IOSR Journal of Nursing and Health Science (IOSR-JNHS)

e-ISSN: 23201959.p- ISSN: 23201940 Volume 4, Issue 4 Ver. V (Jul. - Aug. 2015), PP 01-06
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Evaluation of Nurses' Practices toward Cardiopulmonary

Resuscitation in Emergency Unit at Azadi Teaching Hospital
*Saad A. Mahmood, MSc. / Nursing **Widad K. Mohammed, PhD Adult / Nursing
* Academic Nurse Specialist, Manager of Nursing Unit Kirkuk Health Directorate,
** Assistant Professor, Managerial Dean Assistant, College of Nursing, University of Baghdad,

Abstract:
Objectives: To identify and evaluate the practices of the nurses who work in emergency unit at Azadi teaching
hospital toward cardiopulmonary resuscitation.
Methodology: Descriptive study were conducted by evaluation the sample which that consist of (44) nurses,
through pre-test and post-test, they are chosen purposively (non-probability) for period 15th August 2014 to 30th
September 2014. This study was applied in emergency unit at Azadi teaching hospital in Kirkuk city. For this
purpose, checklist was introduced which consist of two parts; the first involves the demographic characteristics
of the nurses, and the second involves a scientific checklist (pre-test post-test) in main domains with (30) items
about application of cardiopulmonary resuscitation basic life support, automated external defibrillator use
and advance life support, the sample was divided into two groups (case group and control group), theory and
practical lectures were presentedfor case group only between the pre & post-test. The validity of the instrument
was determined by using of face validity through the panel of experts, and the reliability of the instrument was
determined by internal consistency through the computation of Pearson' Correlation Coefficient (Pearson'
Reliability). The data were collected through the utilization of the checklist via observation. Data analysis was
employed by applying the Statistical Package for Social Sciences (SPSS)version 21.
Results: The results indicated that the majority of sample was males and who aged 25-34 years old who were
graduated from secondary school, and who had less than 3 years of employment in emergency unit make
majority proportion. There are significant differences in sample's practices toward CPR and using the AED
between the pre-test and post-test for the case sample, and there is no relationship between demographic
characteristics of the sample and their practices except in domain of the AED use.
Recommendations: The study recommends providing more CPR training sessions and encouraging nursing
staffs to participating in these sessions, replication of the study with a large sample is important and reestablish
program of the 1000 Palmer.
Keyword: Cardiopulmonary Resuscitation, Emergency unit, Evaluation, Nurses and Practices.

I.

Introduction

Cardiopulmonary resuscitation CPR is a lifesaving intervention and the cornerstone of resuscitation

from cardiac arrest. Survival from cardiac arrest depends on early recognition of the event and immediate
activation of the emergency response system, but equally critical is the quality of CPR delivered. Both animal
and clinical studies demonstrate that the quality of CPR during resuscitation has a significant impact on survival
and contributes to the wide variability of survival noted between and within systems of care(1).
The purpose of cardiopulmonary resuscitation is to temporarily maintain a circulation sufficient to
preserve brain function until specialized treatment is available. Rescuers must start CPR if the victim is
unresponsive and not breathing normally. Even if the victim takes occasional gasps, rescuers should start CPR.
CPR should commence with chest compressions. Interruptions to chest compressions must be minimized. In
victims who need resuscitation, by stander CPR dramatically increases the chance of survival. Bystander CPR
rarely leads to harm in victims who are eventually found not to have suffered cardiac arrest: bystander CPR
should be actively encouraged(2)(3)(4)(5).

II.

Methodology

A descriptive study was conducted by evaluation the sample which that consist of (44) nurses, they are
chosen purposively (non-probability) for period 15th August to 30th September 2014.
The administrative arrangements procedure for conducting the present study has been takenby the
nursing college university of Baghdad to Kirkuk Health Directorate.
This study was applied in emergency unit at Azadi teaching hospital in Kirkuk city. For this purpose,
checklist was introduced which consist of two parts; the first involves the demographic characteristics of the
nurses such as (age, sex, educational level, years of employment, years of experience in emergency unit,
DOI: 10.9790/1959-04450106

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Evaluation of Nurses' Practices toward Cardiopulmonary Resuscitation in Emergency

participating in CPR training sessions), and the second involves a scientific practical checklist(pre-test posttest) in main domains; application of CPR basic life support, using of automated external defibrillator AED
and advance life support, these domains with (30) items. Under the strict supervision of the researcher .Each
nurse was given a time period about (2030) minutes to apply the procedures. Between the pre and post-test,
theory and practical lectures were presented for case group only.
The validity of the instrument was determined by using of face validity through the panel of experts (14
experts). These experts were 7 faculty members from Nursing colleges, 3 Anesthetists from inside and outside
Iraq, 4 Emergency Surgeons from Kirkuk hospitals.
The reliability of the instrument was determined by internal consistency through the computation of
Pearson' Correlation Coefficient (Pearson' Reliability) (6). The data were collected through the utilization of the
checklist via observation. Data analysis was employed by applying the Statistical Package for Social Sciences
SPSS version 21.

III.

The Results

Table (1): Distribution of the Demographic Characteristics of the Study Sample. No.: 44
Demographic
Characteristics

Age Groups (Years)

Gender
Educational Level
Years of Employment

Years of Employment
in Emergency Unit

Participating in CPR
training sessions

Subgroups
18 - 24 Years
25 - 34 Years
35 - 44 Years
45 years and more
Mean of Score
Male
Female
Institute
Secondary School
1 - 5 Years
6 - 10 Years
11 - 15 Years
1 - 3 Years
4 - 6 Years
7 - 9 Years
Mean of Score
Not Participating
1 Training session
2 Training session
3 Training session and more

Case Group
f.
%
10
22.7
7
15.9
1
2.3
4
9.0
5.5
16
36.4
6
13.7
8
18.1
14
31.8
17
38.6
4
9.0
1
2.3
17
38.6
4
9.0
1
2.3
7.33
8
18.1
10
22.7
3
6.8
1
2.3

Control Group
f.
%
6
13.7
9
20.5
7
15.9
0
0
7.33
14
31.8
8
18.1
9
20.5
13
29.6
17
38.6
2
4.7
3
6.8
18
40.9
1
2.3
3
6.8
7.33
9
20.4
7
15.9
4
9.0
2
4.7

Total
f.
16
16
8
4
22.5
30
14
17
27
34
6
4
35
5
4
11
17
17
7
3

%
36.4
36.4
18.2
9.0
68.2
31.8
38.6
61.4
77.3
13.7
9.0
79.6
11.4
9.0
38.6
38.6
15.9
6.9

f. = frequency, %= percent, CPR= cardiopulmonary resuscitation.

Table (1) shows the demographic characteristics of the study sample; the first and second age group
was (36.4%) of the study sample at age (18 34) years higher than other groups. The majority of the study
sample was males (68.2%). Relative to their educational status, the greater number of them was secondary
school graduates were of (61.4%) of the sample and (38.6%) of them were institute graduate. The majority of
the sample were who had one to five years of employment and they accounted (77.3%) of the whole sample.
The same percentage of the sample had one to three years of employment in emergency unit and they accounted
(79.6%). Concerning to participating in CPR training session, (38.6%) of the sample not participating in CPR
session, also (38.6%) had one training session in CPR, (15.9%) had two training sessions in CPR, and only
(6.9%) had three training sessions in CPR (table - 1).
Table (2): Effectiveness of the CPR'sTheory and Practical Lectures on Nursing Staff Practices between
Pre-test and Post-test for both Case and Control Groups.
The Groups

The tests
S.D.
5.828
Pre-Test
Control Group
10.477
Post-Test
6.160
Pre-Test
Case Group
4.261
Post-Test
The difference proportion between pre and post test for control group
The difference proportion between pre & post test for Case Group (effectiveness of CPR Lectures)

M.
49.18
54.36
47.32
73.41
5.18
26.09

M.: the Mean , S.D.: Standard Deviation, CPR: Cardiopulmonary Resuscitation.

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Evaluation of Nurses' Practices toward Cardiopulmonary Resuscitation in Emergency

This table shows the proportion of the difference for effectiveness of the CPR theory and practical
lectures on nursing staff's practices between pre-test and post-test for case group is (26.09%) which mean good
effectiveness of these lectures, while the proportion of the difference between pre-test and post-test for control
group is (5.18%) which mean very slight elevation due to no lectures they are exposed to.
Table (3): Distribution of the Association between the Educational Level of the Study Sample and all
Items of CPR domains
Domains
Check
Domain
items)

Responses
and
Call
(include 5

CPR
Application
Domain (include 20
items)
AED use and PostResuscitation
Care
Domain (include 5
items)
Total

Secondary Graduates
f.
%
6
5.5

Total

Ignore

Institute Graduates
f.
%
4
3.6

10

1.5

Partial Applied
Complete Applied
Ignore
Partial Applied
Complete Applied
Ignore
Partial Applied
Complete Applied

16
20
20
32
108
4
22
14

14.6
18.2
4.5
7.3
24.6
3.6
20
12.7

26
38
32
67
181
16
38
16

23.6
34.5
7.3
15.2
41.1
14.6
34.5
14.6

42
58
52
99
289
20
60
30

6.4
8.8
7.9
15
43.8
3
9.1
4.5

240

36.4

420

63.6

660

100

f.:frequency, %: percentage, CPR: Cardiopulmonary Resuscitation, AED: Automated external

defibrillator, df.: 2, Critical (tabulated) degree: 5.991, p-value 0.05.
Table (3) shows thatthe domain of AED uses and Post- Resuscitation Care have a significant
relationship with educational level, especially secondary graduates at p-value 0.05.
Table (4): Distribution of the Association between Years of Employment of the Sample in the emergency
unit and all Items of CPR domains
Domains
Check
and
Call Domain
CPR
Application
Domain
AED uses and
PostResuscitation
Care Domain
Total

Responses
Ignore
Partial Applied
Complete Applied
Ignore
Partial Applied
Complete Applied
Ignore
Partial Applied
Complete Applied

1 3 Years
f.
8
34
43
42
75
223
18
46
21

4 6 Years
f.
%
0
0
7
6.4
13
11.8
8
1.8
20
4.6
52
11.8
0
0
12
10.9
8
7.3

10 Years & more

f.
%
29
1.8
1
0.9
2
1.8
2
0.4
4
0.9
14
3.2
2
1.8
2
1.8
1
0.90

Total

%
7.3
30.9
39.1
9.6
17.0
50.7
16.4
41.8
19.1

10
42
58
52
99
289
20
60
30

1.5
6.4
8.8
7.9
15
43.8
3
9.1
4.5

510

77.3

120

30

660

100

18.2

4.5

f.: frequency, %: percentage,CPR: Cardiopulmonary Resuscitation, AED: Automated external

defibrillator,df.: 4, Critical (tabulated) degree: 9.488, p-value 0.05.
Table (4) shows that the domain of AED uses and Post-Resuscitation Care have a significant
relationship with years of employment in emergency unit, especially who have (1-3) years of employment at pvalue 0.05.

IV.

Discussion

1- Discussion of the Demographic Characteristics of Nursing Staff:

Analyses of nurses' demographic characteristics ensure the equivalency in both groups and there are
slight differences between case and control groups, this result of the study are accepted in the non-equivalent
(pre-and post-test) quasi experimental design. Relative to their age groups, most of the nurses in the control
group 9 (40.9 %) are second age group (25 - 34 Years), and in the case group 10 (45.5%) are first age group (18
- 24 Years) (Table -1). But these findings disagree with a study that reported that the age group (26 30) makes
the majority of nurses (43.1%) is more than other groups(7). This study reveals that the majority of nurses in the
case group 16 (72.7 %) were male, and the majority of nurses in the control group 14 (63.6 %) were male
(Table-1); the researcher confirms that the number of female assignments in the hospitals as general, is little,
and the working in emergency unit is difficult work, so it's hard to female. But these findings disagree with a
study that reported that the female (86.3%) is more than male (13.7%)(7).
Related to their educational level, most of the nurses in case group 14 (63.6%) and in control group 13
(59.1 %) are nursing secondary school(Table-1). Also these findings disagree with a studythat reported that who
had diploma in nursing makes the majority of nurses (69.6%) is more than other educational levels(7). This study
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Evaluation of Nurses' Practices toward Cardiopulmonary Resuscitation in Emergency

has revealed that the majority of the nurses in the casegroup 17 (77.3 %), and control group 17 (77.3 %) are less
than 5 years of employment as general (Table-1). This result indicated that the (5) years are predominant
among the nursing' staff. These findings agree with a study that demonstrated that had employment 5 years and
less makes the majority of nurses (55%) are more than other groups(7). This study has revealed that the majority
of the nurses in the case group 17 (77.3 %), and control group 18 (81.8 %) are less than 3 years of employment
in emergency unit (Table-1). The researcher confirms that the transition of nurses from unit to other cause the
nurses not to wish to work in the emergency unit because this unit needs difficult duty. These findings agree
with a studythat demonstrated who had employment 5 years and less makes the majority of nurses (55%) are
more than other groups(7). This study shows that the 10 (45.5 %) of nurses in case group have one Training
session in CPR, and 9 (40.9 %) of nurses in control group have no trainings in CPR (Table -1). These findings
agree witha studythat noted that more than half of nurses (52%) have no participating in CPR training sessions
(7)
. The researcher confirms that conference regarding the knowledge and practice related to the CPR, are not
fortunate to be enrolled in any training session or conferences because such session or conferences is not
available and present to them so that the researcher suggests an opportunity for nurses to be enrolled in CPR
training sessions, workshops and conferences to improve their knowledge and skills, and to keep them updated.
This suggestion is in agreement with the findings obtained from a study suggests that education programs have
been designed to keep nurses up to date with current practices and trends. They ensure nursing staff' abilities
through mandatory annual competency sessions(8).
2- Discussion of CPR Program Effectiveness on Nursing StaffPractices in Emergency Unit:
During measures the effectiveness of the CPR program on nursing staff's practices between pre-test and
post-test for both case and control groups, table (2) shows the Mean difference for effectiveness of the CPR
theory and practical lectures on nursing staff's practices between pre-test and post-test for case group is (26.09),
this means that the lectures have a good effectiveness on the nursing staff's practices apparent and clear in the
difference between the pre-test and post-test of the case group, and confirms the credibility of this result is that
there is very little difference in the Mean of (1.86) for control group. This result agrees with other studies, one in
Botswana(7) the CPR skills of the nurses improved by (67.8%) after their CPR training, similar findings were
reported by another study reported in Ireland(9). While the difference between pre-test and post-test for control
group is (5.18%) which means very slight elevation. The researcher confirms that the nurses in the control group
are not changed in pre and post-test, they remain the same practices at all measures. This outcome is in
agreement with a studywhich stated that the nurse does not participate in continuing education opportunities; the
nurse will not be able to renew her license to the practice(10).
3- Relationship between Nursing Staff's Practices in CPR with Demographic Characteristics (Educational
Level and Years of Employmentin Emergency Unit)
The results revealed that the case and control groups are comparable practices with regard to the demographic
characteristics (educational level and years of employment in emergency unit) to find out the relationship.
A- Educational Level:
As a result of the data analysis, there is no significant association between the nurses' practices of the
case group with their educational level related to main domains with all items of CPR application, except in the
domain of AED use and Post-Resuscitation Care have a significant relationship with educational level at p-value
0.05 (table -3). The researcher confirms that all nurses who work in emergency unit are graduated from
secondary nursing school and nursing institute, their study curriculum is almost equal, also they are work
together in same unit, so there are very slight or no differences between them in providing CPR, and they must
be prepared to implement any changes in patient care as soon as the changes become necessary (as the changes
in CPR guidelines).
In agreement with this result, a study reports that in the event of a cardiac arrest, nurses are perceived
by the community to be competent and ready to perform effective CPR. Irrespective of their educational level,
nurses have a professional responsibility to maintain competence in CPR through regular updates (11).
B- Years of Employmentin Emergency Unit:
As a result of the data analysis, there is no association between the nurses' practices of the case group
with their years of employment in emergency unit related to main domains with all items of CPR application,
except in the domain of AED and Post-Resuscitation Carehave a significant relationship with years of
employment in emergency unit at p-value 0.05 (table -4). Researcher sees the reason is that most nurses are
those who have a few years of employment in the emergency unit, and they have almost the same knowledge
and skills. While there is a study indicates that the important need according to that must be fulfilled if nurses
are to be in a position to administer effective CPR is the need for expert instruction, expertise and education
(collectively referred to as learning). Only nurses who have learned everything that they need to know about the
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Evaluation of Nurses' Practices toward Cardiopulmonary Resuscitation in Emergency

correct administration of CPR are in a fit state to administer CPR wherever it's required(12). There is an Iranian
study which stated that there are several authors showed that CPR skill decreased with time.
They demonstrated that retention ability of CPR skill in training was weak. The extent to which nurses CPR
knowledge and psychomotor skills were retained 2 years after re-test decreased from 80.6% to 64.3% (13).
Recommendations:
1- Providing more CPR training sessions and encouraging nursing staffs to the participating.
2- Replication the study with a large sample is important.
3- Reestablish program of the 1000 Palmer.

References
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Meaney P, et al, Cardiopulmonary Resuscitation Quality: Improving Cardiac Resuscitation Outcomes Both Inside and Outside the
Hospital A Consensus Statement From the AHA, 2010 :20
Shuster M, Lim SH, et al, Part 7: CPR techniques and devices: International Consensus on Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care Science With Treatment Recommendations, Circulation, 2010, 122 (suppl. 2) :4-8
Markenson D, Ferguson A, et al, Part13: First-aid, AHA & American Red Cross International Consensus on First-aid Sc. With
Treatment Recommendations,AHAjournal,2010 :3
Nolan J, Hazinski M, Billi JE, et al, International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care Science With Treatment Recommendations, 2010 :6-13
American Heart Association (AHA), Basic Life Support for Healthcare Providers, 2011: 1-4
Yount R, Correlation Coefficients, 4 th edition, chapter 22, Pearson' Reliability, 2006 :2-7, Accessed April 3 2013, weblog
http://www.napce.org
Rajeswaran L. and Ehlers VJ, Cardiopulmonary resuscitation knowledge and skills of registered nurses in Botswana, AOSIS-Open
Journals Inc., doi:10.4102/curationis.v37i1.1259, 2014 :1-7
Kingwood (Campus) Certificate III in (NRT) Health Services Assistance (Assisting in Nursing Work in Acute Care) Course no.
17596 Training Package/s: CHC02 Community Services National Course Code: 2012: HLT32507Course.
Madden, C., Undergraduate nursing students acquisition and retention of CPR knowledge and skills, Nurse Education Today
28(1), 2006, 218227. http://dx.doi. org/10.1016/j.nedt.
Margo U, Ehow C, Importance of Continuing Education in Nursing State of Michigan: Continuing Education Requirements for
Michigan Nurses, 2012
Terzi A.B., Nurses Role in the Modern Resuscitation Era, Evangelismos General Hospital chronicles, Supplement: 1619, Athens,
Greece Cardiology update, 2008 :1-4
Rajeswaran L, Cardio-pulmonary Resuscitation: Perceptions, Needs and Barriers experienced by the registered nurses in Botswana,
PhD. Dissertation, University of South Africa, Nov-2009 :145-198
Nori J, Saghafinia M, et al, CPR Training for Nurses: How often Is It Necessary .Iran Red Crescent Med J, 2012, 14, (2) :104-7

Checklist Domains and its Items

Check and Call Domain:
Check and Call step-1 General Assessment: Scene, Cars, Peoples, Electrics, Water, Smoke or fireetc.
Check and Call step-2 Specific Assessment: Be sure in safety place, no threats to him/her victim or others.
(with Explanation).
Check and Call step-3: Insurance of victim's consciousness by shake the victim's shoulder.
Check and Call step-4: Be sure of victim's consciousness by asking him/her "are you OK" (with
Explanation).
Check and Call step-5 Call: Shouting for help or activates Emergency medical service system (with
Explanation).
------------------------------------------------------------------------------------------------------------------CPR Application Domain:
CPR step-1: Starts with CPR according to the international guidelines: right setting (Sitting on knees beside
the victim).
CPR step-2: Put the rest one hand on the victim's chest (Middle chest = lower half of the sternum).
CPR step-3: Place the other hand on the first hand and fingers interlock.
CPR step-4: Make sure the pressure of his/her hands not on the ribs, the end of the sternum and not on the top
of the abdomen.
CPR step-5: Put arms straight vertical over the victim's chest non-flexing
CPR step-6: Start by compress on the exact location in depth (5-6) cm.
CPR step-7: Make sure that after each compression return the chest back completely.
CPR step-8: Do not leave the hands touching the victim's chest.
CPR step-9: Repeat the process of pressing the chest until 30 compressions.
CPR step-10: Time of compression is equal to the time of relaxation no more and no less.
CPR step-11: After 30 compressions, open the airway by tilting the head and lift the Chin.
CPR step-12: On the header of the victim is filling the nostrils with a soft part of it by the index finger and
thumb.
CPR step-13: Taking normal breath put lips on victim's mouth (and its open).
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Evaluation of Nurses' Practices toward Cardiopulmonary Resuscitation in Emergency

CPR step-14: Blowing into the victim's mouth with notes rise chest and it take about one second like his rise
in the normal state.
CPR step-15: With maintaining the victim's head is tilted and lifted his chin, and notes down the chest with
air outlet.
CPR step-16: Taking another normal breath (second) put the lips on the victim's mouth, and blowing it with
note rise chest that takes no more than 5 seconds.
CPR step-17: Return without delay to the positioning of the vertical compression on the victim's chest, and
the fingers interlocked and give 30compressions as in the first step.
CPR step-18: Continue compressions to breath ratio by 30:2 (30 compressions with 2 breaths).
CPR step-19: Stop only when the note marks of the return of consciousness or recovery as cough, open eyes,
speaking, purposive movements or normal breathing, or continue CPR without interruptions.
CPR step-20: Stop every two minutes to assess (check) the condition of the patient or injured, only when
absence of marks of return the consciousness or recovery.
--------------------------------------------------------------------------------------------------------------------------------------AED and Post-Resuscitation Care Domain:
AED and Post-Resuscitation Care step-1: Connecting the AED to the victim correctly.
AED and Post-Resuscitation Care step-2: Reading the diagnosis of AED correctly and distinguish
shockable condition from the other (VF&VT) and (PEA &Asystol).
AED and Post-Resuscitation Care step-3: The use of AED correctly, not touching the victim and alert
people by advocating a "Clear".
AED and Post-Resuscitation Care step-4: Advanced life support and special care for post CPR correctly
when the availability of the monitor, medicines, fluids and other medical supplies.
AED and Post-Resuscitation Care step-5: Identifying the complications as a result of CPR application
(fractured ribs, ruptured lungs and their pneumothorax & hemothorax) and others, and good handling with each
case.

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