WhentheconsciouspatientdevelopedVT,nursesweren’t sureofthescenario.Isuggestedcallingthedoctorand preparing the medication. Some nurses prepared for deﬁbrillation when they saw VTand didn’t assess the patient’s haemodynamic state. They should assess the waveformﬁrstandthenpreparethemedication.(N2)

Supportingnurse-leddeﬁbrillation

Mostparticipantssupportedtheperformanceof defibrilla-tionbynursesprovidedthatadequatesupportwasavailable. This included obtaining supportfromthehospital, collab-orating with the doctor, providing training opportunities and sponsorship and considering the use of alternative equipment. As the performance of defibrillation is mini-mallyaddressed in thegeneral nursingtraining, obtaining support from the hospital to ensure that all nurses were issuedwiththeACLScertificatetoperformdefibrillationwas regardedbytheparticipantsashighlyimportant.The hospi-tal’srecognitionandacknowledgementofthisqualification wouldenablenursestoadvancetheirICUpracticeandinstill greaterconfidence:

Itdependsonwhethertheorganizationandthehospital recognize your qualiﬁcationto perform deﬁbrillation. We don’t perform it in this hospital. We should seek training, whichlegally allows ustodo it.Wecan per-form itstepby step,andthe hospitalandunitshould allowustotry.(N10)

In the trial of nurse-led defibrillation programmes, it is essential to reach a consensus and move towards closer collaborationbetween nursesand doctors, particu-larlywhendoctorsmakeinfluentialdecisionsaboutpatient care and outcomes. Some participants suggested making compromises with the doctor about the practicalities of the programme and asking them to provide the initial supervision until nurses gain confidence in managing the defibrillationscenarioontheirown:

When nurseswant to promotesuch a programme, we areconfronted withthe constraintofdoctorsrefusing to promoteit. In Hong Kong hospitals, doctorsalways taketheleadandhaveasayinthemanagement(ofthe

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patient).Ifwewanttopromotethisprogramme,we’d needtoseewhetherthedoctorswillsupportus.(N11) Theprovisionofopportunitiesandsponsorship(interms oftimeorfinancialaid)fortrainingwouldcertainly demon-stratethesupportofthehospitalfornurse-leddefibrillation, although only a few privileged staff members were nom-inated to attend the training. ACLS attendees reported payingandspendingtwodaysfor thetrainingcourse,and receivingnoworkbenefitsorsalaryincrementsafterwards. Thiscoulddiminishnurses’motivationtoupdatetheir resus-citationknowledge:

Althoughwecan’tbefullysponsored,theyshould spon-sorsomeofthetrainingfee.Onlyafewnursesgotthe sponsorship. Sponsorship is needed to train usto per-formdeﬁbrillation.Wemusthaveadequatetrainingand recognition.(N10)

To promotenurse-led defibrillation successfully,it was believedthatnursesshouldhaveup-to-dateknowledgeand be familiar withthe protocols. It wassuggested that the hospitalshouldconsiderincreasingregulartraining,suchas in-hospitalresuscitationtrainingandin-houseCPRdrillsfor nurses, to build up and refresh their defibrillation skills. However,oneparticipanthadreservations about the ben-efitsofdrillpractices.Duringadrill,theenvironmentand equipmentwerewell-preparedforparticipantstoundertake asimulatedactivityinanunrealsituation— therea possi-bilitythatthesenursescouldperformpoorlyinemergency clinical situations. A transition phase of using alternative equipment suchas AED wasproposed to build up nurses’ confidencebeforeproceedingtouseofthemanual defibril-lator:

NurseswillbemoreconﬁdenttouseAEDbecausethere’s no need to interpret the ECG. It’s easy to use. It’ll interprettheECG.Wepresstheshockbuttonwhen deﬁb-rillationisneeded.There’salsoshock advicefromthe AED.(N2)

Discussion

Thefindingsrevealedthatintensivecarenurseswere crit-ical of their resuscitation skills, which they believed had tobeofa higherstandardof proficiencybeforenurse-led defibrillationcouldbepursuedtoimproveservicedelivery intheICU.Whilstthefocusofthisstudywasonthe partici-pants’perceptionsofintroducingnurse-leddefibrillation,it alsoprovidedanopportunitytoreviewexistingresuscitation practicesintheICUsothatsubstandardpracticescouldbe identified.

Theparticipantswerealwaysthefirstrespondersto car-diac arrest and activated the code system very quickly. However,thestudyhighlightedtheirexperienceofrole con-fusionandtheneedtobemorecoordinated,especiallyat thebeginningoftheresuscitationprocedure.Therefore,a cleardepartmentalguidelineshouldbeinplacetodefinethe roleofnurseswhenperformingdefibrillationandthe man-powerflowshouldbeprovidedtotheassignednurseduring resuscitation. This would avoid role confusion and ensure thatearlydefibrillationisdeliveredbythedelegatednurse.

Expectationwashighof allintensivecare nursesabout theirabilitytobefullycompetentinperformingthe resus-citationprocedure.This is a crucialaspect of BLSskill to getrighttoimprovethechanceofsuccessfulresuscitation (Enohumahetal.,2006).MorefrequentreviewofCPRskills canhelpovercomethechaosandconfusionassociatedwith emergencysituations in hospitals. Therefore,regular CPR drills,includingnurse-leddeﬁbrillation,shouldbe encour-agedandmaybesetasoneoftherequirementsforhospital accreditation.

Recently,personalcommunicationwithsomelocal hos-pitals in Hong Kong revealed that nurse-led defibrillation has been adopted in the ICU, cardiac care unit (CCU) and in medical wards with cardiac care nurses. These nursesarerequiredtoattendregularin-housedefibrillation coursesandtotake examinationstoensuretheyhave up-to-dateresuscitationknowledge. Regularrecertification is alsorequiredtomaintainthecompetenceofnursing prac-tice.Hospitalscanconsidermotivatingnursestoapplytheir knowledgeinclinicalpracticebyexemptingyearly recerti-ficationexaminationsforthosewhohave performedmore thantwocasesofdefibrillationinayear.Fromtheauthors’ observation,thesenursesaremorewillingtoplaytheirrole innurse-leddefibrillationwhensuchanexemptionsystem isinplaceasanincentive.

Accordingto theliterature,nurses trainedin ACLS are abletoperformresuscitation betterand moreeffectively (Vincent, 2003). ACLS is a skill that can be life-saving or death-provokingduring criticalsituations,it is imperative thatnursesarecompetentinperformingeffective resusci-tation.Previousstudieshaveshownasigniﬁcantassociation between ACLS-trained nurses and higher patient survival rates from cardiac arrest (Dane et al., 2000; Pottle and Brant,2000).Theﬁndingshighlightedtheeffectof resusci-tationtrainingontheinitialoutcome(returnofspontaneous circulation), lending support to the provision of regular trainingtoupdatetheskills andpracticeofnursesinCPR. However,resuscitationtrainingdidnotappeartoaffectthe patients’long-termsurvival(PottleandBrant,2000).

SinceACLS-trainednurseshaveasystematicwayof per-formingresuscitation in emergencysituations,theywould beexpectedtotake theleadandactivate thein-hospital resuscitationproceduremorepromptlyandfollowtheACLS protocol withless delay than nurses nottrained in ACLS. Hence,delaysininitiatingdeﬁbrillationcanbereducedby havingmore ACLS-trained nurses. However,Reznek etal.

(2002)reportedthatthereisusuallyinsufficienttime allo-catedforACLStraininginhospitals.AccordingtoLeeetal. (2005),majorfactorshinderingHongKongnursesfrom par-ticipatingin continuingnursing educationwere cost,time andinadequate supportfrom employers. Similarly, in the currentstudy,themainreasonsfornurses’reluctancetojoin ACLStraining werefrustration, lowmotivation, time con-straintsandlimitedopportunitiesandsponsorshipprovided bythehospital.Supportfromtheorganizationtorecognize nursesinundertakingcontinuouseducationandskill train-ingarethereforeimportantforencouragingthemtoextend theirroleinresuscitation(LeeandLow,2010).Somelocal hospitalshaveformulatedpoliciestomakeACLS certifica-tioncompulsory forcardiaccarenurses.ACLS traininghas alsobecomeabasicrequirementfornursestoperform defib-rillationinsomeadvancedpatientcareareassuchasICUand

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CCU.Additionally,thesehospitalsprovidesponsorshipanda studyleaveof twodaystosupporttheirnurses afterthey arerecruitedintotheseunits.

Due to lack of supervised practice, the participants statedthattheywere‘afraidofmakingmistakes’evenafter theyhad received ACLS certification.This study revealed thatnurseswereonly expectedtoadopta passiverolein preparingtheequipment,toassistthedoctorwhoperforms the CPR-defibrillation procedure. Many claimedthat they wereill-preparedforandfeltchallengedbytherealclinical scenario(whichdifferedsignificantlyfromthetraining envi-ronment)coupledwiththelack ofsupervisionprovidedto helpthemimproveperformance.Thesefindingswere consis-tentwiththoseofDeVitaetal.(2004),whichillustratedthe unsatisfactoryperformance of ACLS-certified nurses when firsttestedinaclinicalemergencyscenario.Otherstudies havehighlightedACLStrainees’poorretentionof resuscita-tionskills(MurphyandFitzsimons,2004).Thisisconsistent withfindingsofthecurrentstudy,inwhichACLS-trained par-ticipantswerereportedtoexperiencefadingmemoryand inabilitytodeploytheirlifesupportskillsandprofessional knowledgeinarealclinicalscenarioafteraperiodwithout practice.

Therehavehowever,beensuccessesinnurse-led defibril-lation.Instudiesevaluatingelectivenurse-ledcardioversion servicesforatrialfibrillation(Boodhooetal.,2004;Shelton et al., 2006), nurses were found to provide safe and cost-effectiveservice afterthecompletionofappropriate training and accumulation of experience. In Hong Kong, thereis only one published study on nurse-led defibrilla-tionintheCCUsetting(Chanetal.,1998).Trainednurses were able to correctly diagnose cardiac arrest, identify thearrhythmia andthe need to defibrillate,and execute sequentialstepstocompletedefibrillation.Thestudy high-lightedthatsupportobtainedfromthehospitalwasakeyto success.Recently,somehospitalsinHongKonghaveinvolved doctorsintheprovisionoftrainingandsupervisionfor nurse-led defibrillation programmes. The senior medical officer is responsible for on-site or retrospective certification of nurseswhohaveperformeddefibrillation.

Manualdefibrillatorsarestillthestandardequipmentfor in-hospital defibrillation in Hong Kong. Some participants wereunfamiliarwithitsuse,asitrequired interpretation of ECG arrhythmia; thus, introducing AED could offer an acceptable alternative for nurse-led defibrillation in hos-pitals (Kenward et al., 2002; Winkle, 2010). By adopting AEDsinhospitalnurse-leddefibrillationprogrammes,early defibrillationcanbeachievedbyshorteningthedelayfrom sudden cardiac arrest to defibrillation (Hanefeld et al., 2005;Huangetal.,2002).Some hospitalshavealsomade itcompulsoryforallnurses,includinggeneralwardnurses, toparticipatein thethree hourAED training programme. ThiswouldempowerallnursestoperformAEDdefibrillation evenintheabsenceofadoctor.

Limitations

Thereweretwolimitations inthecurrent studythathave to be acknowledged. The selected ICU primarily catered forpatientswithmultiorganfailure,renalfailureand sep-tic shock, and there were fewer cardiac cases requiring

defibrillation.Thus,selectionofasitewithanappropriate patientmixtoimplementthenurse-led defibrillation pro-grammewouldbeafactortoconsider.Moreover,selection ofasitewherenurseshavefrequentexposuretotheuseof manualdefibrillators(evenifdefibrillationisperformedby doctors)mightprovidedifferentresultswithregardtothe participants’ perceptions and experience. Although valu-able information on nurses’ resuscitation experience was obtained,memoryrecalloftheCPRexperiencemighthave resulted in omission of some detailed reflections of the emergencysituation.

Conclusions

The study shed light on the experience of ICU nurses in resuscitation and the possibility of performing nurse-led defibrillationinanICUsetting.Thefindingshaveincreased knowledgeofhownursescaredforcardiacarrestpatients, the procedure they followed when assisting in defibrilla-tion,andtheperceivedconstraintsandsupportivemeasures requiredforimplementationofnurse-leddefibrillation.

Our findings have also highlighted the need for an emphasisonaconsistentpolicytopromotenurse-led defib-rillation practice. A nurse-led defibrillation programme would require considerable effort in terms of clear hos-pital guidelines and support, effective ACLS training and supervision, certification to acknowledge practice exper-tise, consideration of a transitionto theuse of AEDs and achangeinnurses’traditionalphilosophyand responsibili-ties.Furtherresearchinotherspecialties,includingtheCCU andaccidentandemergencydepartments,isrecommended toobtaintheviewpointsofnursesofvariousspecialtiesso as to explore the possibility and support the decision of introducingnurse-leddefibrillationinhospitals.

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