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Effect of Nursing Care Standards on Nurses Perfomance Regarding Caring for Patients with Cardiac Arrhythmias Rawia Ali Ibrahim, Medical surgical nursing, Faculty of Nursing, Benha University Pro.Dr. Kamelia Fouad Abd-Allah, Medical Surgical Nursing, Faculty of Nursing, Ain shams Univeristy. Pro.Dr. Osama Sanad Arafa, Cardiology department, Faculty of Medicin ,Benha University. Dr. Sabah Said Mohammed Medical surgical nursing, Faculty of Nursing, Benha University. Abstract: The nursing care should be guided by clearly defined standards to ensure the high quality of care. Standards of care are definitive statements that describe a common or acceptable level of patients care or performance. The aim of this study is to evaluate the effect of nursing care standards on nurses' performance regarding caring for patients with cardiac arrhythmias in coronary care unit (CCU) at Benha university hospital. Research hypothesis are: the mean score of nurses' knowledge and practices level post NCSs implementation may be higher than their score pre NCSs. A quasi-experimental research design was utilized to conduct the aim of this study. This study was conducted in coronary care unit (CCU) at Benha University Hospital. Two groups of subjects were included in the study, namely experts and staff nurses working in CCU. Three data collection tools were used in the different phases of this study: First: Experts opinionnair sheet was designed to test the face and content validity of the designed NCSs. Second tool: Self-administered questionnaire sheet for nurses to assess nurses’ knowledge. Third tool: Nurses' practice observational checklist based on the designed NCSs. The results of the study showed that, the majority of jury group agreed upon the general form (face and content validity) of the NCS, the jury agreement ranged between(85.7% to 100%). Furthermore, the findings revealed that a statistical significant improvement in the total mean knowledge scores of nurses in all items of the study post implementing the standards (P= 0.000) as compared to pre implementing period. Also there was statistical significant improvement in the total mean practices scores of nurses in all items of the study post implementing NCSs (P= 0.000). Conclusion: there is a statistically significant improvement in nurses' performance regarding caring of patients with cardiac arrhythmias in CCU post NCSs implementation. The study recommended NCSs for management of patient with cardiac arrhythmias should be revised, updated and available in CCU in both Arabic and English language. Key Words: Nursing care standards, Cardiac arrhythmia, and Nurse’s performance 1 Introduction: Cardiac arrhythmia is an irregular heart rate, which actual performance can be compared. rhythm, or both. Arrhythmias are often Their main purpose is to promote, guide and grouped according to where in the conduction direct professional nursing practice and system the abnormality occurs: the SA node, optimal quality of care (Linda, 2014). the atria, the AV junction (the area around the Several frames are used in establishing AV node and the bundle of His), or the standards. According to American Nurses ventricles (Carter and Stegen, 2010). Association, (2010) the nursing process is suited to formulate standards based on valid Approximately one third of people with principle: assessment, diagnosis, planning, arrhythmia do not exhibit any symptoms, preventing their timely diagnosis implementation and patient's care goal. Process standards include or pounding heart, chest pain, of breath, dizziness, procedure, practice guidelines, plans and light documentation (Masters, 2014). headedness, anxiety, fainting or near fainting, Significant of the study: and reduced capacity to exercise, which can In Egypt, Approximately 4 million people impair the quality of life in some cases, symptoms can be dangerous and have arrhythmias. (Statistics by country for life- arrhythmias, 2011).On the duration of 2011- threatening, and may even lead to sudden cardiac death (Schmidt, Kisselbach 2012, the number of patients admitted to CCU & were 2315 patients, about 50-60% having Schweizer, 2011). arrhythmias. Nursing care standards (NCSs) may be defined as authoritative statements, Process activities necessary to achieve the desired symptoms, these may include feelings of a shortness evaluation. standards focus on the specific nursing treatment. For individuals who do have racing and (Benha university hospital statistical office, 2012).As well as from the the clinical experience and observation for the standard is a written rule or measuring criteria actual situation in cardiac care unit for 5 years to measure the quality of care, all standards of ,the practice provide a guide to the knowledge, arrhythmias skills; judgment and attitudes that are needed encountered in CCU and represented a major to practice safely .They reflect a desired and source of morbidity, there are a dangerous achievable level of performance against arrhythmias lead to sudden death and heart 2 researcher are noticed that common cardiac problem failure ,so this study has been conducted to 2-Experts :( No 21).The jury group of experts increase knowledge and practice of nurses consisted of caring for patient with cardiac arrhythmias Nine nursing educators from Medical – through implementing NCSs and to help them Surgical Nursing departments of Faculty of in promoting the quality of nursing care and Nursing decreasing morbidity and mortality for such University and Ain-Shams University, they group of patients. consisted of 2 professor,2 assistant professor Benha University, Zagazig Aim of the study and 5 lecturer. Nine physician representing This study aims to evaluate the effect of clinical cardiologists from Faculty of nursing care standards on nurse's performance Medicine at Benha University Hospital, they regarding caring for patients with cardiac composed of 4 residents, 2 assisstant lecturer, arrhythmias in CCU at Benha University 1 lecturer and 2professors and three nursing Hospital. administrator members representing head nurse Research hypothesis: The mean score of nurses’ knowledge level post manager from Benha University Hospital. NCSs implementation may be higher than their Data collection tools: score pre NCSs implementation and the mean Tool (1): Experts opinionnair sheet .This score of nurses' practice level post NCSs tool was designed to test the face and content implementation may be higher than their validity of the designed NCSs through score pre NCSs implementation. eliciting opinions of the jury group regarding Subjects and methods: agreement upon the proposed standards. The jury group members' response to the standards Design: statement and its criteria with either agree or Quasi experimental design was used to was disagree and comments. utilized to conduct the aim of this study. This sheet consisted of three parts: Setting: Part This study was conducted in coronary care unit I: This part consisted of jury characteristic (demographic characteristics) at Benha University Hospital. such as the job title, age, gender, educational Subjects: level, and years of experience. Part II: This 1-Nurses:All available nurses (No =30) who part was designed to test the agreement of were working in CCU at the time of study jury group upon the general form of the were included in this study. designed NCSs (face validity). It consisted of 3 10 items. Part III: This part was designed to Ahmed,( 2008), Shaaban, (2012) and AHA, test the agreement of jury group upon the (2011). It based on the designed NCSs. designed NCSs (content validity), this part It concerned with process standard of care consisted of (232) criteria under main (9) for patients with cardiac arrhythmias in CCU. standards statements that identify the specific This part consists of (232) items under main nursing activities for patients with cardiac nine headings that identify the specific arrhythmias. nursing activities for patients with cardiac arrhythmias as follows: Tool (2) Self-administered questionnaire sheet for nurses: It was developed by the 1. Nursing assessment (9 Items) researcher based on review of related 2. Nursing diagnosis (3 Items) literature. It compromised Arabic structured 3. Nursing planning (13 Items) items 4. Nursing implementation (12 Items) as follow related to different aspects of assessment the nurses’ knowledge about caring of patients with cardiac arrhythmias .It sub items: ■ Intervention regarding management of consisted of two parts:- Part 1: Demographic characteristics of nurses such as: age, sex, arrhythmias.(9 Sub items) ■ Nursing care in case of emergency level of education, marital status, years of arrhythmias.(15 Sub items ) experiences and previous attendance of ■ Connecting patient to monitor. (18 Sub items) training ■ Obtain 12 leads ECG and interpretation. (17 courses related to cardiac arrhythmias. Part 2: Nurses' knowledge about Sub items) ■ cardiac arrhythmias, standards of care. The scoring system of self administered Emergency medication for arrhythmias. (13 Sub items) ■ questionnaire sheet: Each right answer was given one score Cardiopulmonary resuscitation. (13Sub items) with total scores of 85. ■ Emergency defibrillation .(28 Sub items) ≥ 80% considered satisfactory knowledge. ■ Emergency cart preparation. (8 Sub items) < 80% considered unsatisfactory knowledge. ■ Care for patient with pacemaker.(16 Sub items) ■ Help patient for mobilization (6 Sub items) Tool(3): checklist: Nurses’ practice observational It was constructed by the ■ Hygienic care (3 Sub items) ■ Encourage patient to sleep (4 Sub items) researcher after reviewing relevant literature. 5. Safe environment. (20 items). It was adapted from Mahrous, (2003), 6. Ethics and patient rights. (4 items) 4 7. Health education. (13 items). action must take place in order to achieve 8. Communication. (13 items). them. 9. Nursing evaluation. (7 items). 2-Tools validity and reliability: Tools Scoring system of observational checklist validity were tested though a jury of (21) Each item was scored as follows Zero =not done. experts. The experts reviewed the tools for (1) = done incorrectly simplicity (2) = done correctly modification were done. This phase took one The total scores were (464) as follows; month from May 2014 to June 2014.Testing ≥ 80 % considered satisfactory level of reliability of proposed tools was done by clarity, relevance, and comprehensiveness, applicability, minor practice. Cronbach alpha test. < 80 % considered unsatisfactory level of 3- A Pilot study was carried out on 5 nurses practice. of the studied subjects, who were included in Operational design: the main study. The pilot study was done to 1-Preparatory included the phase: following; This phase the conduction of the study tools, and time available literature and different studies needed for each tool to be filled in. Few related to research problem, and theoretical modifications were done according to the knowledge of its various aspects of the study, pilot study findings.. This phase took one using month from (July 2014 to August 2014). textbooks, reviewing ensure clarity, applicability, feasibility of evidence-based articles, internet periodicals and magazines in order to 4-Field work: The process of data collection collect tools of this study . This period was carried out from the beginning of extended September 2014 to the end of March 2015. from (October 2013 to January2014). The researcher visited the CCU three days Designing nursing care standards: This was weekly (morning & afternoon) to collect the taken period of time from January 2014 to data by using previous tools. The researcher April 2014.It based on literature review, the interviewed with available nurses in CCU and researcher designed the NCSs for patients explained the aim of the study and took their with cardiac arrhythmias to be applicable by approval to participate in the study prior to staff nurses working at CCU in Benha data collection, then the researcher assessed university hospital. The standards used in this the nurses' performance level (knowledge and study "Process Standards" describe what practice) regarding caring of patients with 5 cardiac arrhythmias by using questionnaire helped to evaluate the effect of implemented sheet and observational checklist (pre NCS standards .This was done immediately after implementation) as following: the intervention. This phase took about Firstly, the researcher observed nurses' 6weeks. practice during caring for patients with Administrative Design: Permission was cardiac arrhythmias using the observational granted from the hospital directors and head checklist based on NCSs. Each skill was of the department of cardiac care unit at evaluated 3 times and the mean was Benha university hospital. After obtaining the calculated. approval for data collection. The objectives Secondly, The questionnaire sheets were and the nature of the study were explained administered by the researcher to all nurses and then it was possible to carry out the study individually to assess their knowledge about with minimum resistance. Additional to oral standards of care for arrhythmic patients and consent was taken from the nurses who explanation of the questionnaire sheet was participate in the study after explanation of done by the researcher. The average time the nature, aims and expected outcomes of the needed for the completion of each interview study. (by nurses) was between 25 – 35 minutes. Results This period of pre tests (knowledge and weeks. Table(1) illustrates the agreement of all jury The groups upon designed NCSs for patients with implementation phase was achieved through cardiac arrhythmias. It is illustrated that sessions at a period of 18 weeks. The total agreement of jury ranged between (85.7%) to numbers of sessions were 12. It divided as (100%). follows: four sessions for knowledge, and Table practice) took Implementation 6 of NCSs: (2) shows the demographic eight sessions for the practice. The duration of characteristics of staff nurses. Data in this each session ranged between 45 minutes to 6o table reveals that more than two fifth of minutes for each group including 10 minutes studied subjects (43.3%) their age ranged for discussion and feedback. between (25-<30) years old, the majority of 4-Evaluation phase: After implementing of them (98.3%) were female and the highest nursing care standards, the post tests were percentageof them (80%) were married. As administered to assess nurses' knowledge and well as two thirds of them (66.6%) practice using the same forms of pre tests, this having from (5-<10) years of experience and 6 were most of them (40%) holding bachelor of resuscitation, nursing care for emergency nursing degree. medications, arrangement of emergency crash Figure (1) Distribution of the studied nurses cart knowledge score respectively .while post its according to their total implementation they had satisfactory level of levels pre and post NCSs implementation ,this practices related to obtaining 12 lead ECG, figure nursing care in emergency defibrillation, and documented that only one third of nurses (33.3%) were having a satisfactory nursing knowledge level pre NCSs implementation. arrhythmias with percent (93.3%,90%,86.7%) However, the respectively. With statistically and highly majority of nurses (86.7%) were having a statistically significant difference between pre satisfactory and post NCSs implementation in all items of post its implementation, knowledge level. care in case of emergency nursing activities. (P<0.05 and p<0.001). Table (5): shows the total mean practices Table (3) demonstrates the mean score of nurses’ knowledge pre and post scores of study subjects pre and post NCSs NCSs implementation.. It is noted that a general implementation. It shows that a general improvement in the total mean practices improvement in the total mean knowledge scores of nurses in all items post NCSs scores of nurses in all items post NCSs implementation as compared to pre implementation as compared to pre its its implementation with mean (82.53±11.91) and (45.96±17.48) respectively. With highly implementation with (404.33±20.73) and the mean (232.73±25.88) respectively. There were highly statistically statistically significant differences (P= 0.000). significant differences observed between pre and post implementation in all items Table (4) describe nurses’ practices with P= 0.00. regarding nursing activities implementation Discussion component of the designed NCSs for patients The aim of this study is to to evaluate the with cardiac arrhythmias at CCU .It can be effect of nursing care standards on nurse's noted from this table that, nearly two thirds of performance regarding caring for patients the studied subjects(66.7%,70%, and 63.6% ) has unsatisfactory implementation practices pre with cardiac arrhythmias in CCU at Benha NCSs University hospital. related to most of nursing activities such as performing cardiopulmonary As regard to agreement of jury on designed 7 NCSs, the findings of the present study learning module with highly statistically showed that majority of the experts group significant differences. agreed upon all criteria of process standards Also, This results supported by Ahmed, (content validity). Their agreement ranged etal,(2015), who stated that nurses had between (85.7%to 100%). This finding is unsatisfactory knowledge related to standard supported by Sabra,etal (2014) , Shaaban of care for patient after coronary artery bypass (2012), and Saleh (2007) who found that the graft surgery pre NCSs implementation and great majority of jury group agreed upon the post its implementation showed an improvement in nurses’ knowledge. proposed standards. As regarding to nurses knowledge about In this respect, Change (2006); mentioned standards of care for patients with cardiac that nurses must be able to expand their arrhythmias .The current study revealed that knowledge of this area through ongoing an obvious improvement in the total mean education, knowledge scores of nurses post NCSs Consequently, teaching programs for nursing implementation as compared to pre its staff constitute an important part. implementation programs are urgently designed to assess significant with highly statistically difference. This improvement nursing staff might be related to the fact that majority of Journal and seminars. These in developing and enhancing the skills needed to provide high standards of them are young and are enthusiastic to learn. care to their patients. In addition to, the highly expressed needs of As regard to nurses’ practices after NCSs this group of nurses to learn more about implementation, the results of present study certain areas like arrhythmia interpretation. revealed that, the majority of nurses had Also this finding reflects that standards of unsatisfactory care had good effect in improving nurses’ implementation. This might be due to lack of knowledge and this could be due to the standardized nursing care recorded. Post concise presentation of each session using a NCSs implementation, there is a general simple improvement in nurses’ practices score with language and clear educational methods and instructional media. practice before NCSs highly statistically significant differences This finding is congruent with Ali (2012) between pre and post phase. who found an improvement in nurses’ This result agreed with Shaaban (2012) knowledge score after implementing of self who found that statistically significant improvement in all criteria of process 8 standard post application of the designed With NCS. regard to practice score of implementation nursing activities, there was As regard to assessment, the present study plainly enrichment in nurses’ practices score showed that there is a highly statistically in all nursing activities in post phase with a significant difference in nurses practices highly statistically significant differences.This related to initial and physical assessment result supported by Ibrahim (2014), who between pre and post implementation phases. stated that there was an improvement in This finding is in agreement with Munroe nurses’ practices score in intervention phase. and Curtis, (2013) who identified that As regards of nurses’ performance about assessment is the first integral step of the connecting patient to monitor, the study nursing care process. A comprehensive demonstrated that there was statistically patient assessment is necessary to understand significant the condition of the entire patient, comprising performance. of a complete health history and full physical findings, examination. Findings resulting from patient improvement in nurses practice score post assessment forms baseline data through which program implementation related to cardiac any changes in the patient’s condition can be monitor. Also Collins (2001) emphasized on measured the importance of cardiac monitoring as an against and treatment needs determined. Regarding improvement In of agreement Taha(2006) nurses’ with these that their stated important first step in the treatment program to nursing diagnosis and regardless of patient condition on admission planning the study revealed that the most as it is indicative of any arrhythmias to give common neglected practices among nurses meaning to the concept of CCU and to pre implementing the standards were analyze prevent and interpret data to drive a nursing diagnosis, monitoring system is a necessary component. cardiac crisis. An electronic develop time schedule to achieve plan and Nurse’s practices about recording a 12- documentation of plan ,while post standards implementation ,the nurses practices score lead ECG and arrhythmia interpretation. The was improved in these items with statistically present study showed that there was a highly significant significant differences. This findings improvement of nurse’s supported by Shaaban (2012) who found that performance. Post NCSs implementation, the most nurses apply nursing diagnosis and nurses’ performance scores were satisfactory. planning post application of the standards. This might be due to the fact that the 9 procedure of ECG was practiced under procedures manual and satisfactory after supervision and guidance from the researcher using the nursing procedures manual. that would ensure the continuation of high Regarding to nurse’s practices about crush level practice, In the same line Mahdy( 2009), cart, the present study showed that there was revealed that the nurses had unsatisfactory statistically practice pre program regarding 12 lead ECG nurses’ and arrhythmia interpretation . implementation. This result agreed with Taha significant practices improvement post of standard (2006), who reported that, the nurses’ Regarding to nurses performance about performance about crash cart unsatisfactory emergency medication, it was found that there pre program and satisfactory post program. was a highly significant improvement of the nurse’s performance standards and infection control in CCU, the present implementation. This result agreed with El- study reveals that an improvement in nurses Metwally highly practices score post standards implementation statistically significant differences in nurses’ with statistically and highly statistically practices between pre and post phase related significant differences. This results supported to by Ghoneim(2011) who documented that (2012), monitoring after Regarding to providing safe environment who intravenous found infusion of emergency drugs. nurses practices score related to infection As regard to nurses’ practices related to control in ICU was improved after program cardiopulmonary resuscitation (CPR) and implementation. defibrillation, the present study showed that Regarding to follow ethics and patient there was a highly significant improvement rights, the present study showed that all of post standards implementation than pre nurses follow ethics and respect patient rights implementation. This results supported by after standards implementation. This result Taha(2006), Mahdy( 2009) and El-Metwally( disagreed with Ahmed (2008) who reported 2012), who stated that the nurses had that the minority of nurses applied items of adequate practice post program regarding ethics and patient rights. CPR with highly statistically difference . Also Regarding health education for patient and Abd –Elkareem, etal, (2012), mentioned that the nurses’ cardiopulmonary satisfactory performance resuscitation before using the family, the present study revealed that nurses about is had unsatisfactory practice pre standards and not satisfactory practice post standards regarding nursing patient teaching. This is in likeness with 10 Saleh (2004) reported that nurses had Conclusion Based on the findings of the current study, it can be included that: The majority of nurses had unsatisfactory practices related to patient teaching pre program implementation. This may be due to lack of health education from unsatisfactory medical staff related to treatment, nature of knowledge and practices pre NCSs implementation. disease and complication .In addition nurses consider the education about disease is a Post NCSs implementation, there was an obvious improvement in nurses’ responsibility of doctors. This finding was knowledge and practices score with also supported by Sheta (2006) who found highly that there was highly statistically significant statistically significant differences between pre and post difference between pre /post phase in nurses phase. practices related to patient teaching before Recommendations discharge. study 1-Standards of nursing care for management there was a highly of patient with cardiac arrhythmias should be statistically significant differences in practice revised ,updated and available in coronary scores of nurses related to all items of care unit in both Arabic and English language. As regards to evaluation, documented that evaluation pre and post the standard 2-Continuous evaluation of nurses' knowledge implementation. This result supported by Urden, etal(2014) who stated that and practice is essential to identify their needs the in coronary care nurse must evaluate progress plan of care, evaluate units about cardiac 3- Further study is needed to apply the document revisions in diagnoses, outcomes, the care arrhythmias. towards attainment of outcomes through and coronary standards with larger sample size including the structure and outcome standards in addition to effectiveness of interventions in relation to process standards &evaluate its impact on outcomes and document the patient's response nurses’ performance regarding caring for to interventions . patients with cardiac patients’ outcomes. 11 arrhythmias and Table (1): Agreement of jury groups upon the designed NCSs for patients with cardiac arrhythmias (Content validity) (No=21). Items Agree Standard I-Assessing and Data gathering I.1: The nurse shall identify competently patient base line data. I.2 The nurse shall perform the physical assessment for the patient Standard II-Nursing diagnosis Standard III-Planning Standard IV-Implementation IV.1.Carry out interventions regarding management of arrhythmia IV.2-Provide nursing care in case of emergency arrhythmias. IV.3-Connect the patient to monitor IV.4-Obtain 12- LEAD ECG Interpreting A 12- LEAD ECG IV.5-Emergency medications IV.6-Perform Cardiopulmonary Resuscitation IV.7-Emergency defibrillation IV.8-Emergency crash cart IV.9-Pacemaker IV.11-Nursing care for hygienic measures IV.12-Nurse encourages the patient to sleep Standard V:Safe Environment Nurse shall provide safe environment for patient care within available resources Standard VI –Ethics and patient's rights Nurse shall follow ethics and respect patient's rights Standard VII -Health Education VII.1 Nurse provide information to patient /family Standard VIII-Communication VIII .1:Written communication VIII.2:Verbal communication with health team VIII.3:Verbal communication with patient and family Standard IX-Nursing Evaluation Nurse shall evaluate continuously the patient's progress toward attaining expected out comes 12 Disagree % No 0 .0 No 21 % 100.0 21 100.0 0 0 18 20 85.7 95.2 3 1 14.3 4.8 21 21 21 21 18 21 18 18 21 21 21 21 21 100.0 100.0 100.0 100.0 85.7 100.0 85.7 85.7 100.0 100.0 100.0 100.0 100.0 0 0 0 0 3 0 3 3 0 0 0 0 0 .0 .0 .0 .0 14.3 .0 14.3 14.3 .0 .0 .0 .0 .0 21 100.0 0 .0 21 100.0 0 .0 21 100.0 0 .0 21 100.0 0 .0 Table (2): Distribution of the nurses according to their demographic characteristics (N=30) Socio demographic characteristics Age in years 18-<25 25-<30 30-<35 No=30 10 13 7 Mean ± SD Gender Male Female Marital status Single Married Percentage 33.3 43.3 23.3 25.30 ± 3.05 Educational qualification Secondary nursing education Technical nursing education Bachelor of nursing Years of experience 1-<3 3-<5 5-<10 Mean ± SD training courses about cardiac arrhythmias No Yes 13 1 29 1.7 98.3 6 24 20.0 80.0 10 8 12 33.3 26.7 40.0 8 26.7 2 6.7 20 66.7 5.56±2.58 14 16 46.7 53.3 Figure (1): Distribution of the studied nurses according to their total knowledge score levels pre and post implementing the standard 14 Table (3): The mean score of nurses’ knowledge regarding components of the designed NCSs for caring patients with cardiac arrhythmias pre and post its implementation Pre-implementing standards Post - implementing standards Paired t – test P value Knowledge items Mean± SD Nurses' general knowledge about cardiac arrhythmias Concept of standards of care Standard I: Assessment Standard II: Diagnosis Standard III: Planning Standard IV: Implementation ECG procedure and interpretation connecting patient to monitor Emergency medications for cardiac arrhythmias. Emergency cart Defibrillation Cardiopulmonary resuscitation Standard V: Safe environment Standard VI: Ethics and patient's rights Standard VII: Health education Standard VIII: Effective communication Standard IX: Nursing evaluation Total knowledge score Mean ±SD 7.83 ±2.46469 16.7667±1.71572 16.409 .000 .1667±.37905 .6333±.49013 .3667±.49013 1.3333±.60648 1.5333±.50742 1.0000±.00000 .8333±.37905 2.7667±.43018 9.786 4.097 4.065 9.607 .000 .000 .000 .000 10.3000±3.66860 7.7000±1.70496 17.5333±3.91049 8.8333±.37905 8.532 3.616 .000 .001 3.7667±1.54659 7.6667±.71116 14.085 .000 1.9333±.73968 2.7667±.43018 5.473 .000 2.8000±.99655 4.7333±.63968 10.435 .000 5.5333±1.75643 .2000±.40684 8.5000±.82001 1.6000±.49827 7.828 15.389 .000 .000 .2667±.44978 1.5333±.50742 15.425 .000 2.2333±.77385 4.6000±.49827 21.079 .4667±.50742 .9667±.18257 4.385 .000 .000 .4333±.50401 .9000±.30513 4.065 82.5333±11.9146 32.095 45.9666±17.48519 15 .000 .000 Table (4): Nurses ‘practices regarding nursing activities implementation component of the designed NCSs for patients with cardiac arrhythmias at CCU (no=30) Standards Pre implementing standard N=30 Unsatisfact Satisfactor ory y No % No % Post implementing standard N=30 Unsatisf actory No % Satisfactory No % Chi squar e Test P Value Standard IV-Implementation IV.1.Carry out interventions regarding management of arrhythmia: IV.2.Provide nursing care in case of emergency arrhythmias. IV.3-Connect the patient to monitor IV.4-Obtain 12- LEAD ECG IV.5-Nursing care for emergency medications IV.6-Perform Cardiopulmonary Resuscitation: IV.7-Nursing care in emergency defibrillation IV.8-Arrangment of emergency crash cart IV.9-Nursing care for pt with pacemaker IV.10-Nursing care in helping patient for mobilization. IV.11-Nursing care for hygienic measures IV.12-Nurse encourages the patient to sleep 14 46.7 16 53.3 6 20.0 24 80.0 4.80 <0.05* 14 46.7 16 53.3 4 13.3 26 86.7 7.93 <0.05* 15 50.0 15 50.0 6 20.0 24 80.0 5.93 <0.05* 17 56.7 13 43.3 2 6.7 28 93.3 17.33 <0.001* * 21 70.0 9 30.0 4 13.3 26 86.7 19.81 <0.001* * 20 66.7 10 33.3 5 16.7 25 83.3 15.42 <0.001* * 15 50.0 15 50.0 3 10.0 27 90.0 11.42 <0.001* * 19 63.3 11 36.7 7 23.3 23 76.7 9.77 <0.05* 17 56.7 13 43.3 4 13.3 26 86.7 12.38 <0.001* * 16 53.3 14 46.7 5 16.7 25 83.3 8.68 <0.05* 16 53.3 14 46.7 7 23.3 23 76.7 5.71 <0.05* 18 60.0 12 40.0 7 23.3 23 76.7 8.29 <0.05* 16 Table (5): The total mean practices scores of study subjects pre and post NCSs implementation Nurses Practices Standard I: Assessment Standard II: Diagnosis Standard III: Planning Standard IV :Implementation Standard V: Safe environment Standard VI: Ethics and patient's rights Standard VII: Health education Standard VIII: Effective communication Standard IX: Nursing evaluation Total practice Pre-implementing standards Post - implementing standards Paired t –test P value Mean± SD Mean ±SD 9.3000±2.26137 .6000±.89443 11.0000±3.58156 167.2667±15.73692 20.4667±4.12506 18.7333±1.50707 3.7333±1.57422 20.3333±1.51620 265.6000±13.27066 32.9667±2.25118 19.608 11.788 14.456 54.748 20.823 .000 .000 .000 .000 .000 4.6000±1.45270 7.5667±.50401 11.395 .000 8.2667±3.85006 22.2667±1.77984 17.576 .000 7.9333±2.88795 21.8333±3.28091 19.619 .000 3.3000±1.80325 11.3000±2.56165 14.691 .000 57.320 .000 232.7333±25.88027 17 404.3333±20.73700 Practice. 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