ICU nurses perceptions of potential constraints and anticipated support to practice defibrillation: A qualitative study

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1 Intensive and Critical Care Nursing (2011) 27, a va i la b le at jo ur n al homepage: ORIGINAL ARTICLE ICU nurses perceptions of potential constraints and anticipated support to practice defibrillation: A qualitative study George C.M. Hui a,1, Lisa P.L. Low b,, Iris S.F. Lee c,2 a Intensive Care Unit, United Christian Hospital, 130, Hip Wo Street, Kwun Tong, Hong Kong b The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Esther Lee Building, Shatin, N.T., Hong Kong c Cardiac Diagnostic Laboratory, Ruttonjee and Tang Siu Kin Hospitals, Queen s Road East Central, Wan Chai, Hong Kong Accepted 29 April 2011 KEYWORDS Nurse-led defibrillation; Intensive care; Qualitative; Hong Kong Summary Aim: The study examines the experience of intensive care nurses in caring for patients in cardiac arrest, and their perceptions of introducing nurse-led defibrillation. Method: This was a descriptive, exploratory and qualitative study at an intensive care unit (ICU) of an acute regional hospital in Hong Kong. Twelve registered nurses were purposefully selected for interview. Results: Although all the participants were trained in basic life support, only 50% were trained in advanced cardiac life support (ACLS), and those trained in ACLS described having limited opportunities to apply their defibrillation knowledge. Whilst participants believed that they were theoretically prepared to influence the patient s resuscitation outcomes, newly qualified nurses were reluctant to be accountable for defibrillation. In contrast, experienced nurses were more willing to perform nurse-led defibrillation. Support from management, cooperation between nurses and doctors, regular in-hospital real-drill programmes, sponsorship for training, and the use of alternative defibrillation equipment should be considered to encourage nurse-led defibrillation in ICU settings. Conclusion: Nurse-led defibrillation is an approach of delivering prompt care to critically ill patients, and a way ahead for intensive care nursing in Hong Kong. Emphasis on a consistent policy to promote nurse-led defibrillation practice is needed Elsevier Ltd. All rights reserved. Corresponding author. Tel.: ; fax: addresses: [email protected] (G.C.M. Hui), [email protected] (L.P.L. Low), [email protected] (I.S.F. Lee). 1 Tel: Tel: /$ see front matter 2011 Elsevier Ltd. All rights reserved. doi: /j.iccn

2 ICU nurses perceptions of defibrillation 187 Introduction Sudden cardiac arrest is the most common fatal manifestation and outcome of heart disease (American Heart Association (AHA), 2005a), accounting for 63.7% of deaths arising from cardiovascular causes. In the United States, sudden cardiac arrest causes an estimated 350,000 deaths per year (Capucci et al., 2002). The goal of the American Heart Association (AHA) is therefore to promote basic life support (BLS) and advanced cardiac life support (ACLS), so as to improve the survival rate of individuals with sudden cardiac arrest. In Hong Kong, 5309 individuals died from heart disease in 2006, accounting for 14.6% of the total mortality (Department of and Health, 2006). The main cause of sudden arrest is ventricular tachycardia (VT) and ventricular fibrillation (VF) (Powers and Martin, 2002). Previous studies have shown defibrillation as an effective therapy for VF, with the ability of improving survival of sudden cardiac arrest if performed early within four to five minutes (Cook et al., 2003; Kwok et al., 2003). Since 1997, the International Liaison Committee on Resuscitation (ILCOR) (Kloeck et al., 1997) has recommended that resuscitation personnel should be authorized, trained, equipped and directed to operate a defibrillator if their professional responsibilities require them to respond to persons in cardiac arrest. This recommendation includes all first responders, in both hospital and out-of-hospital settings. Although performing early defibrillation within the chain of survival will ensure the highest possible survival rate of inhospital cardiac arrest, the low survival rate of in-hospital sudden cardiac arrest (around 10 20%) as a result of resuscitation has become a cause for concern (Zafari et al., 2004; Zheng et al., 2001). Limited attention is given to the understanding of the survival rate of in-hospital sudden cardiac arrest cases and the potential contribution of nurses in caring for these patients in Hong Kong. Whilst earlier work in the United Kingdom (UK) has demonstrated that in-hospital survival rates of cardiac arrest can be improved by early defibrillation performed by nurses (Coady, 1999), at the time of this study nurse-led defibrillation was not currently practised in Hong Kong hospitals. Given the changes in technology and the availability of new defibrillators in recent years, this paper examines the potential contribution of intensive care nurses, as well as their potential constraints and anticipated support in the introduction of nurse-led defibrillation for improving survival of sudden cardiac arrest patients in an acute care setting. This study also hopes to highlight the constituents of a policy that should be in place to promote nurse-led defibrillation for the delivery of prompt care to critically ill patients in Hong Kong. Background Since most victims of sudden cardiac arrest demonstrate VF, studies have shown poor survival when the chain of survival is not met. This indicates that at the time of collapse, if early cardiopulmonary resuscitation (CPR) and defibrillation are not performed, the chance of returning to spontaneous circulation is diminished by 7 10% per minute (AHA, 2005a). In the course of a few minutes, VF will become asystole if treatment is not initiated, cardiovascular shocks will rapidly become irreversible and hypoxic brain damage will occur (AHA, 2005b). Consequently, the interval between sudden cardiac arrest and defibrillation is critical, and the recommended time is four to five minutes (Hajbaghery et al., 2005; Lo et al., 2003). According to Cusnir et al. (2004), the low survival rate of in-hospital sudden cardiac arrest could be explained by the time required to recognize cardiac arrest, the time spent waiting for the resuscitation response team to initiate defibrillation and the time required to attach the defibrillator to detect the cardiac rhythm. Despite improvement in healthcare professionals knowledge in identifying sudden cardiac arrest patients with pulseless VT or VF, the in-hospital survival rate is still low due to the difficulty in reducing the time from collapse to defibrillation (Herlitz et al., 2005; Weil and Fries, 2005). Traditionally, nurses are usually the first responders to sudden cardiac arrest who initiate CPR. In the United States and Italy, nurses would activate the resuscitation response team, initiate CPR and prepare the equipment for the resuscitation response team to initiate manual defibrillation (Peberdy et al., 2003; Sandroni et al., 2004). In Hong Kong, the management of sudden cardiac arrest resuscitation is similar. In the UK, a manual defibrillation course was introduced in the development of a strategy for nurse-led defibrillation in a general ward to improve patient outcomes following cardiac arrest (Coady, 1999). The course covered rhythm recognition and defibrillation, with the objective of training a large number of nurses and making defibrillation an accepted nursing procedure. Of the 98 nurses trained in 1996, nurses in the general ward performed 80% of the defibrillation on 25 patients. Another 149 nurses were trained during , but no increase was found in the overall percentage of nurses performing defibrillation following this period of training. However, the number of patients in VT or VF who were defibrillated before the arrival of the cardiac arrest team had markedly increased to 46%. Although nurses were taught how to perform manual defibrillation, they were reluctant and hesitant about using these skills without supervision. Coady (1999) believed that as more nurses gained experience in supervised defibrillation, they would be highly confident to defibrillate unsupervised. Furthermore, studies have shown that when training was provided to nurses and physicians, early CPR can increase the survival rate of in-hospital sudden cardiac arrest (Herlitz et al., 2002). However, there is also evidence to support the problem with recall of essential CPR knowledge, and the lack of professional responsibility in dealing with this issue (Marzooq and Lyneham, 2009). A study found that BLStrained nurses with skills in operating an automated external defibrillator (AED) were expected to practice early defibrillation using an AED on sudden cardiac arrest patients (Gombotz et al., 2006; Kaye and Mancini, 1996). The inhospital chain of survival can indeed be strengthened by early defibrillation carried out by the first responder (usually the nurse), and by the performance/teaching of advanced life support (Xanthos et al., 2009). In the local context, manual defibrillators are used to interpret and recognize cardiac arrhythmias. However, interpretation of cardiac arrhythmias is insufficiently covered in the basic nursing training in Hong Kong. As such,

3 188 G.C.M. Hui et al. studies have highlighted the use of AEDs by nurses in responding to patients in sudden cardiac arrests and providing early defibrillation (Gombotz et al., 2006; Mattei et al., 2002; Spearpoint et al., 2000). Currently, no published data are available to compare the use of traditional manual defibrillators versus AEDs in hospitals (International Liaison Committee on and Resuscitation, 2005). Nurse-led defibrillation is believed to improve the survival rate of patients with sudden cardiac arrest, enhance nurses role, and advance nursing practice. Dwyer et al. (2007) highlighted that if nurse-initiated defibrillation is to be accepted, it should be integrated into educational programmes to enhance skill development. This study explores the perceptions of nurses on whether it will be realistic to include the performance of early defibrillation in current CPR practices. Study design The purpose of this study was to examine the experience of ICU nurses in caring for patients with cardiac arrest, and their perceptions of introducing nurse-led defibrillation for patients presenting with VT or VF. An exploratory and descriptive research design using semi-structured interviews was adopted. Broad and interactive questions were asked to explore CPR experience, existing defibrillation practices with regard to the input of nurses, as well as potential constraints and anticipated support in the introduction of nurse-led defibrillation in an acute care setting. Setting and participants The study was conducted at an adult ICU with 20 beds and an emergency admission unit in an acute care hospital in Hong Kong. The nursing staff (n = 79) comprised 71 registered nurses, five nursing officers, two nurse specialists and one advanced practice nurse. Purposive sampling was used to select 12 informative nurses who had cared for patients in cardiac arrest with VF or VT. The inclusion criteria were: male or female, currently working full-time and have been working at the ICU for at least one year, experienced in caring for VT or VF patients who needed defibrillation in the ICU within the past two years, and completion of a post-registration CPR training course. Table 1 shows the demographic data and specialty training of the participants. All participants had completed BLS certificate training. Six (50%) had obtained the ACLS certificate, and 11 (91.6%) had completed the ICU specialty certificate training. Data collection Data were collected from September to December 2006, after ethical approval was obtained from the Survey and Behavioral Research Ethics Committee of the University and the Hospital Ethics Committee. A briefing session was held in the ICU to explain the purpose of the study and data collection method to the nurses. The importance of voluntary participation was emphasized. The researcher circulated a form and gave the nurses one week to sign up if they wished to participate in the study. The completed form was put into the drop box, which was accessible only to the first author. However, the initial response rate was low. Another briefing session was conducted and an extra week was given to recruit the participants. Each participant signed a consent form before the interview. A demographic data sheet comprising gender, age, education background, years of nursing experience, years of experience working in an ICU and training record was completed. An interview schedule was developed (Table 2) from a review of the literature, and advice was obtained from the ICU Department Operation Manager, nurse specialists, AHA ACLS instructor and ICU nurses. All interviews were MP3-recorded and each lasted minutes. During the interview, the participants had to recall clinical experience and incidents they had experienced when caring for patients in cardiac arrest, VT or VT, and their perceptions of being involved in defibrillation. The researcher was cautious of the emotions and distress that could possibly arise when participants shared the experience of caring for patients who were distressed as a result of cardiac arrest. The credibility of qualitative research is based on the consistency of responses collected over time and on asking different questions about the same topic to ensure the equivalence of the information (Morse, 1991). Consistency of data collection was guaranteed in the study as only one researcher conducted the interviews. Trustworthiness of data was maintained by selectively approaching participants to read through their transcripts and to check that the data had accurately captured their experience. Data analysis Content analysis was performed to analyse the unstructured interview data (Morse and Field, 1995). The strategy involved preparing and managing the data for analysis, developing categories, and making interpretations of the data. The procedure involved coding the transcripts and entailed a process of linking (rather than labelling) the data to form abstract ideas or subcategories (Morse and Richards, 2002). As codes were searched for emergent patterns and meanings, they were collapsed into explicit subcategories and categories. All incoming data were checked against the emerging framework that eventually comprised four categories describing the nurses experience of caring for cardiac arrest patients, perceived knowledge about managing resuscitation and defibrillation, current practices that constrained its implementation, and ways to support nurseled defibrillation. Findings Resuscitation experience in ICU The ICU was regarded as an advanced setting for nurses to take care of critically ill patients. Well-equipped haemodynamic monitoring systems were available to alert nurses of the patient s changing condition so that resuscitation could be performed promptly: This ICU has more patient monitoring systems. We can quickly detect the patient s changing condition so the CPR success rate will be higher. (N9)

4 ICU nurses perceptions of defibrillation 189 Table 1 Demographic data and specialty training of participants. Nurse Age Gender ICU work experience (years) Rank Education (Nursing) Training ICU specialty Basic life support Advanced life support N M 7 9 Registered Nurse Bachelor N F 7 9 Registered Nurse Certificate N F 7 9 Registered Nurse Bachelor N4 41 or F Over 10 Nurse Specialist Master above N F Over 10 Registered Nurse Bachelor N6 41 or F Over 10 Registered Nurse Bachelor above N M 4 6 Registered Nurse Bachelor N M Over 10 Registered Nurse Bachelor N M 1 3 Registered Nurse Bachelor N10 41 or M Over 10 Advanced Practice Bachelor above Nurse N F 4 6 Registered Nurse Bachelor N M 4 6 Registered Nurse Bachelor Although all participants described themselves as the first person to respond to the resuscitation scenarios, this leading role was quickly taken over by the doctor on his/her arrival: Usually the first responder is the case in-charge. The case in-charge acts as a leader, coordinates the CPR procedure and monitors the rundown. When they find asystole, they call for help and arrange other nurses to call the doctor. (N9) Although manpower was not an issue in this ICU, coordination between the nurses should be enhanced to ensure a smoother resuscitation procedure, particularly in the initial critical seconds. As for the specific role of nurses in resuscitation, most participants described role confusion in the CPR process. Whilst the patient s nurse in-charge usually organized the manpower and assigned tasks to other nurses, confusion arose when inexperienced nurses were unclear about their roles and duties during resuscitation: I find the CPR process quite confusing. Our nurses are willing to help during CPR, but they re unclear about the role they should take. Sometimes nurses focus on the circulation and no one does the documentation. Sometimes no one checks the time for the next medication, or we forget to call the patient s relatives. If the doctor is present, he/she will give different orders: take blood or give medication. These things make us quite confused. This is quite a big problem when we do CPR. (N1) Perceived knowledge about managing resuscitation and defibrillation Fifty percent of participants possessed the ACLS certificate, and claimed to be knowledgeable and confident about managing resuscitation scenarios. The ACLS training had provided them with background knowledge about resuscitation skills and protocols, and developed their confidence in handling CPR: Since I ve more background knowledge, I know the rationale behind what I do (resuscitation) and how it helps the patient. I m familiar with the ACLS algorithm and protocol and it s easy to handle the CPR scenario. (N10) When the participants were asked about their knowledge of defibrillation, all of them correctly stated the aims of using it, the types of defibrillation and patients who needed to be defibrillated. ICU nurses general knowledge about defibrillation was therefore satisfactory. As most patients admitted to the ICU suffered from respiratory failure, the participants mainly focused on respiratory rather than cardiac care. As such, some participants expressed having Table 2 Interview schedule. Can you share experiences of caring for patients in CPR? Can you share your knowledge about defibrillation? Tell me your experiences/views of caring for VT or VF patients who needed defibrillation? What would you need in order to perform nurse-led defibrillation in the hospital? Can you identify constraints confronting you if nurse-led defibrillation is practiced?

5 190 G.C.M. Hui et al. insufficient knowledge in cardiac care and lacked confidence in ECG interpretations: ICU nurses feel hesitant about performing defibrillation. They re not confident about ECG interpretation and management. We rarely deal with the patients cardiac problems. They re transferred to the CCU [cardiac care unit], so we re weak in cardiac care. We deal with postoperative, renal failure and neural cases here. (N2) Despite the completion of advanced ACLS training, the performance of defibrillation was still strongly perceived as a doctor s duty and the duties of nurses were to assist them: When the case develops VT or VF, the doctor orders defibrillation. Why does the doctor perform defibrillation? He/she has obtained the ACLS license and practises defibrillation so well he/she can do it naturally. This is the problem in clinical practice. We ve a concept that defibrillation is not done by nurses. We re just responsible for switching on the button and connecting the cable. When the doctor arrives, he/she will perform it. This is the nurses problem. (N12) Some participants did challenge this traditional belief of the doctor performing defibrillation and believed that nurses had responsibility to practise timely defibrillation to save the patients lives. They described exemplars of ACLS-trained nurses who were able to confirm shockable VT scenarios and defibrillated with confidence in special situations. Constraints of nurse-led defibrillation The main constraints that prevented participants from wanting to implement nurse-led defibrillation in the ICU included limited exposure and experience in defibrillating VT or VF patients, lack of confidence and fear of making mistakes. Although they had acquired knowledge of defibrillation practice after the ACLS training (i.e., familiarity with the arrhythmia and the protocol), memory faded over time due to the lack of practice: We ll miss some information if we don t practise systematically. Although we ve attended the course, we re not familiar with the steps. We may forget to follow the sequence of ABCD. (N12) Many participants stated that the incidence of VT or VF varied every year and, on the whole, was considered to be quite low in the ICU: It s not the problem of training. Training provides the knowledge, but we can t apply it to the real clinical situation. Trained (ACLS) nurses are scared when they encounter the first real scenario without a doctor s presence. Although we ve been trained and issued with the certificate, which is valid for a year, it takes a long time before we can manage a defibrillation scenario. (N4) Whilst the low number of cases meant that ACLS-trained nurses had little practice, some nurses did not mind doing less as this guaranteed that no mistakes would be made, and there was no need to shoulder any responsibilities: Nurses claim to have forgotten the knowledge after a few months. After a long wait, they lose confidence. I believe it s difficult to promote nurse-led defibrillation programmes. Not every nurse is willing to take accountability. (N4) The fear of making mistakes, such as incorrectly managing a scenario, making the wrong interpretation and doing harm to the patient, was reiterated: I worry about the outcome of the patient and whose responsibility it is. I worry about incorrectly managing a defibrillation scenario and bearing the responsibility if I hurt others. (N9) Unfamiliarity with the patient s haemodynamic status also added to the participants fear of making mistakes. Indeed, familiarity with the patient s haemodynamic state was regarded as a prerequisite for initiating defibrillation: When the conscious patient developed VT, nurses weren t sure of the scenario. I suggested calling the doctor and preparing the medication. Some nurses prepared for defibrillation when they saw VT and didn t assess the patient s haemodynamic state. They should assess the waveform first and then prepare the medication. (N2) Supporting nurse-led defibrillation Most participants supported the performance of defibrillation by nurses provided that adequate support was available. This included obtaining support from the hospital, collaborating with the doctor, providing training opportunities and sponsorship and considering the use of alternative equipment. As the performance of defibrillation is minimally addressed in the general nursing training, obtaining support from the hospital to ensure that all nurses were issued with the ACLS certificate to perform defibrillation was regarded by the participants as highly important. The hospital s recognition and acknowledgement of this qualification would enable nurses to advance their ICU practice and instill greater confidence: It depends on whether the organization and the hospital recognize your qualification to perform defibrillation. We don t perform it in this hospital. We should seek training, which legally allows us to do it. We can perform it step by step, and the hospital and unit should allow us to try. (N10) In the trial of nurse-led defibrillation programmes, it is essential to reach a consensus and move towards closer collaboration between nurses and doctors, particularly when doctors make influential decisions about patient care and outcomes. Some participants suggested making compromises with the doctor about the practicalities of the programme and asking them to provide the initial supervision until nurses gain confidence in managing the defibrillation scenario on their own: When nurses want to promote such a programme, we are confronted with the constraint of doctors refusing to promote it. In Hong Kong hospitals, doctors always take the lead and have a say in the management (of the

6 ICU nurses perceptions of defibrillation 191 patient). If we want to promote this programme, we d need to see whether the doctors will support us. (N11) The provision of opportunities and sponsorship (in terms of time or financial aid) for training would certainly demonstrate the support of the hospital for nurse-led defibrillation, although only a few privileged staff members were nominated to attend the training. ACLS attendees reported paying and spending two days for the training course, and receiving no work benefits or salary increments afterwards. This could diminish nurses motivation to update their resuscitation knowledge: Although we can t be fully sponsored, they should sponsor some of the training fee. Only a few nurses got the sponsorship. Sponsorship is needed to train us to perform defibrillation. We must have adequate training and recognition. (N10) To promote nurse-led defibrillation successfully, it was believed that nurses should have up-to-date knowledge and be familiar with the protocols. It was suggested that the hospital should consider increasing regular training, such as in-hospital resuscitation training and in-house CPR drills for nurses, to build up and refresh their defibrillation skills. However, one participant had reservations about the benefits of drill practices. During a drill, the environment and equipment were well-prepared for participants to undertake a simulated activity in an unreal situation there a possibility that these nurses could perform poorly in emergency clinical situations. A transition phase of using alternative equipment such as AED was proposed to build up nurses confidence before proceeding to use of the manual defibrillator: Nurses will be more confident to use AED because there s no need to interpret the ECG. It s easy to use. It ll interpret the ECG. We press the shock button when defibrillation is needed. There s also shock advice from the AED. (N2) Discussion The findings revealed that intensive care nurses were critical of their resuscitation skills, which they believed had to be of a higher standard of proficiency before nurse-led defibrillation could be pursued to improve service delivery in the ICU. Whilst the focus of this study was on the participants perceptions of introducing nurse-led defibrillation, it also provided an opportunity to review existing resuscitation practices in the ICU so that substandard practices could be identified. The participants were always the first responders to cardiac arrest and activated the code system very quickly. However, the study highlighted their experience of role confusion and the need to be more coordinated, especially at the beginning of the resuscitation procedure. Therefore, a clear departmental guideline should be in place to define the role of nurses when performing defibrillation and the manpower flow should be provided to the assigned nurse during resuscitation. This would avoid role confusion and ensure that early defibrillation is delivered by the delegated nurse. Expectation was high of all intensive care nurses about their ability to be fully competent in performing the resuscitation procedure. This is a crucial aspect of BLS skill to get right to improve the chance of successful resuscitation (Enohumah et al., 2006). More frequent review of CPR skills can help overcome the chaos and confusion associated with emergency situations in hospitals. Therefore, regular CPR drills, including nurse-led defibrillation, should be encouraged and may be set as one of the requirements for hospital accreditation. Recently, personal communication with some local hospitals in Hong Kong revealed that nurse-led defibrillation has been adopted in the ICU, cardiac care unit (CCU) and in medical wards with cardiac care nurses. These nurses are required to attend regular in-house defibrillation courses and to take examinations to ensure they have upto-date resuscitation knowledge. Regular recertification is also required to maintain the competence of nursing practice. Hospitals can consider motivating nurses to apply their knowledge in clinical practice by exempting yearly recertification examinations for those who have performed more than two cases of defibrillation in a year. From the authors observation, these nurses are more willing to play their role in nurse-led defibrillation when such an exemption system is in place as an incentive. According to the literature, nurses trained in ACLS are able to perform resuscitation better and more effectively (Vincent, 2003). ACLS is a skill that can be life-saving or death-provoking during critical situations, it is imperative that nurses are competent in performing effective resuscitation. Previous studies have shown a significant association between ACLS-trained nurses and higher patient survival rates from cardiac arrest (Dane et al., 2000; Pottle and Brant, 2000). The findings highlighted the effect of resuscitation training on the initial outcome (return of spontaneous circulation), lending support to the provision of regular training to update the skills and practice of nurses in CPR. However, resuscitation training did not appear to affect the patients long-term survival (Pottle and Brant, 2000). Since ACLS-trained nurses have a systematic way of performing resuscitation in emergency situations, they would be expected to take the lead and activate the in-hospital resuscitation procedure more promptly and follow the ACLS protocol with less delay than nurses not trained in ACLS. Hence, delays in initiating defibrillation can be reduced by having more ACLS-trained nurses. However, Reznek et al. (2002) reported that there is usually insufficient time allocated for ACLS training in hospitals. According to Lee et al. (2005), major factors hindering Hong Kong nurses from participating in continuing nursing education were cost, time and inadequate support from employers. Similarly, in the current study, the main reasons for nurses reluctance to join ACLS training were frustration, low motivation, time constraints and limited opportunities and sponsorship provided by the hospital. Support from the organization to recognize nurses in undertaking continuous education and skill training are therefore important for encouraging them to extend their role in resuscitation (Lee and Low, 2010). Some local hospitals have formulated policies to make ACLS certification compulsory for cardiac care nurses. ACLS training has also become a basic requirement for nurses to perform defibrillation in some advanced patient care areas such as ICU and

7 192 G.C.M. Hui et al. CCU. Additionally, these hospitals provide sponsorship and a study leave of two days to support their nurses after they are recruited into these units. Due to lack of supervised practice, the participants stated that they were afraid of making mistakes even after they had received ACLS certification. This study revealed that nurses were only expected to adopt a passive role in preparing the equipment, to assist the doctor who performs the CPR-defibrillation procedure. Many claimed that they were ill-prepared for and felt challenged by the real clinical scenario (which differed significantly from the training environment) coupled with the lack of supervision provided to help them improve performance. These findings were consistent with those of De Vita et al. (2004), which illustrated the unsatisfactory performance of ACLS-certified nurses when first tested in a clinical emergency scenario. Other studies have highlighted ACLS trainees poor retention of resuscitation skills (Murphy and Fitzsimons, 2004). This is consistent with findings of the current study, in which ACLS-trained participants were reported to experience fading memory and inability to deploy their life support skills and professional knowledge in a real clinical scenario after a period without practice. There have however, been successes in nurse-led defibrillation. In studies evaluating elective nurse-led cardioversion services for atrial fibrillation (Boodhoo et al., 2004; Shelton et al., 2006), nurses were found to provide safe and cost-effective service after the completion of appropriate training and accumulation of experience. In Hong Kong, there is only one published study on nurse-led defibrillation in the CCU setting (Chan et al., 1998). Trained nurses were able to correctly diagnose cardiac arrest, identify the arrhythmia and the need to defibrillate, and execute sequential steps to complete defibrillation. The study highlighted that support obtained from the hospital was a key to success. Recently, some hospitals in Hong Kong have involved doctors in the provision of training and supervision for nurseled defibrillation programmes. The senior medical officer is responsible for on-site or retrospective certification of nurses who have performed defibrillation. Manual defibrillators are still the standard equipment for in-hospital defibrillation in Hong Kong. Some participants were unfamiliar with its use, as it required interpretation of ECG arrhythmia; thus, introducing AED could offer an acceptable alternative for nurse-led defibrillation in hospitals (Kenward et al., 2002; Winkle, 2010). By adopting AEDs in hospital nurse-led defibrillation programmes, early defibrillation can be achieved by shortening the delay from sudden cardiac arrest to defibrillation (Hanefeld et al., 2005; Huang et al., 2002). Some hospitals have also made it compulsory for all nurses, including general ward nurses, to participate in the three hour AED training programme. This would empower all nurses to perform AED defibrillation even in the absence of a doctor. Limitations There were two limitations in the current study that have to be acknowledged. The selected ICU primarily catered for patients with multiorgan failure, renal failure and septic shock, and there were fewer cardiac cases requiring defibrillation. Thus, selection of a site with an appropriate patient mix to implement the nurse-led defibrillation programme would be a factor to consider. Moreover, selection of a site where nurses have frequent exposure to the use of manual defibrillators (even if defibrillation is performed by doctors) might provide different results with regard to the participants perceptions and experience. Although valuable information on nurses resuscitation experience was obtained, memory recall of the CPR experience might have resulted in omission of some detailed reflections of the emergency situation. Conclusions The study shed light on the experience of ICU nurses in resuscitation and the possibility of performing nurse-led defibrillation in an ICU setting. The findings have increased knowledge of how nurses cared for cardiac arrest patients, the procedure they followed when assisting in defibrillation, and the perceived constraints and supportive measures required for implementation of nurse-led defibrillation. Our findings have also highlighted the need for an emphasis on a consistent policy to promote nurse-led defibrillation practice. A nurse-led defibrillation programme would require considerable effort in terms of clear hospital guidelines and support, effective ACLS training and supervision, certification to acknowledge practice expertise, consideration of a transition to the use of AEDs and a change in nurses traditional philosophy and responsibilities. Further research in other specialties, including the CCU and accident and emergency departments, is recommended to obtain the viewpoints of nurses of various specialties so as to explore the possibility and support the decision of introducing nurse-led defibrillation in hospitals. References American Heart Association. Part 3: Overview of CPR. Circulation 2005a;112:IV-12 IV-18. American Heart Association. Part 5: Electrical therapies: automated external defibrillators, defibrillation, cardioversion and pacing. Circulation 2005b;112:IV Boodhoo L, Bordoli G, Mitchell AR, Lloyd G, Sulke N, Patel N. 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