Knowledge And Practice Of Cardiopulmonary Resuscitation Among ...

Researchjournali’s Journal of Public Health Vol. 3 | No. 1 January | 2017

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Knowledge And Practice Of Cardiopulmonary Resuscitation Among Public Health Nurse

Dorothy

Joseph

Offiong

(RN,RM,

DIP

[Anaesthesia],B.Ed., BNSc.)

Practitioners In Calabar Metropolis Of Cross

University of Calabar Teaching Hospital, Calabar, Cross River State, Nigeria

Alberta David Nsemo (Ph,D,

MSc.,PGDE,

BNSc.,RN/RM) Department of Nursing Science, University of

River State, Nigeria

Calabar, CRS, Nigeria

Affiong Ekpenyong (Ph.D,MSc.[Community Health],BNSc.,PHCE, MPA, RN) Department of Public Health Nursing, College of Health Technology, Calabar, CRS, Nigeria

www.researchjournali.com


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ABSTRACT Cardio Pulmonary Resuscitation (CPR) is a lifesaving technique useful in many emergencies, and nurses’ competence in this lifesaving procedure is a critical factor in patient outcome from cardiac arrest. However, studies reveal compelling evidences that suggest lack of competence in the performance of proper CPR among registered nurses. This study assesses the knowledge and practice of cardiopulmonary resuscitation among public health nurse practitioners in Calabar metropolis. The study employed a questionnaire-based cross sectional descriptive design. Purposive sampling technique was used to elicit information from 57 respondents. Findings reveal good knowledge of CPR. Generally, very few nurses actually practise CPR. No significant relationship existed between knowledge and practice of cardiopulmonary resuscitation (cal. r=0.090.05). The need for training and retraining of Public Health Nurse Practitioners with the ultimate aim of equipping them with the requisite skills, methods or techniques of practicing cardiopulmonary resuscitation becomes imperative. More so, government should provide the necessary incentives, facilities and other enabling environment that will facilitates appropriate practice of cardiopulmonary resuscitation. Key Words: Knowledge, Practice, Cardio Pulmonary Resuscitation, Public Health Nurse Practitioners.

1. INTRODUCTION Improvements in public health and medical care during the twenty first Century have led to substantial increase in life expectancy globally. As a result, the principal cause of death has undergone a substantial paradigm shift from predominantly communicable diseases to non-communicable diseases. Heart failure is a major clinical problem worldwide and has become a public health problem reaching epidemic levels (WHO, 2008). Oke (2014) described as alarming the rate at which many Nigerians die as a result of heart related diseases. Sudden cardiac death is the most prevalent yet preventable clinical problem. It is estimated to cause 300,000 to 400,000 deaths annually with 63% cardiac deaths (Beauchamp, Tom, Walters, Khan

& Anna, 2008).

Cardiopulmonary arrest occurs as a result of a combination of factors but the common pathway is hypoxemia. The brain cells cannot withstand hypoxemia and hypoglycemia beyond four minutes. Oxygen reserve in the body when atmospheric air is breathed is 1.535 litres. This reserve is exhausted in 3-4 minutes in the absence of maintained circulation. Hypoxemia leads to anaerobic metabolism, with the accumulation of lactic and pyruvic acid, the brain becomes irreversibly damaged and the patient becomes a vegetable even after having been resuscitated because of time wasted (Beauchamp, et al, 2008). The latest weekly poll results released by NOIPOLLs (Nigerians Leading Opinion Pool and Research Organization Limited) revealed that 52 per cent of adult Nigerian population are unaware of cases of heart diseases in their locality. Hence, they neglect medical checkups, resulting in incidents of heart diseases,



including heart failure and sudden deaths. To some extent, some of these sudden deaths caused by heart diseases or heart failure may have been prevented if they were skilled bystanders present to offer prompt resuscitation measures on the victims before they were rushed to the hospital. According to Morley (2007) the first apparent attempt at resuscitation was recorded in 2nd Kings 4:34 (KJV). That was in 800B.C when Prophet Elisha resuscitated a dead child of a Shunammite woman. The account stated thus: “And he went up and lay upon the child, and put his mouth upon his mouth and his eyes and his hands upon his hands, and he stretched himself upon the child. And the flesh of the child waxed warm” (Morley, 2007:9). In 1960, life guard personnel were instructed to perform mouth to mouth resuscitation inside water, using rescue buoys paddle boards, boats and canoe as notation support. As time went on, another form of cardiopulmonary resuscitation emerged. This was known as Basic Life Support (BLS) which followed the simple Airways Breathing and Circulation (ABC) form of resuscitation. However, in recent times, there has been a paradigm shift from ABC form of resuscitation to Circulation Airways and Breathing (CAB) method of resuscitation. The emphasis of CAB is to start resuscitation by establishing circulation through chest compressions, clear airways and then breathing (Khalid & Juma, 2010). Presently, the new guideline adopted by the American Heart Association is the AB-CABS. The AB portion of AB-CABS reminds emergency responders to quickly check if the patient airway is open and if he is breathing normally. If not, the responder moves straight into delivering chest compression, opening the airways and then breathing for the patient (30:2). If the patient breathing is normal, then the responder care provider can move further in the circle of care, code-named “S”. This means checking for serious bleeding, shock and spinal injury (Dal & Sarpkaya, 2013). Indeed, early cardiopulmonary resuscitation (CPR) remains a critical element in the prevention of sudden death, especially when it is combined with an efficient and immediate emergency medical service and advanced cardiac life support capability that can double or triple the victim’s chances of survival. Sufficient cardiopulmonary resuscitation knowledge of health personnel including physicians, nurses, dentist and pediatrician is highly crucial. The ability of qualified nurses to manage a cardiac situation competently is of considerable importance for a variety of reasons. It has been observed that of all healthcare personnel, nurses are most likely to discover and recognize cardiac arrest. Hence, nurses would be the most important factor in increasing the patient’s chances of survival (Hammond, Simes & Cross, 2010). Hemming, Hudson, Durham and Richuso also affirmed that when patients face a life threatening event such as cardiopulmonary arrest, they rely on the competence and skill of healthcare professionals. Nurses are often the healthcare providers closest to the bed side and the first to respond to patient’s needs, therefore their knowledge and skill needs to be optimal. In other words, it is necessary for nurses to be armed with the knowledge, skills and practice of basic life support such as performance of cardiopulmonary resuscitation (CPR) as they are often needed to safe life. However, studies have shown almost total ineffectiveness of some health care professionals to perform cardiopulmonary


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resuscitation which is the fundamental technique for the emergency treatment of cardiac arrest (Bull & Alex, 2007). In the study area, it was observed with dismay that whenever cardiopulmonary resuscitation was mentioned among public health nurse practitioners, they make expressions such as: “I cannot remember when last I practiced that”, “I do not know how to go about it”, “please bring your devices and teach us, we do not know it”. Again, it was observed that nurses in general were in the habit of calling the anaesthetist to resuscitate the patient when the need arises, instead of starting cardiopulmonary resuscitation and making it an ongoing process before the arrival of the anaesthetist. Furthermore, it is most frustrating to note that cardiopulmonary resuscitation is not made part of the public health nurses’ training. Besides, there is no manikins and other devices to practice cardiopulmonary resuscitation in their demonstration room. It is against this background that this study was proposed to investigate the knowledge and practice of cardiopulmonary resuscitation among Public Health Nurse Practitioners in Calabar Metropolis of Cross River State, Nigeria.

2. STATEMENT OF PROBLEM Ekeredu (2013) asserted that 52 per cent of Nigerian adults are suffering from heart diseases, and the rate has raised from 32.5 per cent in 2005 to 62.3 per cent in 2012. It is also estimated to cause 300,000 to 400,000 deaths annually with 63 per cent cardiac deaths (Beauchany, Townwater, Khan & Anna, 2008). Thus, in order to deliver high quality first aid to those that suffer from cardiac arrest and other cases that might result to sudden deaths such as suffocation, drowning, fire victims, etcetera, nurses in Nigeria just as obtained in other countries of the world, should be fully knowledgeable and skilled in life saving measures such as cardiopulmonary resuscitation. It is however unfortunate that in spite of all the advantages and benefits of cardiopulmonary resuscitation (CPR), its knowledge and practice by nurses in many health care settings in developing countries like Nigeria have been poor (Agunwah 2010). This is also confirmed by study reports that many nurses particularly in developing world rarely know or use the lifesaving process (Basavanthappa, 2013). In other words, the practice of cardiopulmonary resuscitation to save life in Nigeria is at low ebb, and it is worrisome that majority of nurses do not know that most of the sudden deaths arising from cardiac arrest could have been prevented with timely and appropriate intervention. It is obvious that many nurses claim ignorance of this life saving strategy. Besides, it is observed that while some health professionals see the need to acquire knowledge and skills in cardiopulmonary resuscitation that can save life, many others do not recognize the need for it. Thus this study became necessary to determine the knowledge and practice of cardiopulmonary resuscitation among public health nurse practitioners in Calabar Metropolis of Cross River State, Nigeria.


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3. SIGNIFICANT OF THE STUDY The study will be of immense benefit to public health nurse practitioners, other health care providers, individuals, government, scholars/ researchers, to mention but a few. To the nurses, the study would create awareness on the intricacies of pulmonary heart diseases, cardiac arrest and ways of preventing their occurrences as well as providing skillful and timely intervention thereby reducing the rising rate of sudden deaths. It would also enable them see the need to go for training to acquire the necessary skills in cardiopulmonary resuscitation. Besides, this finding would help doctors and other health workers to appreciate the problems related to the non-practice of cardiopulmonary resuscitation to reduce sudden death in the society. To the public, the result will serve as a source of information on the appropriate strategies towards the prevention, control and management of heart diseases and cardiac arrest which result in sudden deaths. To policy makers, it will help in the formulation of appropriate policies and laws on life saving first aid measures. Moreover, it will help the government to come out with health measures aimed at providing the necessary facilities and materials for public health nurse practitioners to enable them practice cardiopulmonary resuscitation. To researchers, findings from this study will serve as a source of knowledge and reference to other researches in this area, that is, the study will contribute to the existing body of knowledge in Nursing and allied health discipline.

4. STUDY OBJECTIVES The broad objective of this study is to assess the knowledge and practice of cardiopulmonary resuscitation among Public Health Nurse Practitioners in Calabar Metropolis in Cross River State. To achieve the above aim, the study specifically sought to answer the following questions: 

Does knowledge relate to practice of cardiopulmonary resuscitation among Public Health Nurse Practitioners?



To what extent do Public Health Nurse Practitioners in Calabar Metropolis practice cardiopulmonary resuscitation?



What are the factors influencing the practice of cardiopulmonary resuscitation among Public Health Nurse Practitioners in Calabar Metropolis?

Research hypotheses: The following hypothesis was formulated to guide the study;


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There is no significant relationship between knowledge and practice of cardiopulmonary resuscitation among Public Health Nurse Practitioners in Calabar Metropolis.

5. LITERATURE REVIEW 5.1 CONCEPT OF CARDIOPULMONARY RESUSCITATION (CPR) Cardiopulmonary resuscitation is a series of life-saving actions that improve the chances of survival following cardiac arrest (Homlberg & Herlitz, 2011). Successful resuscitation following cardiac arrest requires an integrated set of coordinated actions represented by the links in the chain of survival. The links include immediate recognition of cardiac arrest and the activation of emergency response system, early cardiopulmonary resuscitation with an emphasis on chest compressions, rapid defibrillation, effective advanced life support and integrated post-cardiac arrest care (Kwangha, 2012). Chugh, Gunsou, Stecher John & Thompson (2014) asserts that cardiopulmonary resuscitation is the level of medical care which is used for victims of life threatening illnesses or injuries until they can be given definitive medical care in the hospital. It can be provided by trained medical personnel, including emergency medical technicians, paramedical staff, and by lay persons who have received cardiopulmonary resuscitation training. Cardiopulmonary resuscitation is generally used in the pre-hospital setting, and can be provided without medical equipment (Beauchamp, LeRoy, Kahn & Mastroianni, 2008). Mooney (2009) described basic life support as maintenance of circulations of oxygenated blood to the brain in a collapsed patient, by external cardiac massage (Chest Compressions). Chest compression is administered at the rate of 100 compressions per minute with the patient’s airway held in the open position (Patient in a supine position, head tilt backwards, neck extended, lower jaw pulled forward; 30 chest compression (that is at 100/minute) may be alternated with two rescue breathing administered by the rescuer or an assistant. Cardiopulmonary resuscitation is continued until normal heart function resumes and the patient breaths spontaneously, or until the patient can be passed to the emergency rescue service for ongoing care (Mooney, 2009) Professional bodies in many countries have formulated guidelines on how to provide cardiopulmonary resuscitation. The guideline outlines algorithms for the management of a number of conditions such as cardiac arrest, choking and drowning. Cardiopulmonary resuscitation generally does not include the use of drugs or invasive skills, and can be contrasted with the provision of advanced life support (ALS). Most lay persons can master cardiopulmonary resuscitation skills after attending a short course. Fire fighters, life guards, and police officers are often required to be certified in cardiopulmonary resuscitation. Cardiopulmonary resuscitation is also immensely useful for many other professions such as daycare providers, teachers, security personnel, social


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workers especially those who are working in the hospitals and ambulance drivers (Beauchamp, LeRoy, Kahn & Mastroianni, 2008). Nigeria does not have cardiopulmonary resuscitation guideline, but do follow that of American Heart Association. However, there is a paradigm shift in the cardiopulmonary resuscitation guidelines over the years with more improvement in outcomes (Onah, Ezugwu, & Eze, 2007). The cardiopulmonary resuscitation guidelines – “ABCD” is now “AB-CABS”. According to Hyacinth, Adekeye, Ibeh, & Osoba (2012) the traditional ABCS order of priority care in cardiopulmonary resuscitation courses has been expanded to the new order of AB-CABS. The AB portion of AB-CABS reminds emergency responders to quickly check if the patient’s airway is open and if he is breathing normally. If the patient is not breathing normally, the health care provider moves straight into delivering chest compressions, opening the airway and then breathing for the patient (Mantelblatt, Lawrence, & Gaffikin (2010). If the patient is breathing normally, then the health provider can move further in the cycle of care that is the “S” to check for serious bleeding, shock and spinal injury (AHA, 2010) with the recommended steps as follows: 

D = Check for danger



R = Check for response

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S = Send for help

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C = directs rescuers to perform 30 compressions to patients who are unresponsive and not breathing normally followed by 2 rescuer breaths

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A = directs rescuers to open the airway

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B = direct rescuers to check breathing but no need to deliver rescue breaths

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D = direct rescuers to attach on AED as soon as it is available and follow promptly. Any attempt at resuscitation is better than no attempts.

Berg, Hemphill, Abella, Aufderheide, Cave & Hazinski (2011) documented the critical lifesaving step of cardiopulmonary resuscitation as thus; 

Immediate recognition of danger signs and activation of the emergency response system,

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Early cardiopulmonary resuscitation and Rapid Defibrillation for VF,

When an adult suddenly collapses, whoever is nearby should activate the emergency system and begin chest compressions on a hard surface as the victim is made to lay on his/ her back (regardless of training) and that trained rescuers and health care providers should provide compressions and ventilations. Cardiopulmonary resuscitation is not harmful but not taking action is harmful and cardiopulmonary resuscitation can be lifesaving. However, the quality of cardiopulmonary resuscitation is critical. Hakama, Joutsenlahti, & Virtaren (2006) opined that chest compressions should be delivered by pushing hard and fast in the center of the chest in the mediasternum, compressions should be of adequate rate and depth.


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Rescuers should allow complete chest recoil after each compression and minimize interruption in chest compressions. They should also avoid excessive ventilation. If and when available, an AED should be applied and used without delaying chest compressions. With prompt and effective provision of these actions, lives are saved every day (Berg,`Hemphill, Abella Aufderheide cave & Hazinski, 2010). 5.2 KNOWLEDGE OF CARDIOPULMONARY RESUSCITATION AMONG PUBLIC HEALTH NURSE PRACTITIONERS Studies have shown that knowledge of healthcare professionals including nurses on cardiopulmonary resuscitation (CPR) in developing countries is low. A survey carried out by Henxiu-zheh, Zhang, Rui-Lian, FU Yan-mei & Wang Tae (2008) to assess the knowledge of nurses on cardiopulmonary resuscitation in community-based service in Haiwan province of China, revealed that knowledge of cardiopulmonary resuscitation was very low (23.18%) in Haiwan province of China. The study concluded that nurses of community-based health services in the rural region of Hainan province, China lack the basic knowledge of cardiopulmonary resuscitation. In a similar study conducted by Alegro (2013) to determine the relative influence of level of knowledge of cardiopulmonary resuscitation and qualifications of nurses, the result showed that there is a significant difference between level of knowledge and different levels of qualifications of nurses. The result implies that nurses with higher qualifications tend to be more knowledgeable in cardiopulmonary resuscitation than nurses with lower qualifications. Also, a cross sectional survey carried out by Jallin & Gbangu (2012) to determine the perceived competence in cardiopulmonary resuscitation among qualified nurses in Kuwait, showed that nurses’ knowledge of cardiopulmonary resuscitation was high and appreciative. Examining nurses’ knowledge on what condition of a patient suffering from cardiac arrest will a nurse call a doctor in the emergency room, Kanday, Jeherdli & Al. faid (2007) reported that 41.9 per cent choose the wrong answer on a trial flutter while only 1.2 per cent selected the right answer. The overall median knowledge score of the registered nurses who participated in the study were 42.9%. for cardiopulmonary resuscitation (CPR) and 52.0% for ECG. Okimba (2012) carried out a study in the University Collage Hospital, Ibadan to determine whether nurses have the right knowledge about the pattern of performing cardiac compression if they were alone. The result revealed that only 4.8 per cent of the respondents had the right knowledge, indicating a low level of knowledge among the nurses on the pattern of performing cardiac compression if they were alone and no one was there to help them. Steen & Kramer-Johansen (2008) reported that knowledge of cardiopulmonary resuscitation includes recognition of signs of sudden cardiac arrest (SCA), heart attack, stroke and foreign-body airway obstruction (FBAO). Same authors further added that it is very important that every nurse and doctor working in the hospital and persons living in the community know about cardiopulmonary resuscitation to save lives and improve the quality of life of individual with life threatening situation. Doctors, nurses and paramedical staff are expected to know about it, as they are frequently coming in contact with cases of life threatening conditions and the


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knowledge of CPR will be definitely useful (Steen et al, 2008). Shrestha, Batajoo, Piryani & Sharma (2012) conducted a study on the knowledge and attitude of nurses and medical/paramedical professionals on cardiopulmonary resuscitation, their personnel experience, attitude and knowledge of cardiopulmonary resuscitation based on the 2005 cardiopulmonary resuscitation guidelines of European Resuscitation Council. The result showed that out of 121 respondents, doctors who had the knowledge on cardiopulmonary resuscitation obtained a highest mean score of 1.62, whereas those who had no knowledge of cardiopulmonary resuscitation obtained a mean score of 5.38 (P=0.001). In the same study, nurses who had the knowledge of cardiopulmonary resuscitation had a higher median score of 2.43 in comparison to those who had no knowledge of cardiopulmonary resuscitation who had a mean score of 6.09 (P