|Year : 2017 | Volume
| Issue : 3 | Page : 251-258
Effect of nursing care standards on nurses’ performance in caring for patients with cardiac arrhythmias
Rawia A Ibrahim1, Kamelia F Abd-Allah2, Osama S Arafa3, Sabah S Mohammed1
1 Department of Medical Surgical Nursing, Faculty of Nursing, Benha University, Benha, Egypt
2 Department of Medical Surgical Nursing, Faculty of Nursing, Ain Shams University, Cairo, Egypt
3 Department of Cardiology, Faculty of Medicine, Benha University, Benha, Egypt
|Date of Submission||04-Aug-2016|
|Date of Acceptance||18-Aug-2016|
|Date of Web Publication||1-Jun-2018|
Rawia A Ibrahim
MSc in Nursing, Department of Medical Surgical Nursing, Faculty of Nursing, Benha University, Benha, 13511
Source of Support: None, Conflict of Interest: None
Background Nursing care should be guided by clearly defined standards to ensure a high quality of care. Standards of care are authoritative statements that describe a common or acceptable level of patient care or performance.
Aim The aim of this study was to evaluate the effect of nursing care standards (NCSs) on nurses’ performance in the care of patients with cardiac arrhythmias in the coronary care unit (CCU) at Benha University Hospital. This research was based on the hypothesis that the mean score of nurses’ knowledge and practice level after NCS implementation may be higher than their score before NCS implementation.
Participants and methods A quasi-experimental research design was utilized. This study was conducted in the CCU at Benha University Hospital. Two groups of participants were included in the study: experts and staff nurses working in the CCU. Three data collection tools were used in the different phases of this study: first tool, an experts opinion sheet was designed to test the face and content validity of the designed NCSs; second tool, a self-administered questionnaire was administered to nurses to assess their knowledge; and third tool, a nurses’ practice observational checklist based on the designed NCSs was completed.
Results The results of the study showed that the majority of the jury was satisfied with the general form (face and content validity) of the NCS. The jury agreement ranged between 85.7 and 100%. Furthermore, the findings revealed a statistically significant improvement in the total mean knowledge scores of nurses in all items of the study after implementing the standards (P=0.000) as compared with the preimplementation period. There was also statistically significant improvement in the total mean practice scores of nurses in all items of the study after implementing NCSs (P=0.000).
Conclusion There is a statistically significant improvement in nurses’ performance in the care of patients with cardiac arrhythmias in the CCU after NCS implementation. The study recommends that NCSs for management of patients with cardiac arrhythmias should be revised, updated, and available in the CCU in both Arabic and English language.
Keywords: cardiac arrhythmia, nurse’, s performance, nursing care standards
|How to cite this article:|
Ibrahim RA, Abd-Allah KF, Arafa OS, Mohammed SS. Effect of nursing care standards on nurses’ performance in caring for patients with cardiac arrhythmias. Egypt Nurs J 2017;14:251-8
|How to cite this URL:|
Ibrahim RA, Abd-Allah KF, Arafa OS, Mohammed SS. Effect of nursing care standards on nurses’ performance in caring for patients with cardiac arrhythmias. Egypt Nurs J [serial online] 2017 [cited 2018 Dec 9];14:251-8. Available from: http://www.enj.eg.net/text.asp?2017/14/3/251/233665
| Introduction|| |
Cardiac arrhythmia is defined as an irregular heart rate, rhythm, or both. Arrhythmias are often grouped according to the location of the abnormality in the conduction system − whether in the SA node, the atria, the AV junction (the area around the AV node and the bundle of His), or the ventricles (Carter and Stegen, 2010). Approximately one-third of people with arrhythmias do not exhibit any symptoms, preventing their timely diagnosis and treatment. In individuals who do experience symptoms, these may include sensations of a racing or pounding heart, chest pain, shortness of breath, dizziness, light headedness, anxiety, losing consciousness, and reduced capacity to exercise, which can impair the quality of life in some cases. Symptoms can be dangerous and life threatening, and may even lead to sudden cardiac death (Schmidt et al., 2011).
Nursing care standards (NCSs) may be defined as authoritative statements in the form of measurement criteria to evaluate the quality of nursing care. All standards of practice lay down the knowledge, skills, judgment, and attitudes needed for good practice. They reflect a desired and achievable level of performance against which actual performance can be compared. Their main purpose is to promote, guide, and direct professional nursing practice and optimal quality of care (Linda, 2014).
Several frameworks are used to establish standards. According to the American Nurses Association (2010) the standard of care for the nursing process is based on valid principles: assessment, diagnosis, planning, implementation, and evaluation. Process standards focus on the specific nursing activities necessary to achieve the desired level of care. Process standards include procedure, practice guidelines, plans, and documentation (Masters, 2014).
Significant of the study
In Egypt, approximately four million people have arrhythmias (Statistics by Country for Arrhythmias, 2011). Between 2011 and 2012, the number of patients admitted to the coronary care unit (CCU) was 2315; about 50–60% had arrhythmias (Benha University Hospital Statistical Office, 2012). From clinical experience and observations made in the cardiac care unit over 5 years, the researcher concluded that cardiac arrhythmias are a common problem in the CCU and represent a major source of morbidity, some of which lead to sudden death and heart failure; hence, this study has been conducted to increase the knowledge and practice of nurses caring for patients with cardiac arrhythmias by implementing NCSs to help them promote the quality of nursing care and decrease morbidity and mortality in such patients.
This study aims to evaluate the effect of NCSs on nurses’ performance in caring for patients with cardiac arrhythmias in the CCU at Benha University Hospital.
The mean score of nurses’ knowledge after NCS implementation may be higher than their score before NCS implementation and the mean score of nurses’ practice level after NCS implementation may be higher than their score before NCS implementation.
| Participants and methods|| |
A quasi-experimental design was used to conduct the study. Permission was obtained from the hospital administration to conduct the study and oral consent was obtained from the nurses to participate in the study.
This study was conducted in the CCU at Benha University Hospital.
- All available nurses (N=30) who were working in the CCU at the time of the study were included in this investigation.
- A jury group of 21 experts were also included, consisting of the following personnel: nine nursing educators from medical surgical nursing departments of the Faculty of Nursing, Benha University, Zagazig University and Ain Shams University, comprising two professors, two assistant professors, and five lecturers; nine physicians representing clinical cardiologists from the Faculty of Medicine at Benha University Hospital, comprising four residents, two assistant lecturers, one lecturer, and two professors; and three nursing administrators representing the head nurse manager from Benha University Hospital.
Data collection tools
Tool 1: Experts opinion sheet
This tool was designed to test the face and content validity of the designed NCSs by eliciting the opinions of the jury members on the proposed standards. The jury members evaluated the NCSs with either agree or disagree responses and comments.
This sheet consisted of three parts: Part 1 consisted of jury characteristics (demographic characteristics) such as job title, age, sex, educational level, and years of experience. Part 2 was designed to test the agreement of the jury group on the general form of the designed NCSs (face validity). It consisted of 10 items. Part 3 was designed to test the agreement of the jury with respect to the items in the NCSs (content validity). This part consisted of 232 criteria under nine main standards that identify specific nursing activities for patients with cardiac arrhythmias.
Tool 2: Self-administered questionnaire sheet for nurses
It was developed by the researcher by reviewing related literature and comprised structured items in Arabic related to different aspects for assessment of nurses’ knowledge about caring for patients with cardiac arrhythmias. It consisted of two parts: Part 1 comprised the demographic characteristics of nurses, such as age, sex, level of education, marital status, years of experience, and previous attendance of training courses related to cardiac arrhythmias. Part 2 consisted of nurses’ knowledge about cardiac arrhythmias and standards of care.
The scoring system of the self-administered questionnaire sheet: Each right answer was given one score, with a total score of 85.
- Greater than and equal to 80% was considered satisfactory knowledge.
- Less than 80% was considered unsatisfactory knowledge.
Tool 3: Nurses’ practice observational checklist
It was constructed by the researcher after reviewing relevant literature. It was adapted from the studies of Mahrous (2003), Ahmed (2008), and Shaaban (2012) and the American Heart Association (AHA) (2011) and was based on the designed NCSs. It was concerned with the process of standard of care for patients with cardiac arrhythmias in the CCU and consisted of 232 items under nine main headings that identified the specific nursing activities for patients with cardiac arrhythmias, which were as follows:
- Nursing assessment (nine items).
- Nursing diagnosis (three items).
- Nursing plan (13 items).
- Nursing implementation (12 items), divided into the following sub-items:
- Intervention in the management of arrhythmias (nine sub-items).
- Nursing care in case of emergency arrhythmias (15 sub-items).
- Connecting the patient to the monitor (18 sub-items).
- Obtaining 12-lead ECG and interpretation (17 sub-items).
- Emergency medication for arrhythmias (13 sub-items).
- Cardiopulmonary resuscitation (CPR) (13 sub-items).
- Emergency defibrillation (28 sub-items).
- Emergency cart preparation (eight sub-items).
- Care for patient with a pacemaker (16 sub-items).
- Help patient with mobilization (six sub-items).
- Hygiene care (three sub-items).
- Encourage the patient to sleep (four sub-items).
- Creating a safe environment (20 items).
- Adherence to care ethics and patient rights (four items).
- Imparting health education (13 items).
- Communication (13 items).
- Nursing evaluation (seven items).
Scoring system of the observational checklist: Each item was scored as follows:
- 0=not done.
- 1=done incorrectly.
- 2=done correctly.
The total scores 464 revealed the following:
- Greater than and equal to 80% was considered a satisfactory level of practice.
- Less than 80% was considered an unsatisfactory level of practice.
This phase included the following: reviewing the available literature related to the research and gathering theoretical knowledge on various aspects of the study using textbooks, evidence-based articles, internet periodicals, and magazines. This period extended from October 2013 to January 2014.
Designing NCSs: This was carried out from January 2014 to April 2014 on the basis of a literature review. The researcher designed the NCSs for patients with cardiac arrhythmias to be implemented by staff nurses working at the CCU in Benha university hospital. The standards used in this study (process standards) define the steps to be taken to achieve optimum patient care.
Tools validity and reliability
Validity of tools was tested by a jury of 21 experts. The experts reviewed the tools for clarity, relevance, comprehensiveness, simplicity, and applicability, and minor modifications were carried out. This phase lasted 1 month from May 2014 to June 2014. The reliability of the proposed tools was tested with Cronbach’s α.
A pilot study was carried out on five nurses from among the studied participants. The pilot study was conducted to ensure clarity and feasibility of applicability of the study tools, and the time needed for each tool to be completed. A few modifications were made according to the pilot study findings. This phase lasted 1 month from July 2014 to August 2014.
The process of data collection was carried out from the beginning of September 2014 to the end of March 2015. The researcher visited the CCU 3 days a week (morning and afternoon) to collect the data using the above-mentioned tools. The researcher interviewed the available nurses in the CCU and explained the aim of the study and took their approval for participation before data collection. The researcher then assessed the nurses’ performance level (knowledge and practice) with respect to caring for patients with cardiac arrhythmias by using the questionnaire and observational checklist (before NCS implementation):
First, the researcher observed the nurses’ practice while caring for patients with cardiac arrhythmias using the observational checklist based on NCSs. Each skill was evaluated three times and the mean was calculated.
Second, the questionnaire was administered by the researcher to all nurses individually to assess their knowledge about standards of care for arrhythmic patients. The questionnaire was explained to the nurses by the researcher. The average time needed for the completion of each interview (by nurses) was between 25 and 35 min. This period of pretests (knowledge and practice) took 6 weeks.
Implementation of NCS: The implementation phase was achieved over 18 weeks. The total number of sessions was 12, divided as follows: four sessions for knowledge and eight sessions for practice. The duration of each session ranged from 45 to 60 min for each group, including 10 min for discussion and feedback.
After implementing NCSs, post-tests were administered to assess nurses’ knowledge and practice level using the same pretest forms. This helped to evaluate the outcome of the implemented standards. This was done immediately after the intervention and took about 6 weeks.
Administrative design: Permission was granted from the hospital directors and head of the department of the Cardiac Care Unit at Benha University Hospital. After obtaining approval for data collection, the objectives and nature of the study were explained so that the study could be carried out with minimum resistance. Additional oral consent was taken from the nurses who participated in the study after explaining the nature, aims, and expected outcomes of the study.
| Results|| |
[Table 1] shows the demographic characteristics of the staff nurses. More than two-fifths (43.3%) of the studied participants were between 25 and 30 years old. The majority (98.3%) were female and a significant proportion of them (80%) were married. Two-thirds (66.6%) of them had between 5 and 10 years of experience and most of them (40%) held a Bachelor’s degree in nursing.
|Table 1 Distribution of the nurses according to their demographic characteristics (N=30)|
Click here to view
With regard to the distribution of nurses according to the total knowledge score before and after NCS implementation, we found that only one-third (33.3%) of nurses had a satisfactory knowledge level before NCS implementation ([Figure 1]). However, after implementation, the majority of nurses (86.7%) had a satisfactory knowledge level.
|Figure 1 Distribution of the studied nurses according to their total knowledge scores before and after implementing the standards.|
Click here to view
[Table 2] shows the mean score of nurses’ knowledge before and after NCS implementation. It shows a general improvement in the total mean knowledge scores of nurses in all items after NCS implementation as compared with preimplementation (mean score: 82.53±11.91 and 45.96±17.48, respectively). The difference was highly statistically significant (P=0.000).
|Table 2 The mean score of nurses’ knowledge regarding components of the designed nursing care standards before and after its implementation|
Click here to view
[Table 3] describes the nurses’ practices regarding nursing activities for patients with cardiac arrhythmias at the CCU before and after implementation of NCSs. It can be noted from this table that nearly two-thirds of the studied participants (66.7, 70, and 63.6%) had unsatisfactory practice levels before NCS implementation with respect to most of the nursing activities, such as performing CPR, nursing care for emergency medications, arrangement of emergency crash cart, respectively, whereas after implementation they had a satisfactory level of practice with respect to obtaining 12-lead ECG, nursing care in emergency defibrillation, and nursing care in case of emergency arrhythmias (93.3, 90, and 86.7%, respectively). There was a statistically and highly statistically significant difference in all items of nursing activities between pre-NCS and post-NCS implementation (P<0.05 and <0.001).
|Table 3 Nurses’ practice of nursing activities for patients with cardiac arrhythmias in the coronary care unit (N=30)|
Click here to view
[Table 4] shows the mean practice scores of study participants before and after NCS implementation. A general improvement in the mean practice scores of nurses in all items after NCS implementation was noted as compared with the scores before implementation (mean: 404.33±20.73 and 232.73±25.88, respectively). There were highly statistically significant differences between preimplementation and postimplementation scores for all items (P=0.00).
|Table 4 The total mean practice scores of study participants before and after nursing care standard implementation|
Click here to view
| Discussion|| |
The aim of this study was to evaluate the effect of NCSs on nurses’ performance in caring for patients with cardiac arrhythmias in the CCU at Benha University Hospital. The findings of the present study show that the majority of experts agreed with all criteria of process standards (content validity). Their agreement ranged between 85.7 and 100%. This finding is supported by Sabra et al. (2014), Shaaban (2012), and Saleh (2007), who found that the majority of the jury members agreed with the proposed standards.
As regards nurses’ knowledge about standards of care for patients with cardiac arrhythmias the current study revealed an obvious improvement in the total mean knowledge scores of nurses after NCS implementation as compared with preimplementation scores, which was highly statistically significant. This improvement might be related to the fact that the majority of them were young and enthusiastic to learn. This finding shows that standards of care had a good impact in improving nurses’ knowledge, which could be due to the concise presentation of each session using simple language and clear educational methods and instructional media.
This finding was congruent with those of Ali (2012), who found an improvement in nurses’ knowledge score after implementing self-learning modules, with highly statistically significant differences. Further, these results are in agreement with those of Ahmed et al. (2015), who stated that nurses had unsatisfactory knowledge on standard of care for patients after coronary artery bypass graft surgery before NCS implementation but showed an improvement after its implementation.
Change (2006) reported that nurses must be able to expand their knowledge through journals and seminars and through teaching programs for nursing staff. These programs should be designed to aid nursing staff in developing and enhancing the skills needed to provide high standards of care to their patients.
The results of the present study revealed that the majority of nurses had unsatisfactory practice levels before NCS implementation. This might be due to the lack of standardized nursing care. After NCS implementation, there was a general improvement in nurses’ practice scores with highly statistically significant differences between preimplementation and postimplementation periods. This result agreed with that of Shaaban (2012), who found statistically significant improvement in all aspects of process standards after application of the designed NCS.
As regards assessment, the present study showed that there was a highly statistically significant difference in nurses’ practices related to initial and physical assessment between preimplementation and postimplementation phases. This finding was in agreement with those of Munroe et al. (2013), who identified that assessment is the first integral step of the nursing care process. Comprehensive patient assessment is necessary to understand the overall health of the patient, and should comprise a complete health history and full physical examination. Results from pretreatment patient assessment form baseline data against which any changes in the patient’s condition can be measured and treatment determined.
Regarding nursing diagnosis and planning, the study revealed that the most common neglected practices among nurses before implementing the standards were analysis and interpretation of data to arrive at a nursing diagnosis, developing time schedules to accomplish the nursing plan, and documentation of the plan. After implementation of standards, the nurses’ practice scores improved in these aspects with statistically significant differences. These findings were in agreement with those of Shaaban (2012), who found that most nurses undertake diagnosis and planning after application of standards.
With regard to the practice score for implementation of nursing activities, we found improvement in nurses’ practice scores in all nursing activities in the postphase, with a highly statistically significant difference. This result was in agreement with that of Ibrahim (2014), who also found an improvement in nurses’ practices scores in the intervention phase.
As regards nurses’ performance in connecting the patient to a monitor, the study demonstrated a statistically significant improvement. Taha (2006) found the improvement in nurses’ practice score after program implementation to be related to the cardiac monitor. Collins (2001) emphasized on the importance of cardiac monitoring as an important first step in the treatment program regardless of patient condition on admission as it is an indicator of arrhythmias and can prevent a cardiac crisis. An electronic monitoring system is a necessary component.
The present study showed that there was a highly significant improvement in nurses’ performance in recording a 12-lead ECG and in arrhythmia interpretation. After NCS implementation, the nurses’ performance scores were satisfactory. This might be because the ECG was taken under the supervision and guidance of the researcher, ensuring the continuation of high-level practice. In the same line Mahdy (2009) revealed that the nurses had unsatisfactory practice scores before program implementation regarding 12-lead ECG and arrhythmia interpretation.
With regard to nurses’ performance in administering emergency medication, it was found that there was a highly significant improvement after implementation of standards. This result agreed with those of El-Metwally (2012), who found highly statistically significant differences in nurses’ practices between prephase and postphase with respect to monitoring intravenous infusion of emergency drugs.
As regards nurses’ practices related to CPR and defibrillation, the present study showed that there was a highly significant improvement after implementation of standards compared with before implementation. These results are supported by Taha (2006), Mahdy (2009), and El-Metwally (2012), who stated that the nurses had adequate practice scores in CPR after program implementation, with a highly statistically significant difference. Also Abd-Elkareem et al. (2012) mentioned that the nurses’ performance in CPR was not satisfactory before using the nursing procedures manual but was satisfactory afterwards.
Regarding nurses’ practices with respect to using the crash cart, the present study showed that there was a statistically significant improvement after implementation of standards. This result agreed with those of Taha (2006), who reported that the nurses’ performance in the use of the crash cart was unsatisfactory before program implementation and satisfactory afterward.
Regarding the provision of a safe environment and infection control in the CCU, the present study revealed an improvement in nurses’ practice after implementation of standards, with statistically and highly statistically significant differences. These results are supported by Ghoneim (2011), who documented that nurses’ practice scores related to infection control in the ICU improved after program implementation.
Regarding the adherence to ethics and patient rights, the present study showed that all nurses followed ethical conduct and respected patient rights after implementation of standards. This result disagreed with that of Ahmed (2008), who reported that only a minority of nurses followed ethical practices and considered patient rights.
Regarding the imparting of health education to patients and family members, the present study revealed that nurses had unsatisfactory practice before implementation of standards and satisfactory practice afterward. This is in accordance with the result of Saleh (2004), who reported that nurses had unsatisfactory practice scores in patient education before program implementation. This may be due to the lack of health education among medical staff in terms of treatment, nature of the disease, and complications. Moreover, nurses consider the education of patients about the disease to be the responsibility of doctors. This finding was also supported by Sheta (2006), who found that there was a highly statistically significant difference between prephase and postphase in nurses’ practices related to patient education before discharge.
As regards evaluation, the study documented that there was a highly statistically significant difference in the practice scores of nurses related to all items of evaluation before and after implementation of standards. This result was supported by Urden et al. (2014), who stated that the coronary care nurse must evaluate the progress being made towards attainment of treatment objectives by documenting revisions in diagnoses, outcomes, and the plan of care, evaluate the effectiveness of interventions in relation to outcomes, and document the patient’s response to interventions.
| Conclusion|| |
- The majority of nurses had unsatisfactory knowledge and practice levels before NCS implementation.
- After NCS implementation, there was an obvious improvement in nurses’ knowledge and practice scores with highly statistically significant differences between prephase and postphase.
- Standards of nursing care for management of patients with cardiac arrhythmias should be revised, updated, and made available in the CCU in both Arabic and English language.
- Continuous evaluation of nurses’ knowledge and practice is essential to identify their needs while caring for patients with cardiac arrhythmias in CCUs.
- Further study is needed with larger sample sizes to evaluate the application of structure and outcome standards in addition to process standards and evaluate its impact on nurses’ performance regarding caring for patients with cardiac arrhythmias and patient outcomes.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| Appendix|| |
[Additional file 1]
| References|| |
Abd-Elkareem HS, Adam SM, Hassan RM (2012). Effect of nursing procedures manual on nursing performance in the intensive care unit. New Egypt J Med 46:231–232.
Ahmed RE (2008). Nursing standards for post cardiac surgery patient [doctorate thesis]. Tanta: Faculty of Nursing, Tanta University.
Ahmed G, Mohammed Z, Ghanem H (2015). Coronary artery bypass grafting effect of developing and implementing nursing care standards on patient’s outcomes. J Am Sci 11:181–188.
Ali AS (2012). Effect of self learning modules on nurses’ performance regarding electrocardiography [doctorate thesis]. Cairo: Faculty of Nursing, Ain Shams University. pp. 103–115.
American Heart Association (AHA) (2011). Advanced cardiovascular life support: provider manual. Dallas, TX: American Heart Association.
American Nurses Association. (2010). Nursing: scope and standards of practice. 2nd ed. Washington, DC: American Nurses Association.
Benha University Hospital Statistical Office (2012). Number of admitted patients to CCU
Carter P, Stegen A (2010). Lippincott’s advanced skills for nursing assistants: a humanistic approach to care giving. Philadelphia: Wolters Kluwer Health/Lippincott Williams and Wilkins. 162.
Collins M (2001). When your patient has an implementable cardioverter defibrillator. Am J Nurses 94:44–48.
El-Metwally SE (2012). Effect of an educational program on the performance of nurses working with coronary artery bypass grafting patients [doctorate thesis]. Benha: Medical Surgical Nursing, Faculty of Nursing, Benha University.
Ghoneim SE (2011) Impact of designed infection control training program on nurses knowledge and practices at intensive care unit in Benha university hospital [doctorate degree]. Benha: Faculty of Nursing, Benha University.
Ibrahim ZH (2014). Effect of designed implemented nurses’ educational program on minimizing incidence of complication for patients with upper gastrointestinal tract bleeding [doctorate thesis]. Benha: Faculty of Nursing, Benha University. pp. 107–115.
Linda B (2014). AACN standards for establishing and sustaining healthy work environment: a journey to excellency. 2nd edition. Columbia: American Association of Critical Care Nurses.
Mahdy AY (2009). Effect of training program on staff nurses performance and empowerment toward care of patient undergoing organs and tissues transplantation [doctorate thesis]. Benha: Faculty of Nursing, Benha University. pp. 115–116.
Mahrous FM (2003). Standards of nursing care for cardiac arrhythmic patients [master thesis]. Cairo: Faculty of Nursing, Ain Shams University.
Masters K (2014) Role development in professional nursing practice. 3rd ed. XX: Jones & Bartlet Learning Comp. 282.
Munroe B, Curtis K, Considine J, Buckley T (2013). The impact structured patient assessment frameworks have on patient care: an integrative review. J Clin Nurs 22:2991–3005.
Sabra H, El-Shemy H, Mohamed M, Yousef H (2014). Developing and validating nursing care standards for patients with cancer receiving chemotherapy at South Egypt Cancer Institute at Assiut University. J Am Sci 10:37–45.
Saleh AA (2004). Discharge plan model for coronary artery disease patients’ [master thesis]. Cairo: Faculty of Nursing, Ain Shams University. p. 75.
Saleh HA (2007). Developing and Validating standards for operating rooms at Benha University Hospital [unpublished doctorate thesis]. Benha: Faculty of Nursing, Benha University.
Schmidt C, Kisselbach J, Schweizer P (2011). The pathology and treatment of cardiac arrhythmias: focus on atrial fibrillation Vasc Health Risk Manag 7:193–202.
Shaaban EG (2012). Developing and validating nursing care standards for patients with coronary arteries diseases at Sohag University hospital [doctorate thesis]. Benha: Faculty of Nursing, Benha University.
Sheta H (2006). Effect of an educational program on the performance of nurses working with cardiac patients [doctorate thesis]. Benha: Department of Medical Surgical, Faculty of Nursing, Benha University. p. 40.
Taha AS (2006). Emergency nursing care for critically ill patients: impact of a designed teaching protocol on nurse’s knowledge and practices in ICU at Benha University and Benha Teaching Hospital [master degree]. Benha: Department of M.S., Faculty of Nursing, Benha University.
Urden L, Stacy K, Lough M (2014). Critical care nursing diagnosis and management. 7th ed. Elsevier Mosby. 33–34.
[Table 1], [Table 2], [Table 3], [Table 4]