Minia Scientific Nursing Journal (Print) (ISSN 2537-012X) Vol. (7) No.

(1) June 2020

Effect of Educational Protocol about Resuscitation Process on Nurses' Performance
Randa Moustafa Ali(1), Jehan Sayyed Ali(2), Inshrah Roshdy Mohammed(3), Eman Fadel Abd Elkhalek(4).

1. Demonstrator of Medical Surgical Nursing (Critical Care Nursing), Faculty of Nursing - Minia University- Eygpt.
2. Professor of Medical Surgical Nursing Department, Faculty of Nursing – Minia University-Eygpt.
3. Assistant prof. of Medical Surgical Nursing Department, Faculty of Nursing – Minia University- Eygpt.
4. Lecturer of Medical Surgical Nursing, Faculty of Nursing - Minia University.

Abstract
Background: Cardiopulmonary resuscitation (CPR) is an emergency procedure for a person whose heart has stopped
or no longer can breathing, CPR save live. Nurses' role is vital in resuscitation process. Aim of the study: to Evaluate
effect of educational protocol about resuscitation process on nurses' performance. Research design: Quasi -
experimental research design utilized to fulfill the purpose of this study. Subjects: A Purposive sample included sixty
nurses from critical care units. Setting: This study was carried out at five critical care units affiliated to Minia
University Hospitals- Eygpt. Tools of data collection: Two tools designed and used for collecting data for this study,
First: structured questionnaire sheet to assess nurses’ knowledge, second: Observational checklist for nurses′ practice
sheet regard resuscitation process. Results: There was a highly statistically significant difference in nurses' knowledge
and practice pre and post educational protocol regarding resuscitation process. Also, there was no statistically
significance between personal data and their knowledge level or practice score. Conclusion: Based on the results of
this study educational protocol can increase nurses′ performance about resuscitation process. Recommendations:
Greater attention and closely observation from hospital on nurse's performance during resuscitation process.
Replication of the study should be done on a large sample.
Keyword: cardiopulmonary resuscitation, nurses’ performance, critical care nurses, educational protocol,
resuscitation process.

Introduction occurred and approximately 209,000 cardiac arrests occurred

Cardiopulmonary resuscitation (CPR) procedure as a within a hospital. Survival rates from cardiac arrest are
basic skill is one of the most important inventions of the improving, however overall rates of survival are still low
history in medicine with a rapid and urgent intervention to (American Heart Association, 2012).
prevent or postpone death in a patient with cardiac arrest Through my experience as a clinical instructor over a
(Hasselqvist et al., 2015). CPR consists of an initial period of 2 years working in intensive care units I observed
assessment of the patient and a subsequent number of steps lack in nurses’ knowledge and practice during resuscitation
that includes chest compressions, airway maintenance and process that affect on patient’s condition and delayed patient
rescue breathing (Yang, et al., (2012). CPR is one of the out. Therefore, this study designed in an attempt to improve
procedures that can be administered without an explicit order nurses’ performance during resuscitation process.
from a doctor which most incidences of cardiac arrest are both
sudden and unexpected so, immediate actions are necessary Aim of the Study
(Waldron et al, 2016). CPR has been shown to reduce cardiac Evaluate effect of educational protocol about
death in-hospital and related facilities when patients are resuscitation process on nurses' performance.
managed by adequately trained health care professionals
(Simmes et al., 2012). CPR is a medical practice for all Research Hypothesis:
cardiac arrests except where a “Do not resuscitate” (DNR) or The nurses’ knowledge and practice about
“No CPR” order has been given for a particular patient ( resuscitation process will be better than pre educational
Burkle et al., 2013). Nurse is a key role in respond to a protocol.
cardiac arrest and initiate basic life support while waiting for
the advanced cardiac life support team to arrive (Terzi, 2012). Study Design:
Throughout the years, as CPR guidelines are altered and the Quasi - experimental research design was utilized to
roles of the multidisciplinary team members are also fulfill the purpose of this study
subjective to change. So, Some of these new roles include: the
rapid response nurse, the initiation of external defibrillation, Subjects:
the involvement in CPR decision making, chest compression , A purposive sample of about 60 critical care nurses
ventilation role, the understanding of the use of resuscitation who were working in a five Critical Care Units at Minia
drugs and the family support in the cases of witnessed University Hospital at the time of conducting the study and
resuscitation (Monsieurs et al., 2015). Nurses are the central willing to participate in the study was included.
part of the health care system and they are believed to be
knowledgeable and competent in caring for patients.( Ray, Inclusion Criteria:-
2016).  All nurses were in duties.
 Nurses who attended or not attended previous
Significance of the study training courses about resuscitation process.
Cardiac arrest is a major public health problem
affecting thousands of individuals each year in both out-of- Exclusion Criteria:
hospital and in-hospital settings (Hasegawa et al. (2013). In  Nurses refuse participation in the study.
2012 nearly 383,000 out-of-hospital sudden cardiac arrests
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Minia Scientific Nursing Journal (Print) (ISSN 2537-012X) Vol. (7) No. (1) June 2020
Setting: Pilot study: A pilot study was carried out on 6 nurses
All Critical Care units affiliated to Minia University working in the Critical Care units who fulfilled the inclusion
Hospital including (Intensive Care Unit, Emergency unit, criteria to test the feasibility, objectivity, applicability of the
Cardiothoracic Care Unit, Cardiac Care Unit, Stroke). study tools, and to estimate the needed time to fill the data
collection. Based on the results of the pilot study, no
Study Duration: refinement/ modifications were done for data collection
The total data collection was collected for five instruments; nurses who shared in the pilot study were
months from February to July 2019. included in the actual study sample.

Tools for data collection Ethical consideration: Official permission to

Two tools were designed and used for collecting data conduct the study was obtained from faculty ethical committee
for this study, these tools were formulated and tested by the of research, dean of the faculty of nursing at Minia University,
researcher, and the content of the tools was established after Research center afflicted to Egypt Ministry of Health,
extensive literature review. agreement from Egypt academic for the research center and
technology and from directors of Critical Care Units at Minia
First Tool: “Structured Questionnaire Sheet” it consists of 43 University Hospital. Oral consents were obtained from
(two parts): each nurse after explanation of the nature and purpose of the
1st Part: - Nurses’ personal data to collect nurses' data study. Each head nurses who were on duty during study
related to the following (age, gender, years of experience, implementation and nurses were free to either participate or
level of education …etc. not in this study and had the right to withdraw from the study
2nd Part: - Knowledge assessment questionnaire sheet at any time without any rational; also, nurses were informed
about resuscitation process and nurses' role in resuscitation that data will not be included in any further researches without
team.it was multiple choice questions sheet translated into another new consent. Confidentiality and anonymity of each
Arabic language. subject were assured through coding of all data. (60%) was
considered poor, (≥ 60-85%) was considered fair and more
Scoring System: than (85%) was considered good practice scores.
Each right answer takes one grade and the wrong
answer take zero grade with a total scores 38, so (< 60%) was Study Procedure: Once official permissions were
considered unsatisfactory; (≥60%) was considered granted, the pre-educational data (pre-test) collected through
satisfactory. (four weeks) to test studied sample for actual level of
knowledge and practices regarding resuscitation process. The
Second Tool:"Observational checklist for assessment researcher distributed the Knowledge assessment
nurses' practice in resuscitation Process" questionnaire sheet to assess study sample′ s actual level of
This tool consists of (23) items for evaluating nurses′ knowledge after clearly explaining the way to fill it, then
performance regarding their roles during resuscitation for Observational checklist for assessment nurses' practice in
critically ill patients in different critical care units. resuscitation Process"

Scoring System: The total number (60) of the study participants was
Each right answer (Done) take one grade and the divided into twenty classes each class consists of three
wrong answer (Not done) take zero grade with a total scores participants. The appointment for starting educational sessions
23, so (≤ 70%) was considered poor, (>70-85%) was was scheduled with the study sample according to their
considered fair and more than (85%) was considered good circumstances. The educational protocol was conducted as one
practice scores. session for knowledge teaching, two sessions for practice
teaching for every class; each session took about 30- 45
Educational Brochure about CPR Process. It was minutes. At the end of teaching sessions (knowledge &
formulated by the researcher after extensive literature review practice), the researcher gave the study participants brochure
and revised by experts in the field of critical care nursing. It as an educational protocol about resuscitation process: It was
was translated into the Arabic language with figures for more formulated by the researcher after extensive literature review
clarification. by experts in the field of critical care nursing , and translated
into the Arabic language with figures for more clarification.
Tools validity: The researcher collects post educational evaluation
The study tools were developed after reviewing the (post-test) for knowledge through giving the sample the
related literature. To determine content and face validity, these Knowledge assessment questionnaire sheet and
tools were tested by a Jury committee that consists of five Observational checklist.
medical surgical-nursing experts. Recommendations were as an immediate posttest assessment, then follow up
followed; the questions that were not appropriate were taken was done by the researcher after three months by using 2 nd
out and some questions needed clarification and modifications Part (Knowledge assessment questionnaire) &
were done. Observational checklist .
To evaluate the effectiveness of the educational
Tools reliability: protocol regarding study sample′ performance. Statistical
Tools were tested for content reliability using Alpha analysis of data: Data obtained from the study tools were
Cronbach’s test. It was (0.81) for the first tool, (0.79) for the categorized, tabulated, analyzed and data entry was performed
second tool. using the SPSS software (statistical package for social
sciences version 22.0). Descriptive statistics were applied (e.g.

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Minia Scientific Nursing Journal (Print) (ISSN 2537-012X) Vol. (7) No. (1) June 2020
mean, standard 45 deviations, frequency, and percentage). the more significant is the result (*), less than 0.001 was
Pearson's correlation coefficient was applied between considered highly significant (**). The P- value is the
quantitative variables. A significant level value was probability of error of the conclusion.
considered when p<0.05. The smaller the P-value obtained,

Results
Table (1): Percentage distribution of the studied groups as regards personal data (n= 60).
Personal data No. (60 nurses) 100%
Age categories
 20-24 31 51.7
 25-29 7 11.6
 ≥30 22 36.7
Mean ± SD 27.88 ± 7.709 years
Gender
 Male 19 31.7
 Female 41 68.3
Education Level
 Bachelor 9 15
 Technical institute 33 55
 Diploma & secondary school 18 30
Years of experience in ICU
 <5 years 36 60
 ≥ 5years 24 40
Mean ± SD 5.2667 ± 2.655 years
Previous workshop attendance
 Yes 14 23.3
 No 46 76.7

Table (1) revealed that more than half of the study group′s age was between 20-24 years and their Mean average age ± SD
was (27.88 ± 7.709) years and the highest percentage from them constituted (68.3%) were females, also as regards their educational
level results found that above the half among them had graduated from technical institute degree in nursing. On the other hand, the
highest percentage of participants constituted (60%) had less than five years of experience in working at critical units ,but lowest
percentage of them were more than five years of experience and their Mean average ± SD was (5.2667 ± 2.655 years). Finally, as
regards, previous workshop attendance regarding cardiopulmonary resuscitation process results revealed that the majority of the
study group constituted (76.7%) hadn't attended any previous workshop .

Overall total knowledge score level

100% 93.3%
78.3%
21.7
0 6.7

pre-test Imeddiately post-test

satisfactory unsatisfactory

Figure (1): Overall total studied samples' knowledge levels about CPR process in the pre-post education
Figure (1) revealed that 78.3% of studied sample had unsatisfactory knowledge during pre education ‫؛‬while100% of them
had hundred percent knowledge levels immediately post education, while post education after three months 93.3 % of them had
satisfactory knowledge level.

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Minia Scientific Nursing Journal (Print) (ISSN 2537-012X) Vol. (7) No. (1) June 2020

Overall total practice levels

83%

37 18
5% 45 12%
poor
fair
good

post-test pre-test
Figure (2): Overall total practice levels of the Studied groups in about CPR process through pre-post educational protocol
l(three months)
Figure (2) displayed that 83% of study sample had poor practice level during pre test ،while 45 % of them had good practice
level post three months test.

Table (2) Correlations between total knowledge score and total practice score among studied sample pre& post educational
protocol
Total Knowledge score Pre - education Post – education
Total practice score R P R P
 Pre- education 0.310 .016* -0.822 .000**
 Post education -0.136 .300(NS) 0.618 .000**

Table (2) showed that there was highly statistical significance between total knowledge and practice score at pre & post –
educational protocol (three months).

Table (3) Correlations between personal data and total practice score at pre& post educational protocol
Pre- education Post-education
personal data
R p-value R p-value

 Age categories 0.063 .630(NS) -.253 .052*

 Gender -0.091 .487(NS) 0.077 .560(NS)
 Education level 0.079 .550(NS) -0.033 .800(NS)
 Years of experience in working at critical units -0.082 .534(NS) -0.037 .776(NS)
 Previous workshop attendance regarding
-0.067 .611(NS) -.047 .722(NS)
resuscitation process

Table (3) reveled that there was no statistically significant correlation between all personal characteristics for studied groups
and their total practice score pre and post-educational protocol except in a studied sample's age categories it had a significant
correlation with mean practice score after three months post education with p-value (052*).

Discussion Results of the current study were agree with

Cardiopulmonary resuscitation (CPR) is an important (Elazazay et al., 2012) they conducted a study entitled effect
medical procedure which is critically required for individuals of cardiopulmonary resuscitation training program on nurses
who face sudden cardiac arrest or those who suddenly lose knowledge and practice and they found that the highest
their consciousness) Ray, 2016). CPR knowledge and skill is percentage of the study group′ age was between 20 to 25
extremely important to prevent and return the life of suddenly years, Also, results supported by (Parajulee & Selvaraj,
collapsed patient, so that nurse should become knowledgeable 2011) who stated that the majority of the study sample age
and skillful in delivering quality CPR (Wolfe et al., 2014). ranged from 20-25 years, In addition, a further validation by
During the current study the results of 60 nurses (Selman & Ahmed, 2018) who stated that the half of the
included in the study were have age from 20:24 years with the study group nurses who work in critical unites are with age
mean average age ± SD was (27.88 ± 7.709) years; this may range 18-24 years old (50%).
be due to shortage of the staff or the desire of university′s Findings of the present study showed that more
hospitals to provide high-quality health care services, through than two third of the total study group were females. These
employing as possible new graduates of the faculty of nursing results may be explained by the fact that nursing is a universal
or nursing technical institute in critical units. feminine profession especially in our society culture as well as

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Minia Scientific Nursing Journal (Print) (ISSN 2537-012X) Vol. (7) No. (1) June 2020
the enrolment of the male students in this profession was educational protocol improved considerably post intervention
started in the late decades. These findings agreed with given that there was no significant previous training or
(Selman et al., 2018) who conducted a study on critical care attendance any workshop.
nurses and they indicates that the female is the dominant These results confirmed by (Munezero et al., 2018)
gender among the current study, in which 73.3% of nurses in they conducted study that concluded that increase of nurses'
the study group, Also, results validated by (Rajeswaran et knowledge & skills after training, from a pretest average
al., 2018) who stated that the majority of the study sample scores of 46.0% to 81.3% for skills and 53.8% to 82.45% for
(70%) were female. Also, results supported by (Shah et al., knowledge. As well as, (Rajeswaran & Ehlers (2014) stated
2019) that the results of the CPR skills tests showed lower scores
Concerning to educational level; the present study before training was 32.4% indicating a low level of
findings demonstrated that, more than half of the study sample competence while post-test three months reach to high level of
graduated from a technical institute. This may be explained by competence (76.2). Moreover, (Elazazay et al., 2012
a little number of faculty′s graduates had employed in the Regarding Correlations between total knowledge
university hospital and other like to work in schools or score and total practice score among study sample pre&
ministry of health hospital. This study results is similar to the post educational protocol (three months) results revealed
study done by (Eubayd & Abbas, 2017) that stated the that there was highly statistical significance between total
highest percentage related to the educational levels is seen to knowledge and practice score at pre & post education (three
be educated in the nursing clinical institute that are 40% in the months). These results were disagreed with (Elazazay et al.,
study group. This result was contradicting with ( Al-Ani et al., 2012) who stated that decreasing knowledge level at the initial
2014) they found that most of participants (41.2%) held a baseline data assessment for nurses in ICU that also reflected
diploma degree in nursing. in the nurses' practice at pre-intervention of the program, that
Study results displayed that, more than half of the converted to a significant improvement of both knowledge and
studied groups had less than five years of experience in practice after intervention.
working at critical units because they were newly graduated Regarding Correlations between personal data of
and young aged. Studied results were supported by ( Al-Ani et the studied groups and total practice score pre-education
al., 2014) who founded that more than half (56.3%) of nurses and post-education (three months), results revealed that,
have less than five years of critical care units′ experience there was no statistically significant correlation between all
while only (33.7%) have more than five years of experience socio-demographic characteristics for study group and their
in working at ICU. These results contradicting with total practice score pre and post-educational protocol except in
(Rajeswaran et al., 2018) they stated that The duration of a study sample’s age it had a significant correlation with mean
work experience was divided between 49.3% (working from practice score after three months post education with p-value
between 1 and 6 years) and 50.6% (working for more than 7 (.052). These results similar to (Rajeswaran & Ehlers
years). Study findings illustrated that the most of the study (2014) they demonstrated that their no significant differences
sample had not attended any previous workshop regarding in terms of gender, age and experience, although a study
cardio pulmonary resuscitation process (CPR). This may be conducted in Belgium demonstrated that accumulated work
due to negligence from in-service educational training unit in experience was associated with improved CPR skills. On other
the hospital about importance of this topic, no preparatory hand, study results contraindicated with ( Rajeswaran et al.,
program for new staff and lack of interest from critical care 2018) they founded that Male participants scored slightly
nurses to attend any conferences or workshops. These study better than their female counterparts (52.9% vs. 46.1%) in the
findings agreed with ( Al-Ani et al., 2014), they illustrated pre-test, also, The highest improvement realised (28.5%) was
that more than half (61.2%) of critical care nurses had no observed among the participants with 5–6 years of experience
previous workshop attendance regarding cardiopulmonary and the least improvement (22.7%) was among the
resuscitation. participants who have more than 11 years of experience
Regarding overall total studied samples'
knowledge Score levels about CPR process, the results Recommendations
showed that, more than two third of studied sample had 1. Greater attention and closely observation from
unsatisfactory knowledge during pre education ،while 93.3 % hospital on nurses’ performance during resuscitation
of them had satisfactory knowledge level post three months process.
test, these results confirmed by (Tíscar-González et al., 2019) 2. Training program should be arranged for nurses
they founded that the nurses level of knowledge improved working in critical care units about CPR and receive
post educational program, moreover validation by ( regular, periodic CPR courses, updating nurses on the
Rajeswaran et al., 2018) they stated that the majority of latest CPR techniques,technologies and
studied samples' knowledge score 88.6% post 12 week of test. developments.
Further validation by (Selman & Ahmed (2018) they reached 3. The hospital organization must be emphasize to
to that the overall assessment of nurses' knowledge in the develop Mock Code Blue system and it’ s team for
study group showing a fair knowledge towards resuscitation at emergency situations when needed.
cardiopulmonary resuscitation process during the pre-test 4. Future studies have to be carried out in order to
period (86.7%), and their knowledge is increased to a good assess factors associated with poor level of practice
level during the post-test period (100%) after receiving an regarding resuscitation process pre-educational
educational program. protocol.
Regarding overall total practices levels of studied
samples' roles in resuscitation Process pre&post education
regard CPR process, the results showed that, the outcome
of post-test of CPR knowledge and skills of nurses post

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Minia Scientific Nursing Journal (Print) (ISSN 2537-012X) Vol. (7) No. (1) June 2020
Acknowledgment underreporting reasons and preventive measures. Iranian
The researchers would like to acknowledge the journal of pharmaceutical research: IJPR, 13(1), 3.
contribution of all participants who kindly agreed to take part 12. Parajulee S, Selvaraj V. Knowledge of nurses towards
in the study. They generously gave their time and attention to cardiopulmonary resuscitation in a tertiary care teaching
hospital in Nepal. Journal of Clinical and Diagnostic
conduct this study. This study would have been impossible Research, 2011; 5(8): 1585- 1588.
without their generosity. 13. Rajeswaran, L., & Ehlers, V. J. (2014). Cardiopulmonary
resuscitation knowledge and skills of registered nurses in
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