Resuscitation of Patients in Intensive Care Units Essay

If not treated timely, cardiac arrest presents a significant problem for patients in the intensive care unit (ICU). Nurses skills and use of advanced knowledge greatly influence cardiopulmonary resuscitation the use of capnography, for example, is considered to improve CPR results. The purpose of this quantitative, is to determine to what degree the implementation of capnography during cardiopulmonary resuscitation (CPR) when compared to the current practice would impact nurses and increase the use of capnography during CPR for adult ICU patients at an acute care hospital in New Jersey. The project is based on Lewins change theory; the author proposes that any change process has three main steps: unfreeze, change, and refreeze. The quantitative methodology was selected due to its ability to address clinical questions with meaningful, quantifiable, and transparent results. The project utilizes a quasi-experimental design to choose the sample and manipulate the independent variable, the nursing training program of capnography use during CPR, to influence the dependent variable, the number of CPR cases with the use of capnography. The population under investigation is adult patients who had a cardiac arrest and underwent CPR while in the ICU. The data, obtained from the Nurses Knowledge on Capnography Test and EHR, were analyzed with a and Gains score to in nurses use of capnography before and after training. [data results and implications to be added later]

Nurses knowledge pertaining to clinical devices used for monitoring, assessing, and treating patients with heart conditions is an important factor for achieving quality of patient care and organizational effectiveness (Cook & Harrop-Griffiths, 2019). Studies conducted by Linet al. (2017), Novais and Moreira (2015), and Pantazopoulos et al. (2015) alluded to the lack of knowledge among nurses in using capnography as recommended by the Advanced Cardiac Life Support (ACLS) to capture pertinent information about a patients end-tidal carbon dioxide (ETCO2) condition. They found that such low awareness of this approach presents uncertainties and poor clinical monitoring practices. Low-quality nursing practices are exemplified by the lack of awareness in using capnography; especially, when success in patient care is dependent upon the practice knowledge and use of innovative devices such as capnography in a clinical setting (Hamrick et al., 2017).

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In another study, Hamrick et al. (2017), Heradstveit and Heltne (2014), and Kodali and Urman (2014) linked the importance of using capnography in monitoring and gathering patient information during cardiopulmonary resuscitation events to the critical role of nursing practitioners and the knowledge in using capnography to improve patient quality care. The scholarly debate persists regarding the complexities in instituting clinical monitoring devices in the clinical setting and the lack of knowledge to effectively use the device. The rationale for this project lies in its potential beneficial effects on increasing the use of capnography in the intensive care unit (ICU) setting. Finally, the findings presented could be used to enhance the awareness about the project and its objectives.

Background of the Project
Cardiac arrest poses a significant threat to patients in intensive care units and is a significant factor that can subsequently lead to a patients demise if not addressed timely (Hartmann, Farris, Di Gennaro, & Roberts, 2015). As a result, the use of capnography to improve the outcomes of patients during cardiac arrests has been widely studied in the literature (Edelsonet al., 2014; Mader, Coute, Kellogg, & Harris, 2014). According to Cereceda-Snchez and Molina-Mula (2017), capnography has been developed as a measurement for monitoring coronary perfusion pressure (CPP) and coronary blood flow. Recent studies have shown the effectiveness of capnography in patients treatment with chronic hypercapnic respiratory failure, hypoventilation, severe hypothermia, and metabolic changes clinical (Darocha et al., 2017; Cereceda-Snchez & Molina-Mula, 2017; Chhajed et al., 2016). However, Leppink, OSullivan, and Winston (2016) noted that despite the existence and widespread use of capnography in practice improvement, many nurses still show some levels of uncertainty due to the reduced awareness in the knowledge and application of capnography in clinical settings.

Recent studies conducted by Dioso (2014) and Duckworth (2017) amplified the importance of equipping nurses with the knowledge of the application of capnography as a technique to manage cardiac arrest incidence amongst patients. This training approach should address knowledge barriers about capnography and its applications in improving the patients quality of care (Israel, 2014; Jaffe, 2017; Kuisma et al., 2017; Nassar & Schmidt, 2016). The strategic application of capnography is to improve patient care, and the paradigm shifts are often conflicted among nurses introduced to clinical monitoring tools such as capnography.

The major concern for healthcare practitioners is to minimize the negative impact created by the uncertainties and the lack of knowledge by nurses in using capnography. This relationship between nurses adoption of capnography, clinical uncertainty, lack of knowledge to use capnography in clinical settings, and its impact on patient care remains understudied (Kodali, 2013; Whitaker & Benson, 2016). Additionally, Sandroni, De Santis, and DArrigo (2018) argued that the lack of knowledge among users monitoring such as capnography could result in fatality. The scholars also uncovered a gap in the literature pertaining to nursing practices in the use of this monitoring device to minimize medical errors in a clinical setting, as well as nurses adoption of capnography, clinical uncertainty, and the lack of knowledge for using capnography in a clinical setting. Further investigation, as described herein, could expand the understanding of the nurses role in adopting capnography and investigate the levels of clinical uncertainties resulting from the lack of device monitoring knowledge in the healthcare industry.

Problem Statement
It is not known to what degree the implementation of an evidence-based intervention impacts the use of capnography during CPR, when compared to current practice among adult ICU patients undergoing cardiopulmonary resuscitation in the ICU. Previous studies conducted by Hassankhani, Aghdam, Rahmani, and Mohammadpoorfard, (2015) and Kiekkas, Stefanopoulos, Konstantinou, Bakalis, and Aretha (2016) showed that nursing practice pertaining to the application of evidence-based technology such as capnography is essential in managing cardiac-related incidents. In addition to the above mentioned studies, the perception exists that if nurses possess sufficient knowledge pertaining to the use of capnography during cardiopulmonary resuscitation (CPR), they can achieve better outcomes for the patient; especially in monitoring patients heart conditions and reducing risks of complications during a direct peritoneal resuscitation (DPR) (Hassankhani et al., 2015). The general clinical problem in nursing practice is the lack of knowledge about how to use new innovations such as capnography. Specifically, the clinical problem in this project is that managers do not understand the relationship between nurses adoption of capnography, clinical uncertainty, and the lack of knowledge to use capnography in a clinical setting.

To that extent, it is not apparent if or to what degree the implementation of an education and a standardized process for the use of capnography during CPR with nurses from a 20 bed ICU (8-10 bed capacity) at a 240-bed acute care hospital in New Jersey, would impact the rate of use of capnography during CPR when compared to current practice among patients undergoing cardiopulmonary resuscitation in the ICU. It is also not clear whether the nurses lack of knowledge impedes the application of capnography in clinical settings (Kiekkaset al., 2016). Therefore, these pressing questions will become the center of this project.

Purpose of the Project
The purpose of this quantitative, quasi-experimental pretest-posttest project is to determine to what degree the implementation of capnography during cardiopulmonary resuscitation (CPR) when compared to the current practice would impact nurses and increase use of capnography during CPR for adult ICU patients at an acute care hospital in New Jersey. The independent variable identified in this project is the intervention program designed to improve nurses knowledge of capnography use. The dependent variable is the number of instances of the use of capnography during resuscitation. The nurses practicing in the United States at clinical centers within or around New Jersey will be the target population for this project. The selected sample group will be appropriate for the project because of their clinical exposure to the use of capnography.

In examining the level of knowledge, this project will be focused on ascertaining the strength, vulnerabilities, and weaknesses specific to the nursing awareness about the use of capnography during cardiopulmonary resuscitation. Additionally, the author of the project will attempt to examine the correlation between such knowledge and the use of capnography during CPR and determine if any connections exist between nursing knowledge and their resistance against the use of capnography in the cases of CPR.

In addition to addressing the dearth or deficiencies in research on this topic as it pertains to the scholarly work and as well as the necessary insight for clinical managers, this project will also attempt to provide some understanding of the differences in the nursing knowledge in using capnography during cardiopulmonary resuscitation. Moreover, it will offer new information to achieve efficiency in the adoption of capnography in managing patients with CPR. The outcomes of this project include a positive clinical nursing practice change in which clinical managers use the results of the initiative to moderate nurses adoption of clinical devices in the hospital setting.

Clinical Question
The use of capnography by nurses is a strategic approach to achieving positive clinical outcomes. It has been discussed previously that the lack of knowledge and the inability of nurses to adopt innovation such as capnography can result in unintended consequences such as clinical uncertainties, medical error, and even patient fatality in a clinical setting. The central clinical question that guides this project is:

To what degree does implementation of an evidence-based intervention on use of capnography during cardiopulmonary resuscitation (CPR) impact use of capnography during CPR when compared to current practice, among adult ICU patients in an acute care hospital setting in New Jersey within a four-week period?

Advancing Scientific Knowledge
The outcome of the proposed project could contribute to the development of population health outcomes of patients suffering from cardiovascular diseases. This will be accomplished by the abilities of the investigator to provide clinical practice evidence pertaining to the results of the project and its effect on coronary care. The findings in the proposed quantitative pre-test post-test study could be used by clinical managers to moderate nursing practices in the adoption of new clinical devices such as capnography. Edelson et al. (2014), estimated that over 200,000 people suffer cardiac arrest annually, and more than 80% of them do not survive to discharge (p. 353). Kodali and Urman (2014), and Mader et al. (2014) found that thousands of people die from cardiac arrest in the United States every day. It appears from these numbers that cardiac arrest is a common problem the continues to affect various demographic populations in the United States. Thus, the proposed project is relevant and important to the current sphere of medical science.

Studies by Kiekkas (2016) and Lui, Poon, and Tsui (2016) advanced the knowledge for the use of capnography in the clinical settings to monitor and improve survival rates of cardiac-related incidents. However, the research outcomes surrounding the cases in which nurses lack the knowledge to use capnography have proven to be inconsistent, thus creating difficulties and uncertainties for targeted practice improvement measures (Dioso, 2014). To improve capnography practices in clinical settings, nurses and clinical managers must understand the relationship and importance of using capnography to improve patient outcomes. This project has the opportunity to close the gap in the information about nurses adoption of capnography, clinical uncertainty, and the lack of knowledge to use capnography in a clinical setting. It is also a contribution to the larger body of literature and application to nursing practices.

The theoretical foundation for the study will be based on the model of change introduced by Kurt Lewin in the 1940s. The authors theory proposes that all change projects happen in three steps unfreezing, moving, and refreezing (Lewis, 1951). Lewis (2003) further that each stage is invaluable, meaning that they all play a role in the new structure or objective becoming a part of the existing system. This theory implies that people are resistant to change, especially if they do not understand why it is necessary (Burnes & Bargal, 2017). Moreover, the process of a changes introduction can be influenced by using the elements outlined in the unfreeze step.

Lewins (1952) view of change projects will provide a helpful concept to explain the processes and ideas relating to the adoption of new techniques, applications, and systems in varieties of organizational settings such as health care centers. In the case of nursing knowledge and capnography, this theory demonstrates that the complexity of an innovation and its compatibility with the existing system are crucial in the success of its implementation. Thus, the project that targets nursing training can use this approach to measure the correlation between knowledge and use of the procedure and provide insight into nurses changing attitudes towards capnography in CPR.

Significance of the Project
From current observation, it is not known whether increased nurses knowledge of capnography is associated with the increased use of capnography during cardiopulmonary resuscitation. The significance of the project lies primarily in addressing the inconsistent findings in the scholarly literature on capnography and nurses knowledge regarding its use during cardiopulmonary resuscitation (CPR) in the intensive care unit. The studies discussed above, including those by Kodali (2013) and Whitaker and Benson (2016), show that there exists a gap in understanding how nurses awareness of capnography affects their choice of using it during CPR. Furthermore, as evidenced by the analysis of current research, articles on capnography focus mostly on the outcomes and implementation of capnography within this healthcare setting (Kalmar et al., 2018; Langhan, Shabanova, Li, Bernstein, & Shapiro, 2015; Turle, Sherren, Nicholson, Callaghan, & Shepherd, 2015). To facilitate the effective use of capnography, it is essential to determine individual factors that impact nurses knowledge and the understanding behind the readiness to use capnography into practice.

This project aims to explore the link between nurses knowledge and the use of capnography during CPR further, thus providing the basis for further practice improvement and future scholarly work in this area. The results of this initiative could also lead to the improvement of practice approaches in capnography and an enhancement in the quality of patient outcomes in the intensive care unit setting. This project differs from other studies in the field of capnography use in terms of its focus, while it also builds on other research concerning the nurses perspectives on capnography and its importance in promoting successful patient outcomes (Lin et al., 2017; Novais &Moreira, 2015; Pantazopoulos et al., 2015).

Furthermore, the project fills in the gaps pertaining to the literature reviews on the topic by correlating them with the data provided by quantitative studies of capnography and the nurses knowledge of the topic as well as its application within the present intensive care unit setting. The critical implications of the project exist for a variety of stakeholders, including nurses, managers, patients, and the industry as a whole. The results of the data collected during this projects duration rely on practice improvements in education and training. This, in turn, would contribute to population health by enhancing clinical practices in CPR and the improvement of capnography efforts within this setting. Also, it would decrease uncertainty during resuscitation procedures and practices that can stem from a lack of knowledge by nurses, reducing stress and promoting guideline compliance within the intensive care unit. Overall, the project would add value by providing information in support of nursing education and training in capnography, which would help to advance the practice and improve population health.

Rationale for Methodology
The quantitative method was chosen for this project due to its features in addressing clinical questions using the collection of meaningful information on the capnography use and nurses knowledge. In this quantitative methodology, data gathering will be the primary strategy for getting information from the project participants (Kiekkas et al., 2016). The quantitative method was considered for this project because the investigator needed to examine the relationships between individual factors affecting capnography use and nurses knowledge during cardiopulmonary resuscitation (CPR) practice in intensive care units. Quantitative methodologies have many benefits that are relevant to this project. They provide a high level of validity and certainty of results as they apply statistical tools for data gathering, organization, and analysis. (Ali & Bhaskar, 2016; Center for Innovation in Research and Teaching, 2013a; Heale & Twycross, 2015; Leppink et al., 2016; Watson, 2015). The use of the quantitative method in this project will be strategic in answering the formulated clinical question to clarify and provide some insight to underlying phenomena in the variables proposed in the study (Campbell, 2017; Center for Innovation in Research and Teaching, 2013b; Guo et al., 2016; Nelson, 2018).

The qualitative methodology will not be used in this project because it contains some limitations that could possibly influence and hinder the reliability of data findings. Qualitative methods are concerned with abstract concepts, and thus their ability to provide objective information is limited (Flick, 2018; Green & Thorogood2018). This is one of the core concepts behind their use and their limitations in understanding the participants behaviors and attitudes rather than specific activities, or knowledge levels can affect the results of the data (Austin & Sutton, 2014; Barnham, 2015; Flanagan, Greenfield, Coad, & Neilson, 2015; Gunnell, 2016). In addition, qualitative instruments are usually not checked for validity and reliability, which increases the risk of bias. This is partially due to the fact that qualitative studies allow for subjective collection and analysis of data in which the researcher is also a participant in the study (Katz-Buonincontro & Anderson, 2018; Rowley, 2014).

The use of a qualitative method would contradict the purpose of the project and affect the opportunity to use its results for practice improvement. Based on the information above, the chosen approach of a quantitative study proves to be more effective than its qualitative alternative at answering the selected clinical question. The central question posed for the project considers the participants level of knowledge and its connection to the use of capnography. By addressing the chosen question with quasi-experimental analysis, not only will the data provide the answers to address the gaps in the projects design, but it will also address the questions into whether improvements in nursing knowledge in the use of capnography has any significance in influencing its use within the coronary care environment.

Nature of the Project Design
The quasi-experimental pre-test post-test analysis is selected as the primary design for this project. is selected because it contains specific procedures that will be executed to align the project with its purpose and the identified clinical statements. The focus of the project is to assess the degree of capnography use in particular scenarios (CPR) by nurses, depending on their existing and acquired knowledge about the procedure. The clinical question introduces a connection between these two variables as well as the comparison between the outcome before and after the intervention, which leads one to propose their contest and correlation as the center of the project. Furthermore, the use of capnography is juxtaposed with the current practice, which further invites one to compare these variables and evaluate their interrelatedness with nursing education. This research design relies on quantitative data collection and analysis methods to examine the relationship between two or more variables (Ingham-Broomfield, 2014). The variables used in quasi-experimental research, such as nurses knowledge and the use of capnography, closely reflect the true experiences and perceptions of the participants in a study (Price, Jhangiani, Chiang, Leighton, & Cuttler, 2017).

The sample, according to the projects questions, includes patients in the ICU of a hospital located in New Jersey. A sampling of the population in the project will require extracting of a subset from the general frame to be examined. It is vital for the participants to come from a unit where cardiopulmonary resuscitation (CPR) have occurred the patients have to have experienced CPR in the unit. The sample size is based on the fact that the ICU usually has 20 licensed beds, but has been operating at an 8-10 bed capacity. There are 32 nurses working in the unit, which is necessary to know to prepare the educational program.

Structured questionnaires containing the selected survey instruments will be used for data collection in this project. First, some demographic data will be collected in order to create some features for grouping and the participants analysis, but no identifying data will be recorded for the project. Some data collection procedures that are necessary to address the clinical question include testing the nurses knowledge in the use of capnography in cardiopulmonary resuscitation procedures. These survey questions will be relevant to providing to answer the sub-questions framed in this projects premise as well as its main purpose (Campbell, 2017; Kiekkas et al., 2016; Nelson, 2018).

Definition of Terms
This section provides a brief overview of the operational terms of the project:

Capnograph. The instrument used to measure and display the amount of cardon dioxide in ones breath (Kiekkas et al., 2016).
Capnography. Capnography is a non-invasive technique to monitor the concentration of partial pressure of carbon dioxide (Kiekkas et al., 2016). It can aid the nurse in tracking the patients progress and support ones decision-making during cardiopulmonary resuscitation.
Cardiac arrest. This term is defined as the cessation of cardiac mechanical activity confirmed by the absence of a detectable pulse, unresponsiveness, and apnea (Tobi & Amadasun, 2015, p. 132). Cardiac arrest leads to the patients death if the appropriate care is not provided immediately, and this adverse outcome, as well as the tools aiding its solution, are the focus of the present project.
Cardiopulmonary resuscitation (CPR). This term identifies the process of restoring the patients blood flow during a cardiac arrest using chest compression and artificial ventilation (Kodali & Urman, 2014). There are specific, detailed guidelines on how to perform cardiopulmonary resuscitation that provide the foundation on which the assessment of the nurses knowledge regarding this technique will be based in this project.
Electronic Health Record (EHR). A digital version of a patients record that contains information about patients recorded and updated in real time (Lin et al., 2018). An EHR allows hospitals to collect, systematize, share, and use patient data for diagnosis and treatment.
Pretest-posttest design. A type of quasi-experimental design, in which the dependent variable is measured before and after the independent variable is implemented (Valente & MacKinnon, 2017). This gap in examination allows one to see the impact of the intervention or treatment on the dependent variable.
Assumptions, Limitations, Delimitations
Assumptions. The following methodological assumptions were made as part of designing the project:

The information gathered from the participants will reflect the overall situation in an ICU of a 240-bed hospital in New Jersey. Although the sample is small, and there may be individual differences among the participants, it is assumed that their attitudes and perspectives will match those of nurses working within a similar setting under similar situations. It is likely that the hospital has similar standards, training, and equipment available for its medical staff.
The nurses selected for the project will have time to participate in the testing portion of the proposed clinical question. The chosen quantitative methodology implies that each participant will complete the NKCT (Nurses Knowledge about Capnography Test) chosen for testing nurses knowledge of capnography use (Kiekkas et al., 2016). This test will assess the nurses education and information retention on the subject and how they perceive the importance of this procedure within the clinical setting. Nurses have a busy schedule, but an expectation is that their participation in the project will help one to obtain the appropriate data and improve patient outcomes as a result.
Limitations. The project limitations are:

The lack of funding prolongs the data collection process. Providing compensation to nurses for taking part in testing would increase the response rate and nurses willingness to participate in the project.
The projects question and methodology raise some ethical considerations. While conducting studies involving human subjects, scholars face many ethical challenges (Sanjari, Bahramnezhad, Fomani, Shoghi, & Cheraghi, 2014; Zyphur & Pierides, 2017). For example, it may not be possible to conduct observations or test participants as planned. Moreover, the issue of information privacy always exists in quantitative research where ones results should not affect their career and organizational environment.
Delimitations. The proposed delimitations within this project are as follows:

Institutional support for recruiting and testing participants is necessary. This type of help could help to improve nurses willingness to participate in the project and remove the obstacles to conducting observations.
Contingency planning for ethical compliance in performing an analysis could help to identify potential ethical constraints and plan for using alternative tools or techniques if necessary.
Summary and Organization of the Remainder of the Project
Overall, cardiopulmonary resuscitation is an essential process in coronary care settings, and additional techniques could increase the chances of survival. As shown above, the rates of people suffering from cardiac arrest annually are high, while the rate of survivors is low (Edelson et al., 2014). Capnography proves to be a valuable addition to the standard CPR procedures in monitoring the patients condition and predicting adverse events (Hamrick et al., 2017; Heradstveit & Heltne, 2014; Kodali & Urman, 2014; Venkatesh & Keating, 2017). The examination of the available data reveals the need to explore the barriers to the consistent implementation of capnography use and its effects. Furthermore, the previous research also demonstrates the importance of examining the nurses knowledge and attitude toward capnography in CPR and their utilization of these concepts in practice. Some studies suggest that many nurses are hesitant to apply such techniques due to the lack of proper training and experience (Lin et al., 2017; Lin et al., 2015; Novais & Moreira, 2015; Pantazopoulos et al., 2015).

This topic has limited evidence in the works of literature and thus continues to create gaps in data on how nursing knowledge affects their readiness to use capnography while complying with standard procedures. The project aims to advance the knowledge in this area, and the insight gained could be useful for nurses in the improvement of patient outcomes and practice. This present DPI project will seek to address this problem by establishing the relationship between nurses knowledge, the use of capnography, and how they correlate into contributing to positive patient outcomes.

The literature review provided in Chapter Two will present an in-depth view of the barriers associated with capnography use as they relate to nurses knowledge through the examination of scholarly findings on the topic and its importance within the clinical setting. Chapter Three of the project will explore the selected quasi-experimental methodology for data collection and analysis. The data analysis will be documented in Chapter Four, which will also demonstrate the calculations of the study in visual form. Finally, Chapter 5 will provide a discussion of the project and consider its connection to the existing scholarship and practice environment.

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