Abstract
This study aimed to assess the knowledge level of nurses in clinics at the Somalia Mogadishu Turkey Recep Tayyip Erdoğan Training and Research Hospital concerning basic life support (BLS) and advanced life support (ALS).
A questionnaire comprising 10 questions related to demographic data and 24 objective questions assessing knowledge about BLS and ALS was administered to 104 nurses working in the hospital’s clinics. The questionnaire responses were analyzed, and the results were compared across different clinics.
Among the 104 participants, 48 were male and 56 were female nurses. The age distribution analysis revealed that 58 participants were aged between 26 and 30 years or older. Most (n=30) nurses were stationed in the intensive care unit. Participants with over 4 years of professional experience constituted the largest group. Female nurses demonstrated higher accuracy in survey responses than their male counterparts. The emergency medicine department yielded the highest number of correct answers based on the services provided. Significant correlations were identified between years of professional experience and correct answers to ALS questions. A noteworthy difference surfaced between the ability to effectively implement adult life support and accurate responses to the BLS survey questions.
Periodic informative training on adult life support should be provided to all nurses. In particular, nurses working in critical departments should be afforded opportunities to familiarize themselves with new guidelines through periodic reviews. This approach will substantially enhance knowledge levels and service quality in the application of adult life support.
Keywords: Advanced life support, basic life support, cardiopulmonary resuscitation
Introduction
Timely and efficient cardiopulmonary resuscitation (CPR) performed by healthcare professionals plays a pivotal role in the survival of individuals experiencing cardiopulmonary arrest. Despite the low overall survival rates in such situations, the prompt application of effective CPR and defibrillation significantly enhances the likelihood of survival. Basic life support (BLS) is a critical link in the survival chain and constitutes a fundamental aspect of healthcare professional training.
In the United States (US), BLS training has been recommended for all healthcare professionals since 1966, particularly those involved in resuscitation efforts. Conversely, in developing nations like Nepal, BLS is optional in training programs. However, promoting BLS knowledge within communities is crucial for saving lives and enhancing the overall quality of life. Recent BLS guidelines address shortcomings and errors in prehospital and in-hospital CPR, motivating healthcare professionals to enhance their skills (1).
BLS is vital until the patient receives appropriate medical care. Nurses and emergency medical technicians are the primary providers of BLS. Advanced life support (ALS) involves advanced techniques such as intravenous (IV) fluids, medication administration, intubation, and efforts to restore airway patency, breathing, and circulation.
ALS is typically practiced by nurses and physicians, and while the techniques used for ALS and BLS overlap, the associated concepts may vary across countries. The diversity in ALS and BLS concepts, coupled with variations in prehospital care due to political, geographical, cultural, and economic factors, has led to controversies in research outcomes (2).
Despite the constant emphasis on the importance of BLS, post-training studies reveal challenges in acquiring related skills. Feedback from training sessions indicates that only 1.7% of rescue breaths and 3.5% of chest compression are correctly performed. Understanding ventilation training proves challenging, and a decline in the comprehension of BLS concepts, CPR, and ventilation occurs as early as 2 weeks post-training, reaching pre-training levels within 1-2 years (3).
In the realm of ALS, guidelines were initially established in 1974 by the American Heart Association (AHA) to enhance post-cardiac arrest survival rates and improve the knowledge and skills of healthcare practitioners. Subsequent revisions, aligned with decisions from the 2010 International Liaison Committee, Consensus on Science and Treatment Recommendations (CoSTR), are recognized as the gold standard for managing cardiac arrest and other life-threatening emergencies. The CoSTR emphasizes education’s role in enhancing resuscitation quality and post-cardiac arrest care. Globally, substantial financial resources are allocated to provide standardized ALS training courses, with resuscitation committees recommending the renewal of ALS training every two years (3).
Accordingly, in this study, we assessed the knowledge level of nurses in clinics at the Somalia Mogadishu Turkey Recep Tayyip Erdoğan Training and Research Hospital concerning BLS and ALS.
Materials and Methods
In this study, we engaged 104 actively practicing nurses in the Somalia Mogadishu Turkey Recep Tayyip Erdoğan Training and Research Hospital. Participants were given a questionnaire that included 24 objective questions assessing knowledge levels regarding BLS and ALS. Demographic data were also collected. Notably, administrative nurses were excluded from the study. Ethical approval for our research was obtained from the Ethics Committee of Somalia Mogadishu Turkey Recep Tayyip Erdoğan Training and Research Hospital (ethics committee decision number: 2022/472, date: 07.02.2022).
Statistical Analysis
The obtained questionnaire data were compiled, with the results expressed as median values along with the corresponding minimum and maximum values. The Shapiro-Wilk test was employed to evaluate the data distribution.
Analysis of variance between independent groups was performed using either the unpaired t-test or the Mann-Whitney U test. Group differences were further explored by applying one-way ANOVA or the Kruskal-Wallis tests.
Statistical significance was set at p<0.05. All statistical calculations were performed using SPSS statistical software (SPSS for Windows version 21.0; SPSS Inc., Chicago, IL).
Results
The results of our observational study analyzing the responses from 104 nurses regarding BLS and ALS based on the 2021 guidelines of the European Resuscitation Council (ERC) provided valuable insights into their knowledge and experiences.
Nurses aged between 20 and 25 years constituted 25% (n=26), whereas those aged between 26 and 30 years constituted 55.8% (n=58) of the study population. In addition, those aged 31 years and over constituted 19.2% (n=20) of the entire group.
The study involved 46.2% (n=48) male nurses and 53.8% (n=56) female nurses. The distribution of nurses across different departments was as follows: emergency medicine 12.5% (n=13), intensive care unit (ICU) 28.8% (n=30), surgery 10.6% (n=11), internal medicine 17.3% (n=18), operating room 14.4% (n=15), delivery room 6.7% (n=7), and dialysis 9.6% (n=10).
Nurses with less than 1 year of employment constituted 9.6% (n=10), those with more than 1 year and less than 2 years 20.5% (n=21), those with more than 2 years and less than 3 years 22.1% (n=23), those with more than 3 years and less than 4 years 9.6% (n=10), and those with 4 or more years of employment constituted 38.5% (n=40) of the entire study population.
While 17.3% (n=18) had never received adult life support training, 37.5% (n=39) received training at the faculty, 14.4% (n=15) received training within 1 year, 7.7% (n=8) received training more than 1 year and less than 2 years ago, 9.6% (n=10) received training more than 2 years and less than 3 years ago, and 13.5% (n=14) received training more than 3 years ago.
Our analysis also revealed that 27.9% (n=29) of the participants never read a guideline on adult life support, 24% (n=25) read the ERC 2021 guideline, 28.5% (n=30) read the AHA 2020 guideline, and 19.2% (n=20) read a guideline published before 2020.
The analysis regarding the performance of adult life support revealed that 8.7% (n=9) did not perform at all, 32.7% (n=34) performed it every weekday, 34.6% (n=36) performed it once a week, 21.2% (n=22) once a month, and 2.9% (n=3) once a year. The answers given to the three critical questions included in the questionnaire are displayed in Table 1. The demographic data of the participants are shown in Table 2. Analysis of the answers given in the BLS and ALS questionnaires revealed no significant impact of age on the rates of correct answers. However, gender-related differences were significant (p=0.03), with female nurses showing higher accuracy in the BLS questionnaire than male nurses. The department of the nurse did not have a significant effect on the responses to the BLS-related questions.
In ALS-related questions, emergency medicine nurses were significantly more successful than internal medicine (p=0.01), delivery room (p=0.004), and dialysis nurses (p=0.006). On the other hand, ICU nurses gave a significantly higher rate of correct answers than internal medicine (p=0.005), delivery room (p=0.003), and dialysis nurses (p=0.008). Surgery nurses were significantly more successful than the delivery room (p=0.01) and dialysis nurses (p=0.02) in answering ALS-related questions. There was a significant difference (p=0.03) between the internal medicine and operating room nurses in this regard. Similarly, there was a significant difference between the operating and delivery room nurses (p=0.03).
While no significant difference was found in the distribution of years of working life for BLS-related questions, a significant difference was found (p=0.04) for ALS-related questions. The frequency of receiving adult life support training or reading the guidelines did not create a significant difference in answering BLS and ALS questions. The frequency of performing adult life support also did not significantly impact the correct answer rates in the BLS and ALS questions. The yes and no answers to the question “Do you think that all nurses should have knowledge and skills about adult life support?” did not significantly differ in answering the BLS and ALS questions. However, a significant difference (p=0.03) was observed between the yes and no answers to “If necessary, can you effectively implement adult life support?” and answering BLS questions. In contrast, no significant difference was found for the ALS questions. The answer to the question “Do you think repeating ALS training would be beneficial for nurses?” did not relate to answering BLS and ALS questions (Supplementary 1).
Discussion
CPR, involving chest compression and artificial ventilation, is a critical medical intervention to sustain blood flow to vital organs, particularly the brain. Trained healthcare professionals performing CPR contribute to a reduction in in-hospital cardiac deaths. In hospital settings, nurses often play a crucial role as first responders to identify patients experiencing cardiopulmonary arrest and initiate intervention.
Our study, an observational, cross-sectional, single-center survey, aimed to assess nurses’ knowledge of adult life support. The mean age and gender ratio of the nurses in our study is consistent with the existing literature.
Unlike some studies, our findings indicated that female nurses provided more accurate answers to survey questions measuring knowledge about adult life support than male nurses (4).
A multicenter study evaluating CPR knowledge among healthcare workers found higher knowledge levels among cardiology, ICU, and emergency medicine department workers compared with other clinics.
In another study, it was observed that nurses working in places with cardiac risk patients were more successful in answering BLS and ALS questions than those working in other places.
Similarly, in our study, the emergency medicine department and ICU demonstrated higher success in answering survey questions than other units.
Additionally, our study revealed a positive correlation between the number of correct answers about ALS and nurses’ years of experience, which is consistent with findings from previous studies (5-7).
Adult life support practices have been in place for over 50 years, and ongoing training remains crucial. Some studies suggest a decline in nurses’ knowledge and skills six months after initial adult life support training, highlighting the need for recurrent training and certification (4). However, contrary to the existing literature, our study did not find a significant correlation between the frequency of training and correct responses to questionnaire questions (8).
Another study emphasizes that adult life support training is forgotten after a certain period of time; therefore, it is important to repeat the training at certain intervals (9). Another study suggested that nurses should receive frequent training on the subject (10). While most studies argue that there is a decrease in adult life support knowledge and skills over time, two different studies say that knowledge and skills are not forgotten during the working period, as in our study (11, 12).
Contrary to findings emphasizing the importance of the guidelines reading for self-improvement in adult life support knowledge, our study did not reveal a significant impact (13). They found that nurses in a particular branch were quite insecure when applying BLS effectively (14). Nonetheless, our study identified a high confidence level among nurses in adult life support practices. Overall, our findings contribute to the understanding of nurses’ knowledge and practices related to adult life support, emphasizing the potential impact of experience and training frequency on performance.
Study Limitations
The study has notable limitations, primarily stemming from the fact that the participating nurses served temporarily in our hospital, having been assigned voluntarily from different hospitals. Consequently, information regarding the participants’ educational backgrounds and experiences was unavailable, introducing a potential source of variability. Our study was a small-volume, single-center study. Enhanced reliability and a more accurate reflection of adult life support knowledge levels could be achieved with a more extensive and diverse sample, ideally involving participants from multiple centers. Further epidemiological studies are warranted to provide comprehensive insights into the subject.
Conclusion
Our study indicates a high level of self-confidence among nurses regarding adult life support. When we scanned the literature regarding our study, we found that knowledge and skills regarding adult life support generally decrease when it is not repeated for 2 years or longer. Although we could not find any significant results regarding the repetition of training in our study, our recommendation is; In terms of practice, it is obvious that adult life support training should be repeated at certain intervals and that it is important to read the current guideline on the subject.
Regular training for all hospital nurses, particularly those caring for critically ill patients, conducted by dedicated adult life support trainers could reduce in-hospital deaths and enhance the overall quality of adult life support practice. Implementing periodic questionnaires to measure knowledge levels within the hospital, addressing knowledge gaps, finding solutions, and implementing best practices are deemed essential contributions to the healthcare system.
Ethics
Ethics Committee Approval: Ethical approval for our research was secured from the Ethics Committee of Somalia Mogadishu Turkey Recep Tayyip Erdoğan Training and Research Hospital (ethics committee decision no: 2022/472, date: 07.02.2022).
Informed Consent: Survey questionnaire study.
