The effectiveness of an online educational program on nurses’ electrocardiogram interpretation skills

Since 2000, ischemic heart disease (IHD) has been among the top ten causes of death globally [1]. More than four million people in Europe die each year from cardiovascular diseases. Approximately 1.8 million of those deaths are due to coronary heart disease (CHD), whereas 1.1 million are due to stroke [2]. In Türkiye, circulatory system diseases (36.8%), excluding noncommunicable diseases, are the leading cause of death. When deaths from circulatory system disorders are broken down into their underlying causes, ischemic heart disease accounts for 39.1% of these deaths, cerebrovascular diseases account for 22.2%, and other heart conditions account for 25.7% [3].

Electrocardiography (ECG) is the gold standard initial test for diagnosing myocardial infarction (MI) and ischemia [4]. It is widely used because it is a noninvasive, easily accessible, and cost-effective method that provides immediate results [5]. Ward nurses often perform or monitor ECGs to address acute situations or administer special medications requiring ECG monitoring. Intensive care unit (ICU) nurses monitor ECGs to assess their patients hemodynamically. They also perform extra ECGs to follow up with their patients in acute situations. Therefore, it is crucial to correctly interpret ECGs to diagnose and treat serious dysrhythmias that increase the risk of death, such as myocardial ischemia, fluid‒electrolyte imbalances, and long QT syndrome. It is also crucial to recognize any sudden changes in the ECG that may occur because of the patient’s condition to take immediate action [6, 7].

Nurses are the primary caregivers who manage treatment processes 24/7. They are responsible for performing and monitoring ECGs to follow up with their patients [6, 8, 9]. The Nursing Regulation published in the official gazette (No: 27515) on April 19, 2011, stipulates that nurses are responsible for monitoring ECGs and communicating with other healthcare professionals in emergencies [10].

Nurses play an active role in healthcare services. Therefore, they are expected to have the knowledge and skills to provide high-quality and effective care and plan and implement interventions to identify patients with altered health status [11]. However, Çelik et al. [6] reported that emergency room and ICU nurses knew little about ECG interpretation. Özoğul et al. reported that nurses who attended ECG training had a significantly higher mean posttest score (87.6) than pretest score did [11]. İbrahim et al. [12] 201 recruited ICU nurses and provided them with ECG training. They reported three critical results. First, nurses who knew little about arrhythmia learned more about it from training. Before the training, only half of the nurses could monitor patients, but this increased to 80% afterward. Similarly, the percentage of nurses who could perform and interpret ECGs rose from 60% before training to 90% after training.

There is limited literature that ECG training programs make nurses better at interpreting ECGs. The Turkish Society of Intensive Care Specialists Nursing Commission organized the fourth Basic Intensive Care Nursing E-Course in 2022. The feedback from more than half (57.8%) of the nurses who attended the e-course showed that nurses needed training in ECG.

This study investigated the effect of an online ECG education program (intervention) on nurses’ knowledge of ECG interpretation.

Most participants were women (82.2%) between the ages of 20 and 29 years (71.1%) and had bachelor’s degrees (72.2%). More than half of the participants had 1–5 years of work experience (52.3%), with a minimum of one year and a maximum of thirty years of employment. More than half of the participants were ICU nurses (68.3%). Twenty-four participants were inpatient ward nurses (13.3%). Ten participants were emergency room nurses (5.6%). Four participants were surgical nurses (2.2%). Nineteen participants were students or academics (10.6%). Most participants had never previously received training in ECG (74.4%) (Table 1).

The participants had a significantly higher mean posttest ECG-KT score (66.2 ± 17.2) compared to the pretest score (46.5 ± 17.5) (p <.001). The posttest scores (M = 66.2, SD = 17.2) were significantly higher than the pretest scores (M = 46.5, SD = 17.5) (p <.001, Cohen’s d = 1.23). The effect size was calculated as Cohen’s d = 1.23, which is classified as a large effect size according to Cohen (1988) [17]. Additionally, a post-hoc power analysis was conducted, yielding a statistical power of (1 - β) = 99.9%.

They had significantly higher mean posttest ECG-KT “normal sinus rhythm and derivations” (p =.006), “arrhythmia of atrial origin” (p =.010), and “acute coronary syndrome” (p =.043) scores than did the pretest scores. They had the highest and lowest pretest scores for “arrhythmias of ventricular origin” (53.57 ± 21.41) and “blocks” (26.39 ± 1.17), respectively. They had the highest and lowest posttest scores on “pacemaker” (78.33 ± 10.21) and “blocks” (36.39 ± 1.17), respectively (Table 2). Age and sex did not significantly affect our participants’ pretest and posttest ECG-KT scores (p >.05) (Table 3).

Education significantly affected our participants’ pretest and posttest ECG-KT scores (pretest p =.031; posttest p =.021). The participants with master’s degrees or Ph.D.s had significantly higher marks and posttest ECG-KT scores than did those with bachelor’s degrees (pretest p =.024; posttest p =.037). Work experience also significantly affected their pretest and posttest ECG-KT scores (p =.014). Nursing students had a significantly lower mean pretest ECG-KT score than did those with 6–10 years (p =.008) and 11–20 years of work experience (p =.043). The working unit also significantly affected their pretest and posttest ECG-KT scores (p =.006). Nursing students and academics had significantly lower mean pretest ECG-KT scores than ICU nurses did (p =.019). The participants who had previously received ECG training had significantly higher mean pretest and posttest ECG-KT scores than did those who had not (pretest p <.001; posttest p =.007). The participants with intensive care certificates had significantly higher mean pretest and posttest ECG-KT scores than did those without (pretest p <.001; posttest p =.048) (Table 3).

We provided nurses with the Fourth Basic Intensive Care Nursing E-Course between February 21 and 22, 2022. The course also addressed the topic of “common cardiac rhythm disorders in intensive care units.” At the end of the course, we asked all attendees what topic they would like to receive training in. Three of the five attendees said they would like to be trained in ECG (57.8%). Both the demands during the course and the feedback at the end of the course showed that nurses needed training in ECG.

Our participants had a significantly higher mean posttest ECG-KT score (66.2 ± 17.2) than the pretest score (46.5 ± 17.5) (p <.001), indicating that the online ECG education program (intervention) was effective. The effect size (Cohen’s d = 1.23) suggests that the intervention had a meaningful impact beyond mere statistical significance, highlighting its potential clinical relevance in enhancing nurses’ ECG interpretation abilities. Studies have demonstrated that structured education programs significantly improve nurses’ ECG interpretation skills and clinical confidence [6, 7, 9, 11, 16, 18, 19]. In line with this, our findings indicate that nurses with prior ECG training performed better, suggesting that ECG education should be periodically updated to maintain competency and reinforce skills.

Our participants had the highest pretest ECG-KT score for “ventricular arrhythmias” (53.57 ± 21.41), whereas they had the highest posttest ECG-KT score for “pacemakers” (78.33 ± 10.21). Coll-Badell et al. [19] reported that nurses are aware of ventricular tachycardia as well as flutter arrhythmias. In our study, a high rate of ventricular arrhythmias in the pretest was frequently encountered in intensive care units or services, and nurses recognized these rhythms.

Our participants had the lowest pretest and posttest ECG-KT scores on ‘blocks,’ consistent with findings from Ho et al. and Chen et al., who reported that nurses struggle with recognizing heart blocks and abnormal conduction patterns. This result suggests that additional targeted education focusing on identifying and differentiating heart blocks is necessary [20, 21]. This is probably because nurses care for fewer patients with heart blocks than those with other types of arrhythmias (normal sinus rhythm, atrial fibrillation, etc.). The lowest scores were on blocks in the ECG-KT. This suggests that the subject of blocks should receive greater emphasis in subsequent instruction.

Age and sex did not significantly affect our participants’ pretest and posttest ECG-KT scores. While Erişti et al. [7] reported similar results, Zhang et al. [18] and Coll-Badell et al. [19] did not perform any pretest or posttest comparisons in terms of age or sex. On the other hand, Çelik et al. [6] recruited nurses and provided them with a one-hour training program on basic ECGs. They reported that nurses between the ages of 23 and 27 answered significantly more questions correctly than other age groups did before and after the intervention. Rahimpour et al. [15] reported that female emergency room nurses were better at interpreting ECGs than their male counterparts were. On the other hand, Ho et al. [20] reported that male nurses had a significantly higher mean ECG interpretation score than their female counterparts did. These results indicate that more research is warranted to better understand the effects of age and gender on nurses’ ECG interpretation skills.

Our participants who had previously received ECG training had significantly higher mean pretest and posttest ECG-KT scores than those who had not (p =.007). Zhang et al. [18] investigated the effectiveness of an education program on nurses’ knowledge of ECG interpretation and reported similar results. Research, in general, shows that nurses who have received training in ECGs before they learn more about them than those who have not [18‐20]. Our results suggest that nurses are willing to learn new things, as they know that maintaining good nursing skills requires continuous learning and review. Our results also revealed that participants with intensive care certificates had significantly higher mean pretest and posttest ECG-KT scores than did those without intensive care certificates. This result suggests that certification programs are effective ways to help nurses refresh their knowledge of ECG interpretation.

It is evident that education helps nurses acquire professional knowledge and develop professional skills [22]. Our participants with master’s or Ph.D. degrees had significantly higher mean pretest and posttest ECG-KT scores than those with bachelor’s degrees did (pretest p =.24; posttest p =.37), which is consistent with the literature [7, 11, 16]. For example, Özoğul et al. [11] reported that nurses with master’s degrees knew more about ECGs than did those with bachelor’s degrees. Erişti et al. [7] reported that nurses with master’s degrees were better at interpreting ECGs and recognizing deadly rhythms than others. These results suggest a positive correlation between education and ECG knowledge.

Practice makes knowledge more automatic and durable. Our results revealed that nursing students had a significantly lower mean pretest ECG-KT score than did those with 6–10 years (p =.008) and 11–20 years of work experience (p =.043). Tahboub et al. [23] also reported that nurses with less than one year of work experience knew less about ECGs than those with more than six years of work experience did, suggesting that nurses with more work experience are likely to have more ECG knowledge and skills. Although our results revealed that nursing students had higher mean posttest ECG-KT scores than pretest scores did, the difference was statistically insignificant (p >.05). This is probably because they are open to learning new things.

Nursing students and academics had significantly lower mean pretest ECG-KT scores than ICU nurses did (p =.019). Werner et al. [22] also reported that ICU nurses knew more about ECGs than other clinical nurses did. Although Erişti [7] reported that ICU nurses were better at interpreting ECGs and recognizing deadly rhythms than other nurses were, the difference was statistically insignificant. These results suggest that nurses working in critical units know more about ECG interpretation because they constantly monitor ECGs to follow up with their patients. Prior research has demonstrated that systematic training programs markedly enhance participants’ ECG interpretation abilities [9, 15, 19]. This study investigated the effectiveness of online training for nurses, and the results align with existing literature, indicating that the quality of the training process directly influences learning outcomes [16, 20]. These findings are consistent with previous studies on ECG education effectiveness, further supporting the importance of structured training programs in improving ECG interpretation skills [9, 15, 19, 20].

This study shows that an online ECG training program can help nurses improve their ECG interpretation knowledge and skills. This is clinically significant, as nurses’ ability to interpret ECGs correctly and in a timely manner is crucial for patient safety. It allows for the early detection of life-threatening arrhythmias or ischemic signs, enabling faster intervention when necessary.

Our findings emphasize the importance of integrating structured ECG interpretation training into nursing education and ensuring regular professional development opportunities. Moreover, online ECG training appears to be a practical and effective learning tool, offering flexibility and accessibility, particularly for busy nurses who may struggle to attend in-person training.

Since studies suggest that ECG interpretation skills may decline over time, future research should focus on assessing the long-term retention of knowledge gained through online education and evaluating whether regular refresher courses help nurses maintain their competency in ECG interpretation.