Assessment of Nurses’ Knowledge on Cardiopulmonary Resuscitation Drugs in the Hospital Environment

In-Hospital Cardiac Arrest (IHCA) is a medical emergency that can occur in any patient at any time during their hospitalization [1] and is associated with significant morbidity and mortality rates [2]. Studies have reported wide variations in IHCA incidence rates in hospitals worldwide, ranging from 1.3 to 6 patients per 1000 admissions [3,4], with survival outcomes varying widely between hospitals, suggesting potential differences in the quality of CPR [5]. Very often nurses are the first responders to emergency situations, such as cardiopulmonary arrest [6]. Their role in these situations is critical and multifaceted. Keeping them informed and compliant with updated ACLS protocols is of paramount importance [7]. Nurses should be familiar with these protocols, including the recommended medications and specific instructions for their administration, such as epinephrine, amiodarone, medications administered during resuscitation efforts that increase the probabilities of successful resuscitation [4].

Epinephrine has been widely used in cardiac arrest since the 1960s by increasing coronary blood flow and aortic diastolic vascular tone [8]. Epinephrine, 1mg, is used to restore spontaneous circulation (ROSC- Return of Spontaneous Circulation) and has a more therapeutic effect when administered early in the resuscitation effort [9]. Amiodarone is often used by healthcare professionals, including nurses, in cases of IHCA due to its antiarrhythmic properties [10]. More specifically it is used to treat life-threatening ventricular arrhythmias such as Ventricular Fibrillation (VF) and Ventricular Tachycardia (VT) [11]. These arrhythmias can lead to reduced cardiac output and ultimately, cardiac arrest [12]. Amiodarone administration is usually recommended in conjunction with standard advanced protocols, including CPR and defibrillation [13]. It is considered an important component in the pharmacological management of cardiac arrest to enhance the likelihood of recovery and maintenance of a stable and sustainable heart rate [14]. Early administration of drugs in cardiac arrest increases the chances of a positive outcome. Non-compliance with ACLS guidelines, delays in drug administration, including errors in administration, has been shown to reduce the chances of return of spontaneous circulation and survival from cardiac arrest [15]. It is therefore important for nurses to have a good knowledge and understanding of pharmacology so that they can recognize changes in the patient’s condition and respond immediately [16]. This includes being able to identify any need for additional medication, adjusting to appropriate doses and recognizing adverse effects from drug administration [17].

Effective communication within the resuscitation team is vital for coordination and positive patient outcome [18]. Nurses equipped with appropriate knowledge can communicate better with other healthcare professionals (such as doctors, anaesthetists) ensuring that everyone is on the same line of action and following the appropriate treatment plan [19]. Continuous assessment is the next and equally important stage in which nurses should continuously assess the patient’s response to medications and interventions during cardiac arrest [20]. This helps them to make informed decisions about whether to continue, adapt or change the treatment strategy [21]. Overall, a nurse’s knowledge of resuscitation is vital to providing safe, effective and timely interventions for a patient’s survival [22]. Regular training, simulation exercises and keeping up to date with the latest guidelines help to maintain and reinforce this critical knowledge [18]. Engaging in regular simulations and virtual scenarios can help nurses improve their skills and confidence in handling a patient with a cardiopulmonary arrest in high-stress situations [23]. The aim of this study is to investigate and evaluate nurses’ knowledge of the drugs used in cases of cardiopulmonary arrest in a hospital environment.

Study design

The forthcoming study adopts a prospective design, centering on an exploration of nurses’ knowledge and familiarity with drugs administered during cardiopulmonary arrest incidents through a meticulously crafted questionnaire. The primary objective is to scrutinize and analyze nurses’ preparedness in handling such critical situations. To execute this study, the questionnaire was disseminated among both nurses and nursing assistants, given their frequent role as initial responders in emergency scenarios. The questionnaire was thoughtfully structured to extract information about participants grasp of required drug administration and their practical experiences in cardiac arrest situations.

Furthermore, the questionnaire was intentionally designed with a holistic approach, encompassing inquiries about attendance in training seminars, years of professional experience, and exposure to emergency situations. These factors significantly contribute to nurses’ proficiency in administering necessary drugs, facilitating a comprehensive analysis of the participants’ professional profiles. Lastly, the questionnaire delved into health professionals’ theoretical knowledge concerning updated Cardiopulmonary Resuscitation (CPR) protocols and the utilization of advanced life support equipment. Considering the interconnectedness of this knowledge with drug administration, the study sought to unveil the collective expertise of nurses and nursing assistants, aiming to demonstrate their awareness and proficiency in contributing to successful resuscitation outcomes.

Study setting and participants

The survey encompassed the majority of nursing departments within a tertiary university general hospital located in Patras city, Greece. Specifically, pathology and surgery clinics were chosen based on the assumption that a cardiovascular emergency could occur in any nursing department. As one of the largest hospitals in the country, this institution presents a diverse range of clinical conditions and services, making it a representative subject, especially considering the high frequency of cardiopulmonary arrests. The inclusion criteria covered a total of 87 nurses and 66 nursing assistants, all employed in the public National Health System, serving as permanent, contracted, or specialist staff. The study deliberately excluded certain groups, namely: (a) selfemployed private nurses and nursing assistants, (b) unemployed individuals in these roles, (c) students enrolled in nursing programs, (d) other health professionals not falling under the category of nurses or nursing assistants, and (e) professional nurses and nursing assistants working in facilities not participating in the research study.

The questions asked to assess the knowledge of the sample were based on the recently (11/2021) updated Resuscitation Council guidelines on technical life support in adults. By meticulously selecting participants to represent diverse nursing expertise and ensuring alignment with current best practices in emergency care, the study aimed to enhance the validity and relevance of its findings, providing a comprehensive insight into the hospital’s various departments.

Data collection

Between May and October 2023, research data was gathered using the electronic platform Type form. Just prior to the commencement of the theoretical seminar organized by the nursing department of the hospital, participants electronically completed the questionnaire. The questionnaire comprised two sections. The initial section focused on queries related to demographic and anthropometric data, encompassing aspects such as age, gender, work department, years of experience, basic education, postgraduate studies, and more. Meanwhile, the second section delved into the participants’ knowledge and featured 10 multiple-choice questions, where only one correct answer was possible. These questions spanned topics related to both the early recognition of cardiopulmonary arrest and advanced support skills leading up to the arrival of the expert team (resuscitation team). Before wide dissemination, the questionnaire underwent thorough validation procedures to ensure its reliability, validity, coherence, and optimal length. A preliminary pilot test, involving ten nurses outside the final sample, was conducted. The results of the reliability assessment, indicated by Cronbach’s alpha coefficient (α=0.87), affirmed the commendable internal consistency and reliability of the questionnaire.

Ethical issues

This research is in line with the ethical aspects defined by the Declaration of Helsinki [24], and was approved by the Research, Ethics and Deontology Committee (Reference Number: 290/07.06.2023) and the Scientific Council of the university hospital where the study took place. Prior to responding to the questionnaire, participants were briefed on the study’s purpose and granted informed consent. Their involvement was voluntary, and they retained the option to withdraw their agreement at any given moment. Complete confidentiality was assured, with no gathering of personal information such as names, emails, or IP addresses. The collected responses were electronically stored on the Type form platform, safeguarded by password protection. Furthermore, the computer utilized for data processing was also secured with a password to prevent unauthorized access by non-authorized users.

Data analysis

In conducting data analysis, the study used the capabilities of the Statistical Package for the Social Sciences (SPSS), a powerful tool for statistical analysis. The initial phase included a comprehensive descriptive analysis, which incorporated key metrics such as means, standard deviations, and frequencies. A range of relevant statistical methods, including chi-square and Fisher tests, Kendall’s tau-b, tau-c, and Spearman’s correlations, were then applied to thoroughly examine the relationships between the study variables. A constant level of significance (α=0.05) and a 95% confidence interval were maintained in all analyses, ensuring a reliable determination of statistical significance. Finally, the findings were subjected to rigorous review and interpretation, taking into account the objectives of the study and their wider implications for nursing practice in the context of the first response to cardiopulmonary arrest.

Survey participants demonstrate considerable diversity in various characteristics, thus providing a detailed picture of the research sample. Demographic factors highlight the diversity of nursing profiles, including age, gender, work department, employment status, years of seniority, and education level (Table 1). The research sample consists of 153 participants, which came from various pathology and surgical departments of the hospital, predominantly females (89%) compared to males (11.1%). Age distribution shows a relatively balanced representation across different age groups, with the majority falling between 30 to 49 years old. Employment status indicates that 47.1% are permanent employees, while 41.8% are contracted, and 11.1% are specialist staff. Years of seniority vary, with significant proportions having 0-2 years (26.1%) and 20+ years (30.1%) of experience. Education levels are fairly evenly distributed between nursing assistants (43.1%) those with technological education (45.8%), with a smaller percentage having Higher University Education (11.1%).

Table 1:Frequency table with demographic and other characteristics of the study sample.

The findings provide extra insights into the participants with additional qualifications, training experiences, and ongoing professional development activities within the nursing profession. The majority of participants (75.9%) do not have postgraduate studies, while a significant proportion (21.8%) have a Postgraduate Diploma, and a small minority (2.3%) hold a Doctoral Degree. About one-third of participants (31.4%) have attended a BLS certified seminar, while the majority (68.6%) have not. A small percentage of participants (3.9%) are ILS/ALS certified, while the majority (96.1%) are not. A notable portion of participants (35.9%) have attended non-certified seminars or courses, while the remaining (64.1%) have not. Around one-third of participants (30.1%) have attended another seminar, while the majority (69.9%) have not.

Knowledge relating to the administration of resuscitation drugs

The study participants were surveyed regarding the correct administration of medications commonly used during specialist life support for cardiac arrest. The medications included in the assessment were atropine, adrenaline, and amiodarone. The percentage of correct responses for each drug was 7.2% for atropine, 34.6% for adrenaline, and 3.3% for amiodarone. Additionally, 36.6% of respondents indicated that they “did not know” the correct administration of atropine, 35.5% for adrenaline, and 67.3% for amiodarone. Finally, the percentage of incorrect answers was 56.1% for atropine, 30.1% for adrenaline and 29.5% for amiodarone, as observed in (Table 2).

Table 2:Distribution table of responses regarding the administration of atropine, adrenaline and amiodarone..

Cognitive background and socio-demographic variables

Administration of atropine: The analysis showed that the 30- 39 age group had the best performance, with 45.5% (almost 1 in 2) correctly identifying that atropine is not administered in cardiac arrest. In contrast, the 40-49 age group had the lowest performance, with only 9.1% (less than 1 in 10) providing the correct answer (p=0.166). Regarding gender, the majority of both males and females were unaware of the correct answer. Among those who did not know, 89.3% were females and 10.7% were males. However, among those who answered correctly, females performed better, accounting for 81.8% of correct responses, while males contributed only 18.2% (1 in 5) (p=0.712).

By work department, staff from Psychiatry and Cardiothoracic Surgery had the highest level of knowledge, with 18.2% (approximately 1 in 5) correct answers each. They were followed by Pathology, Surgery, Dermatology, Neurology, Emergency, and Anesthesiology departments, where just 9.1% (1 in 10) answered correctly (p=0.571). Employment status also appeared to play a role. Contracted nurses had the highest performance, with 45.5% (almost 1 in 2) correct responses, while permanent nurses and specialist staff achieved similar results at 27.3% (around 1 in 4) (p=0.276). Regarding professional experience, new nurses with up to 2 years of experience performed best, with 36.4% (about 1 in 3) correct answers. Nurses with 5–20 years of experience had the lowest performance, with just 9.1% (less than 1 in 10) answering correctly, while those with more than 20 years of experience achieved 18.2% (1 in 5) correct responses (p=0.096).

Educational background played a significant role. Nurses with higher technological education achieved the highest performance, with 63.6% correct answers, while 22.2% of those who answered correctly held a postgraduate diploma (p=0.088). Statistically, there is a weak positive correlation between the two variables when examining their symmetric relationship, with Somers’ d being 0.156 and p=0.023. Attendance in training programs also had a substantial impact. About 2 out of 3 participants had not attended BLS seminars, and among them, 26.8% (1 in 4) did not know the correct answer. In comparison, only 9.8% (less than 1 in 10) of those who had attended BLS seminars were unaware (p=0.306). Similar trends were observed for ILS and ALS seminars, with non-attendees performing worse (p=0.282). Participants in other non-certified seminars had a 27.3% (1 in 3) success rate (p=0.370), while the majority of those who had not attended any seminar showed 24.2% (1 in 4) lack of knowledge and only 5.2% (less than 1 in 20) correct responses (p=0.712) The time elapsed since training also proved significant. Most participants had been trained 5-10 years ago or 1-3 years ago (28.6% in each group), while those trained more than 10 years ago did not provide any correct answers (p=0.730).

Administration of amiodarone: Regarding the administration of amiodarone, the age groups 30-39 and 50-59 years old demonstrated the best performance, with 40.0% (2 in 5) of respondents in each group answering correctly. (p=0.856) The majority of the sample was female, and 80.0% (4 in 5) of women who answered this question provided the correct answer. (p=0.198) Among work departments, staff in the Psychiatric Clinic showed the highest level of knowledge, with 40.0% (2 in 5) correct answers. This was followed by staff in Cardiothoracic, Neurology, and the Emergency Departments, where 20.0% (1 in 5) answered correctly in each case. (p=0.792) Permanent staff outperformed other groups, with 60.0% (3 in 5) correct answers, compared to 40.0% (2 in 5) for contracted nurses and no correct answers among specialist staff. (p=0.109) In terms of professional experience, 40.0% (2 in 5) of those with 2-5 years of experience answered correctly, as did a similar proportion of those with 10-20 years. However, the majority of newer nurses with 0-2 years (16.3% of the total) and those with more than 20 years of experience (23.5%) admitted they were unaware of the correct use of amiodarone. (p=0.401) Educational background influenced performance. Those with secondary education achieved the highest correct answer rate at 80.0% (4 in 5), while 47.1% (nearly 1 in 2) of respondents without a postgraduate degree said they did not know the answer. (p=0.271) Regarding training attendance, 68.6% (around 2 in 3) of participants had not attended a BLS-certified seminar, and only 3.3% (1 in 30) of them answered correctly (p=0.466). Similar trends were observed for ILS/ALS-certified seminars, where 96.0% of non-attendees did not answer correctly, and just 3.3% provided the correct response (p=0.719). In contrast, those who attended non-certified seminars had a success rate of 80.0% (4 in 5), while among those who had not, the majority (43.8%, or nearly 1 in 2) did not know the answer, and only 0.7% (fewer than 1 in 100) answered correctly (p=0.305).

For those who had not attended any additional seminars, 69.9% (around 7 in 10) participated, of which 47.7% (nearly 1 in 2) admitted they did not know the correct answer, and 2.6% (around 1 in 40) answered correctly. (p=0.756) Training recency also played a role. Respondents who received training 1-3 years ago had the highest correct answer rate at 50.0% (1 in 2). By contrast, the majority of those who had not received any such training in over 5 years (28.0%, or around 1 in 4) stated they did not know the answer (p=0.463).

Administration of adrenaline: Regarding knowledge about administering adrenaline as soon as possible, the 40-49 age group performed best, with 34.0% (approximately 1 in 3) answering correctly, followed by the 30-39 group at 28.3% (about 1 in 4). The lowest performance was observed among the 22-29 group, with 15.1% (fewer than 1 in 6). (p=0.959) Women, representing the majority of respondents, achieved 28.8% (nearly 3 in 10) correct answers, compared to men, of whom only 5.9% (about 1 in 20) answered correctly. (p=0.451) By work department, the 3rd Pathology Clinic stood out, with 17.7% (nearly 1 in 5) of all respondents answering correctly. Psychiatry followed with 13.2%, and Pathology B with 11.3%. (p=0.001) Regarding employment type, resident nurses achieved the highest percentage of correct answers, with 49.1% (almost 1 in 2), followed by contracted nurses at 39.6% (nearly 2 in 5), while specialist staff had the lowest rate at 11.3% (around 1 in 9) (p=0.988). The experience level also played a significant role. Respondents with more than 20 years of experience had the highest rate of correct answers at 34.0% (about 1 in 3), while those with 0-2 years followed with 24.5% (nearly 1 in 4). (p=0.344) Educational level revealed slight differences, with those holding higher technological education achieving 49.1% (almost 1 in 2) correct answers, compared to 45.3% (around 4 in 9) for those with secondary education. (p=0.007) Among those without postgraduate degrees, 25.3% (1 in 4) answered correctly, while of the 21.8% (about 1 in 5) who held a postgraduate degree, 6.9% (about 1 in 15) answered correctly, and an equal proportion stated they did not know the answer (p=0.978).

Training participation significantly influenced knowledge. Among the 48 individuals who attended a BLS-certified seminar, 28.3% (nearly 1 in 3) answered correctly, while 71.7% (almost 3 in 4) of the 105 who had not attended still answered correctly. (p=0.429) Although most participants had not attended ALS/ILScertified seminars, 32.4% (about 1 in 3) of them answered the question correctly. (p=0.398) Among those who attended noncertified seminars, 13.1% (around 1 in 8) answered correctly, compared to 21.6% (about 1 in 5) of those who had not. (p=0.098) For respondents who had attended other seminars, 24.2% (nearly 1 in 4) gave correct answers, while among those who had not attended any seminar, 10.5% (around 1 in 10) responded correctly (p=0.482). Training recency also had an impact. Respondents trained 3-5 years ago had the highest success rate at 32.4% (about 1 in 3), followed by those trained 5-10 years ago at 21.6% (about 1 in 5). Those who had not received training for over 20 years scored the lowest, with only 2.8% (about 1 in 35) answering correctly (p=0.453). However, a statistically significant weak negative correlation was observed between the two variables when examining their symmetric relationship, with Somers’ d for the symmetric relationship being -0.157 and p=0.05.

Nurses are usually the first healthcare professionals to realize that a patient in hospital has suffered a cardiac arrest, so it is critical that they have adequate knowledge and skills in CPR. Previous studies have highlighted that CPR knowledge and skills decline over time when not practiced regularly. In addition, it has been found that the level of knowledge and skills of nurses who are systematically trained is higher compared to those who are not trained [25-27]. The present study assessed nurses’ knowledge of critical drug administration during Cardiopulmonary Resuscitation (CPR) in a hospital setting. Findings revealed significant knowledge gaps between nurses and nursing assistants, particularly regarding the correct administration of atropine, amiodarone and adrenaline during cardiac arrest scenarios. Specifically, the correct response rates were 7.2% for atropine, 3.3% for amiodarone, and 34.6% for adrenaline, and a significant proportion of participants reported not knowing the appropriate protocols for administering these medications.

Analysis of the demographic data further highlighted differences in knowledge of these medications between age groups. Younger nurses had higher success rates in identifying the correct practices for administering atropine and amiodarone compared with their older colleagues, suggesting that their recent training may play a key role in maintaining their knowledge. According to Bukiran et al. [28], even after only one day of training, nurses’ knowledge of resuscitation can be improved and maintained in the short term, as observed at 6 and 12 months, respectively. However, in the case of adrenaline administration, the more experienced nurses (with more than 20 years of experience) in our sample outperformed their younger colleagues. A study by Tomas et al. [29], demonstrated a correlation between good practice and experience in CPR. Specifically, nurses with 6-10 years’ experience or more than 10 years’ experience were twice as likely and significantly more likely, respectively, to succeed and respond correctly to resuscitation cases compared to those with 1-5 years’ experience. This suggests that experience, combined with ongoing training, is key to effective administration of life-saving medications during CPR. This finding is consistent with the study by Kelkay et al. [30], in Japan, which showed that experience influences the application of knowledge in practice. Experienced nurses often face challenges in healthcare settings, which equip them with the courage, strength, and ability to effectively apply CPR.

Regarding the educational background of the nurses, it appeared that those who had received higher technological education achieved the highest percentage of correct answers regarding atropine administration (63.6%). Also, nurses with a postgraduate degree showed a better understanding of the administration of all three drugs (atropine, amiodarone, adrenaline), compared to those who had not received this degree. However, there are conflicting findings in the literature. Kelkay et al. [30]. found that Ethiopian nurses with a diploma were almost seven times more likely to know basic life support compared to nurses who only had a diploma [30]. In contrast, Tomas et al. [29], reported that there was no significant effect of educational status on theoretical knowledge in Kuwait. A possible explanation for this discrepancy is that in Kuwait, nurses, regardless of their educational background, are required to undergo periodic CPR examinations, which keeps their knowledge up to date.

Although attendance of courses such as Immediate Life Support (ILS) or Advanced Life Support (ALS) was low in our sample, participants who had attended these courses demonstrated greater knowledge retention. Similarly, nurses who had attended noncertified educational courses on CPR had very high rates of correct responses for both atropine and amiodarone. Recent education also appeared to have a positive impact, as nurses who had been educated within 1-3 years of the time, we assessed their knowledge appeared to perform better compared to our sample as a whole. As evidenced by other studies, such as Tamu Munezero et al. [31], & Rajeswaran et al. [32], nurses’ knowledge of medications during cardiac arrest increases when there is prior training through educational programs. However, it appears that this knowledge deteriorates over time and their knowledge background disappears. For this reason, it is proposed to establish regular training for health professionals in the management of patients with cardiopulmonary arrest, so that they acquire equal competencies and keep their knowledge and skills up to date.

As mentioned above, in our study, a small proportion demonstrated accurate knowledge about atropine administration (7.2%) and an even smaller proportion, about the administration of amiodarone (3.3%). However, knowledge about adrenaline administration seemed to be maintained at a better level (34.6%). In contrast, in a similar study to ours, that of Lach et al. [33], it was observed that 66.3% of participants possessed correct knowledge about the dosage and administration of amiodarone, as they correctly selected that in cases of manifestation of VF/pVT rhythms, 300 mg of amiodarone should be administered after 3 discharges followed by another dose of 150mg after 5 discharges. In the same study, 68.8% of the participants equally correctly recognized that in the case of nondefibrillable rhythms, 1mg of adrenaline should be administered as soon as possible after circulatory arrest is detected. At the same time, in the survey by Chen et al. [34], only 42.0% seemed to know the correct route for administering amiodarone. Therefore, we conclude that this observed knowledge concordance suggests that while awareness of the role of adrenaline and amiodarone in resuscitation may be widespread, there are still gaps in the knowledge of some groups of nurses, highlighting the need for targeted training and education to ensure consistent understanding and implementation of resuscitation protocols across all healthcare professionals.

Based on the findings, it becomes clear that enhancing nurses’ knowledge of drug administration during cardiopulmonary arrest is crucial. The implementation of regular and comprehensive educational programmes, including certificate courses such as BLS (Basic Life Support), ILS (Intermediate Life Support) and ALS (Advanced Life Support), is deemed essential to improve knowledge and compliance with ancillary evidence. resuscitation. Continuous professional development, combined with real-life simulation exercises, can further enhance the necessary skills, leading to better outcomes for patients during emergencies. In summary, the study highlights the critical importance of continuing education and training for nurses, while highlighting important gaps in existing knowledge that need to be addressed. By emphasizing these areas, healthcare institutions can better equip nurses to effectively manage cardiopulmonary arrests, ensuring higher successful admission rates and improved patient burden levels.

This research study sought to correlate various educational factors regarding the level of knowledge of nurses and nursing assistants in first response to an in-hospital cardiopulmonary arrest case. Despite the great findings, there are some limitations to the study. Firstly, as we are talking about a healthcare setting, future larger studies of a multicenter character are needed so that the findings can be extended to a country wide scale. Also, the study was only concerned with theoretical knowledge of the sample, so it would be inappropriate to seek a correlation with possible practical skills deficits. Finally, the comparative study of theoretical knowledge before and after an educational intervention may in the future indicate the critical and most appropriate educational interventions.

The study revealed significant gaps in nurses’ knowledge about the administration of critical drugs during Cardiopulmonary Arrest (CPR). The rates of correct knowledge for atropine (7.2%), amiodarone (3.3%) and adrenaline (34.6%) were particularly low, highlighting the need for enhanced education. It was also observed that younger nurses and those who had recent training on CPR had better performance than their older colleagues, especially in administering drugs such as atropine and amiodarone. In contrast, more experienced nurses demonstrated superior knowledge in administering adrenaline. Education and experience play a critical role in maintaining CPR skills, with nurses who have received higher education or have participated in accredited, or non-certified, programs (such as BLS, ILS, and ALS) showing better performance. In addition, the study emphasized the importance of continuing education and repeated practice, as knowledge diminishes over time without regular practice. Finally, regular training programs and simulation exercises are recommended to maintain nurses’ knowledge and skills to improve the success rates of resuscitation and increase the chances of patient survival.

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