International Emergency Nursing 21 (2013) 247–251

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International Emergency Nursing

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The effectiveness of an education program on nurses’ knowledge

of electrocardiogram interpretation
Huajun Zhang MSN, RN, (Medium-grade) a,⇑, Lily Lihwa Hsu MSN, RN, (Professor, Dean) b
a
Emergency Center, Zhongnan Hospital, Wuhan University, Wuhan, China
b
Department of Nursing, Shanghai SanDa University School of International Medical Technology, Shanghai, China

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: The aim of the study was to evaluate the effectiveness of a continuing education program on
Received 1 July 2012 nurses’ knowledge of interpretation of 12-lead electrocardiograms (ECGs).
Received in revised form 1 November 2012 Methods: The study used a quasi-experimental design. Fifty-two nurses, including 23 nurses working in
Accepted 9 November 2012
an emergency department, 12 nurses working in a cardiology department and 17 nurses working in an
intensive care unit (ICU) were recruited for the study. Two learning methods were used: a lecture-based
education program and a self-learning handbook. The effectiveness of the methods was evaluated using a
Keywords:
questionnaire containing questions in five domains.
Effectiveness
Education
Results: Data analysis showed that before training, nurses who worked in the cardiology department
Nurses scored higher in basic ECG knowledge than those in the emergency department and ICU; test scores of
Knowledge nurses who had worked for 2–10 years were higher than else. The post-test total and domain scores at
ECG interpretation 2 weeks, and 4 months after the lecture-based learning and 1 month after a self-learning ECG handbook
was presented were higher than the pretest scores.
Conclusions: Prior to training, ECG knowledge differed with respect to the nurses’ different demographic
characteristics. The lecture-based education program and self-learning handbook material were effective
in improving the nurses’ ECG knowledge.
Ó 2012 Elsevier Ltd. All rights reserved.

Introduction
The clinical presentation of chest pain is a major problem for
health care professionals. Chest pain may or may not be accompa-
nied by related symptoms, making an accurate diagnosis difficult
to obtain. The cause of chest pain may be cardiac or non-cardiac.
Many diseases with this symptom may be life-threatening such
as cardiac arrhythmia, myocardial infarction, pulmonary embo-
lism, aortic dissection and so on. So when patients experience
chest pain, they must be investigated as soon as possible.
The National Service Framework for Coronary Heart Disease
provides guidance on important aspects of therapy that may make
a substantial difference to patient care (Docherty, 2003). It high-
lights the need to identify and fast-track patients with an acute
coronary syndrome so that thrombolysis or appropriate interven-
tional care can be applied as soon as possible to optimize myocar-
dial salvage and reduce door-to-needle time. The ECG is a useful
diagnostic test in those who have cardiac chest pain and have ST
elevation. It has no benefit in those with non-STEMI cases and this
⇑ Corresponding author. Address: Donghu Road 169, Wuchang, Wuhan, China.
Tel.: +86 (27)67813000 (business), +86 (27)86788583 (home), mobile: +86
18971497427; fax: +86 (27)67812892.
E-mail address: zhanghuajun_2006@yahoo.com.cn (H. Zhang).
is why other tests such as Troponin are more accurate in emer-
gency presentations. Even so, the ECG remains the most widely
used initial screening test for evaluating patients with chest pain
(Lancia et al., 2008). It is therefore extremely important that nurses
in acute clinical areas are able to record and interpret 12-lead elec-
trocardiograms so that the treatment can be initiated as soon as
possible, leading to better clinical outcomes for this patient group
(Docherty, 2003). The American College of Cardiology/American
Heart Association (ACC/AHA) guidelines specify that an ECG should
be obtained and interpreted within 10 min of arrival to the emer-
gency department in patients with symptoms suspicious of ACS
(Antman et al., 2004; Anderson et al., 2007).
In Australia, Kremser and Lyneham (2007) state that nurses are
very accurate and safe in their ability to recognize patients war-
ranting immediate thrombolysis. Nurse-initiated thrombolysis
has the potential to improve Door To Needle (DTN) time for most
eligible patients, where primary Percutaneous Coronary Interven-
tion (PCI) is not available. This is likely to reduce mortality rates
(Kremser and Lyneham, 2007), as physician workloads increase
and doctors may be busy with other patients. Nurses will continue
to play an important role in the initial assessment and manage-
ment of patients. Although the ECG is not the only diagnostic tool
in the diagnosis of related diseases, the benchmark door to balloon

1755-599X/$ - see front matter Ó 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ienj.2012.11.001
248 H. Zhang, L.L. Hsu / International Emergency Nursing 21 (2013) 247–251
time of 90 min is highly dependent on quick and accurate ECG
interpretation (Calder, 2008). Thus, interpretation of the 12-lead
ECG is essential for all nurses working in critical care settings.
But for many nurses, the ECG can be a confusing and complex sub-
ject (Cowley, 2005). The Harefield Hospital (Harefield, England) has
established a Rapid Access Chest Pain Clinic (RACPC) that enables
nurses to assess the patient and to form a treatment plan quickly
without waiting for a physician (as well as later). When a patient
with chest pain arrives in the clinic, an ECG is recorded and the
nurse consultant then examines the patient and decides if further
investigation is required. Four hundred fifty-four patients visited
the clinic from January 2001 to December 2003. One hundred thir-
teen patients (24.9%) were referred for angiography. Of these, 75
(66.4%) had coronary heart disease. This study demonstrates that
nurses can successfully use the protocol RACPCs without an in-
creased risk of making incorrect diagnoses and provides firm evi-
dence for the value of nurses competent in cardiac monitoring
and dysrhythmia identification (Pottle, 2005). A report by Jeffries
et al. (2003) compared the effectiveness of two methods of teach-
ing nurses how to perform a 12-lead ECG. The traditional method
included a self-study module and a brief lecture by an instructor.
The second method used the same content with an interactive,
multimedia CD-ROM supplemented with a self-study module.
Overall results indicated that both groups were satisfied with their
learning experience and had a similar improvement in their ability
to interpret ECGs (Jeffries et al., 2003). A study of the effectiveness
of a Web-based ECG teaching method versus a traditional lecture
method using a pretest/post-test experimental design with under-
graduate nursing students suggested that knowledge about ECGs
among students in the web-based teaching group was significantly
lower than that of students in the traditional lecture group
(t = 3.527, P < 0.01). Conversely, the ability to interpret ECG
recordings was significantly higher among students in the web-
based teaching group (t = 2.839, P < 0.05) (Jang et al., 2005).
Information is limited about Chinese nurses’ knowledge of
ECGs. Therefore, there is a critical need for clinical instructors to
train nurses in the appropriate hospital units on ECG interpretation
and to evaluate the effects of this training to ensure actual
improvement. Then we developed the following research ques-
tions to address the issue:
1. What are the prior knowledge levels among the participating
nurses who attended an ECG training session?
2. Are there significant differences in the pretest scores of ECG
knowledge among nurses with different demographic
characteristics?
3. Are there statistical differences in the level of knowledge of ECG
interpretation before and after the ECG training?
Methods
Design
This study used a quasi-experimental design with a one-group
pretest/post-test with punctuated training over time to examine
the effects of the education program on the knowledge level of
ECG interpretation. The independent variable was the educational
program on ECG interpretation; the dependent variables were the
nurses’ test scores before and after training, which consisted of
four timed tests.
Sample and setting
Nurses working in an emergency department, a cardiology
department and an ICU frequently encountered patients with car-
diac arrhythmia and have more opportunities to perform ECGs,
they were more likely to have an interest in learning how to prop-
erly interpret ECGs. So this study used purposive sampling and the
sample consisted of 52 nurses working in these units.
Ethical considerations
The study protocol was approved by the ethics committee. The
researcher explained the purpose of the study to the participants.
Each participant was assigned a code number, and names were
not connected to test scores by the researcher. Participants signed
an informed consent form.
Research instrument
Comprehensive ECG assessment questionnaire
Based on clinical experience and a literature review, the re-
searcher developed a questionnaire to examine what the nurses
had learned by referring to the ECG training material from Hand
(2002). The test questionnaire included 38 items and was divided
into five domains (Box 1) to examine the change in the level of
knowledge of the five subject areas at different periods.
Box 1
Domain 1: Basic knowledge of ECGs.
Domain 2: Knowledge of ECGs related to immediate
resuscitation.
Domain 3: Theoretical knowledge of abnormal ECGs.
Domain 4: Recognition of the cardiac arrhythmias which
are ventricular fibrillation and ventricular flutter.
Domain 5: Recognition of other types of abnormal ECGs.
Box 2
T0- Pretest immediately before the lecture-based educa-
tional program.
T1- Post-test 2 weeks after the lecture-based educational
program.
T2- Post-test 4 months after the lecture-based educational
program before giving out the handbook.
T3- Post-test 5 months after the lecture-based educational
program and 1 month after giving out the handbook.
Instrument validity
Using ratings of item relevance by content experts, evaluation
of content validity was conducted by three experts—a director of
an emergency department (an MD), a director of a cardiology
department (a cardiologist), and a head nurse from a cardiology
department having a master’s degree in nursing.
The questionnaire was evaluated three times. As a result of
questionnaire refinement the index of content validity was im-
proved to be 0.85, as measured by the index of content validity
(CVI).
Instrument reliability
The reliability of the test questionnaire was evaluated in a car-
diology department in another large teaching hospital in the same
city. In the assessment, the ECG questionnaire was completed by
10 nurses within 40 min. The reliability was 0.942, by the Kuder–
Richardson-20 (KR-20) formula. KR-20 is used with dichotomous
items.
 H. Zhang, L.L. Hsu / International Emergency Nursing 21 (2013) 247–251 249

Research intervention Table 1

Demographic characteristics of the nurses in the research sample (n = 52).

Lecture-based education program on knowledge of ECGs Item or range N %

The education program included several topics on ECGs. The Hospital unit Emergency department 23 44.2
lecture was given by two experts who specialize in the cardiovas- Cardiology department 12 23.1
cular system. ICU 17 32.7
One lecturer taught basic theoretical knowledge of ECGs: Age 20–29 38 73.1
30–39 9 17.3
1. the principle of cardio-electricity formation and the significance 40–50 5 9.6

of each waveform; Working years 62 16 30.8

2. the method of performing an ECG on a patient; 2–9 22 42.3
10–29 14 26.9
3. the characteristics and normal values of each duration and
interval in normal ECGs; Level of education Diploma 5 9.6
Associate degree 24 46.2
4. a summary of the method of ECG analyses, which was a six-step Bachelor degree 23 44.2
approach; and
Desire to learn about ECGs None 0 0
5. an introduction to common abnormal ECGs. Some 21 40.4
Most 31 59.6
This part of the lecture took 1.5 h. Previous education on ECGsa Yes 10 19.2
Another lecturer taught the following contents: No 42 80.8
a
Any ECG learning prior to the educational program of this study.
1. the classification of arrhythmias;
2. tips for analyzing ECGs;
3. the detailed characteristics of common abnormal ECGs, includ-
receiving the handbook, the participants received the third post-
ing sinus arrhythmia, atrial arrhythmia, junctional arrhythmia,
test. Test demands were the same as the pretest. The return rate
ventricular arrhythmia, atrioventricular block and MI; and
was 100% for the third post-test. All the processes were described
4. a summary of ECG interpretations.
in a simple flow chart (Fig. 1).
This part of the lecture took 3 h, for a total teaching time of
4.5 h. Participants were required to take the full course. Because Data analysis
of shift rotations, each lecture was taught twice in rotation to en-
sure every participant could attend the training session. Data were analyzed using SPSS version 13.0 for Windows. The
level of significance was set at P = 0.05 for all tests. Because data
Clinical nursing handbook on ECG interpretation were not normally distributed and equal variances were not as-
The researcher wrote and edited a handbook entitled ‘‘Clinical sumed, a non-parametric test was used to analyze all data. The
Nursing Training Handbook on the Knowledge of ECG Interpreta- Kruskal–Wallis test was used to analyze the differences in test
tion’’. The handbook was based on the content of the ECG training scores among nurses from different units, in different age groups,
program. The aim of the handbook was to support participants in with different numbers of working years, with different education
retaining the theoretical ECG knowledge that was taught in the lec- levels and in different professional posts. The Mann–Whitney test
ture and to use this handbook as a reference for their future prac- was used to analyze the differences in the pretest scores between
tice. To ensure accuracy, the contents were reviewed by a nurses who had and had not previously received ECG training. The
cardiovascular expert. Wilcoxon Signed Ranks test was used to analyze the differences
among the pretest and the three post-test scores.
Data collection

Researchers collected a pretest and three post-test scores to Results

determine the change in knowledge level in ECG interpretation.
Each test was conducted in a classroom of a Nursing School. Demographic background of the samples
The 52 participants began by filling out the demographic data
questionnaire (Table 1). The participating nurses were instructed Of the study participants, 44.2% (n = 23) worked in an emer-
in the correct form to answer the questions, and then they received gency department, 23.1% (n = 12) worked in an cardiology depart-
the pretest on ECG knowledge. To ensure the study would be as ment, and 32.7% (n = 17) worked in an ICU.
accurate and scientifically rigorous as possible, each participant
answered the questionnaires or test questions individually. Every-
one was requested to complete the test within 40 min, and all the Collected data flow chart for the research
test forms were collected in person from the participants. Sample Baseline data: Lecture on theory and
Immediately after the pretest, the nurses attended the lecture- selection Pretest (T0 ) immediately evaluation of ECGs
based training program. Two weeks after the lectures, the partici-
pants received the first post-test. Test demands were the same as
the pretest. All 52 participants took the first post-test.
Four months later, before giving out the handbook to partici- 2 weeks later Post-test 1 (T1 ) 4 months later Post-test 2 (T2)
pants, all of them took a second post-test to examine their reten-
tion of ECG knowledge with the passage of time. The return rate
was 100% for the second post-test scores. When the nurses re- ECG handbook Self-learning
ceived the handbook, they were informed that they must read Immediately delivered 1 month later Post-test 3 (T3)
and study the information further because ECG interpretation skills
could not be mastered easily without practice. One month after Fig. 1. Collected data flow chart for the research.
250 H. Zhang, L.L. Hsu / International Emergency Nursing 21 (2013) 247–251

The participants’ ages ranged from 21 to 50 years (median
32 years). The nurses’ education level included diploma, associate,
and bachelor degree. All of them were registered nurses (Table 1).
Baseline data on participants’ knowledge of ECG interpretation
Using the Kruskal–Wallis non-parametric test, there were sig-
nificant differences among emergency department nurses, ICU
nurses, and cardiology nurses in the knowledge of Domain 1
(Z = 6.770, P = 0.034), Domain 3 (Z = 13.268, P = 0.001), Domain 5
(Z = 10.936, P = 0.004), and the total score (Z = 8.699, P = 0.001) (Ta-
ble 2). The test scores of nurses in the cardiology department were
higher than those in the emergency department and ICU. When
comparing educational levels, there were no significant differences
in any domain or total scores (Z = 0.878, P > 0.05) among the
groups.
Using the Mann–Whitney non-parametric test to measure dif-
ferences, nurses who had received prior ECG training had signifi-
cantly higher pretest scores in Domain 5 (Z = 20264, P = 0.024)
and the total score (Z = 2.025, P = 0.043) than nurses who had
not receive any ECG training in the past.
Comparison of pretest and post-test results
Data analysis of the pretest and post-test scores was carried out
using the Wilcoxon Signed Ranks non-parametric test (Tables 3
and 4). There were significant differences in every domain and to-
tal scores between the pretest (T0) and the first post-test (T1)
scores (Z = 5.380, P < 0.01). Test scores for each domain and total
scores between T1 and the second post-test (T2) were not signifi-
cantly different (Z = 0.640, P > 0.05). When we compared the test
scores of the T2 and the third post-test (T3) scores, except for Do-
main 2, the domain scores and total scores were significantly dif-
ferent (Z = 5.695, P < 0.001). The test scores in every domain
and total scores between T0 and T3 were also significantly different
(Z = 6.100, P < 0.01).
Discussion
The baseline survey (pretest) completed by all participating
nurses showed that nurses in the cardiology department had high-
er scores in Domains 1, 3, 5, and in their total scores. These results
are to be expected because nurses in the cardiology department
have more opportunities to care for patients with cardiac arrhyth-
mia and have received prior ECG training; therefore, they may be
more familiar with the ECG knowledge of Domains 1, 3, and 5,
and have a higher total score. In fact, we found that nurses in the
study who had prior ECG training had higher Domain 5 and total
scores. Despite their higher pretest scores, cardiology nurses still
ranked high in their desire to learn, presumably reflecting their
understanding that maintaining good nursing skills requires con-
stant learning and review.
Education level did not make a difference among the study’s
participating nurses. These data sets may have been too small to
make useful comparisons and to have sufficient power to recognize
significant differences.

Table 2
Differences in knowledge domain scores among nurses in different hospital units by the Kruskal–Wallis test (n = 52).

Hospital unit Test scores

Domain 1 Domain 2 Domain 3 Domain 4 Domain 5 Total
ðx  sÞ ðx  sÞ ðx  sÞ ðx  sÞ ðx  sÞ ðx  sÞ
Emergency (n = 23) 2.0 ± 1.13 2.1 ± 0.63 4.6 ± 2.39 1.2 ± 1.03 5.8 ± 2.64 15.7 ± 5.31
Cardiology (n = 12) 3.2 ± 1.40 2.2 ± 1.03 8.1 ± 2.31 1.3 ± 1.07 9.7 ± 3.85 24.4 ± 7.35
ICU (n = 17) 1.9 ± 1.22 1.9 ± 0.56 5.9 ± 2.42 1.9 ± 1.11 7.9 ± 2.63 19.5 ± 5.57
Z 6.770 1.711 13.268 4.100 10.936 8.699
P 0.034 0.425 0.001 0.129 0.004 0.001

Table 3
Comparison of domain score and total scores for the pretest and three post-tests scores.

Test Test scores

Domain 1 Domain 2 Domain 3 Domain 4 Domain 5 Total
ðx  sÞ ðx  sÞ ðx  sÞ ðx  sÞ ðx  sÞ ðx  sÞ
T0 (n = 52) 2.2 ± 1.31 2.1 ± 0.71 5.8 ± 2.72 1.4 ± 1.09 7.4 ± 3.29 19.0 ± 6.74
T1 (n = 52) 3.1 ± 0.84 2.4 ± 0.70 8.4 ± 2.43 2.0 ± 0.88 9.5 ± 2.30 25.4 ± 4.76
T2 (n = 52) 3.2 ± 1.16 2.5 ± 0.85 8.5 ± 1.98 1.7 ± 0.87 9.3 ± 2.81 25.0 ± 5.28
T3 (n = 52) 4.0 ± 1.10 2.4 ± 0.50 9.9 ± 2.06 2.3 ± 0.58 11.1 ± 2.50 29.7 ± 4.93

Table 4
Comparison of the differences in test scores between different testing points using the Wilcoxon Signed Ranks test (n = 52).

Value Comparison Comparison Comparison Comparison Comparison Comparison

of Domain 1 of Domain 2 of Domain 3 of Domain 4 of Domain 5 of total scores
T0 and T1 Z 3.932 2.471 4.702 2.781 4.522 5.380
P 0.000 0.013 0.000 0.005 0.000 0.000
T1 and T2 Z 0.493 0.082 0.191 1.900 0.700 0.640
P 0.622 0.934 0.848 0.057 0.484 0.522
T2 and T3 Z 3.879 0.200 4.389 3.893 4.833 5.695
P 0.000 0.841 0.000 0.000 0.000 0.000
T0 and T3 Z 5.376 3.043 5.820 4.175 5.474 6.100
P 0.000 0.002 0.000 0.000 0.000 0.000
 H. Zhang, L.L. Hsu / International Emergency Nursing 21 (2013) 247–251
When comparing the pretest and post-test scores, we observed
that the first post-test (2 weeks after the lecture-based training)
total scores and five domain scores were higher than the pretest
scores. There was no difference in the two test scores collected
2 weeks and 4 months after the lecture-based training and before
handbooks were delivered. This finding is not surprising because
during this period the participants received no training, and the
majority of participants may not have put their knowledge into
clinical practice. The finding suggests that progress in ECG knowl-
edge needs constant learning and practice. This finding is consis-
tent with that of Jeffries et al. (2003) who reported that the
traditional lecture-based teaching method is effective in training
ECG knowledge.
However, the test scores for the questionnaires given before and
after handbooks were distributed were significantly different with
regard to the total score and scores of all domains (except Domain
2 on the topic of immediate resuscitation, where one question in
particular was difficult for the participants to answer), thus dem-
onstrating that the self-learning handbook material was effective.
Finally, there were significant differences between the pretest
and the last test in all domains and the total score, further demon-
strating that an educational program in ECG interpretation is effec-
tive for at least 5 months. Nevertheless, the reading of an ECG is a
skill that requires considerable training and clinical application. In
the past, the recommendation of the American Heart Association
recommended that prospective cardiologists read 800 ECGs of
varying types within a 3-year training period to ensure compe-
tency (ACP/ACC/AHA Task Force, 1995).
Many of the nurses who attended this research program re-
ported that they were more interested in ECG learning than they
had been at the beginning of the study and felt they could now pro-
vide safer nursing care to patients with chest pain. Video record-
ings in the clinical setting showed that the average door to
needle time reduced to 5.6 min from 7.8 min for these patients.
In the meantime, nurses play a key role in health education for
patients and their family members. They would have more confi-
dence in this area if they received proper training on EKG interpre-
tation and emergency cardiac care. So this program has promoted
professional competency in EKG interpretation and safe practice
for pt with chest pain. Some nurses regarded this training as help-
ing them to advance their career.
Conclusion
Prior to training, ECG knowledge differed with respect to the
nurses’ different demographic characteristics. The lecture-based
251
education program and self-learning handbook material were
effective in improving the nurses’ knowledge of ECG interpretation.
Future research is needed to develop more proficient teaching
strategies.
Acknowledgments
The research program was supported by HOPE nursing school of
Wuhan University and Zhongnan Hospital of Wuhan University. So
we would like to acknowledge the supports of the two institutions.
Then we wish to thank Dr. Shu-yuan Yao and Dr. Zhui Yu from
Zhongnan Hospital of Wuhan University who contributed the lec-
tures on knowledge of ECGs. We also thank Dr. Yan Zhao and Dr.
Jiang-hua Ren and head nurse Cui-jiao Tian from the same hospital
who evaluated the validity of the questionnaire. Lastly, we would
like to thank all the participants for their assistance with the
research.
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