The More You Know and the Deskilling of Nursing Practice

By Jackie Russell, RN JD

MNA Nursing Practice and Regulatory Affairs Specialist

My middle-aged male patient worked a labor job. He came to our ED Triage from work wearing jeans and work boots. He was active. He had no significant health history but also chest pain. Because he didn’t have a cardiac history, was otherwise healthy, bright and chatty, he was placed on a monitor in a trauma room for further evaluation. I remember he said he was under stress at work, but I didn’t pry and we talked about other, benign things. Funny how we remember apparently insignificant details about our patients. By the time he was situated, his chest pain had subsided. His heart rhythm was normal. Until it wasn’t.

We were chatting during a routine assessment. He had no complaints. Then, to my alarm, he suddenly stopped talking–literally midsentence. I will never forget the feeling of looking at the heart monitor to see that his normal heart rhythm had turned potentially lethal. It happened in a heartbeat. I saw it. The moment I saw his heart rate decelerate, mine accelerated. Blood rushed to my ears. Everything went silent. I called a code and opened the trauma cart. Another nurse was at the bedside in a second. She drew up epi while I placed the patient in a supine position and checked the patency of his IV. Algorithms danced in my head.

As emergency nurses, running a code is what we were trained to do. Running a code is what we were expected to do, and, it saved his life. I was grateful for the Advanced Cardiac Life Support training that prepared me for that precarious situation. ACLS training has changed drastically since that code, and nurses are not feeling good about it.

Nurses report they do not practice mock codes; they cannot run a code without a physician or provider order; nurse training no longer requires memorization of cardiac arrest algorithms; ACLS training is tiered, depending on what unit a nurse works on; and it is individual simulation training without the benefit of training with a team of nurse colleagues.

Why has cardiac monitoring and code training been taken away from nursing practice when we all know how critical it is to quickly and competently assess and act on a cardiac arrest? What happens when a nurse cannot start a code without a physician? Precious life-saving moments are lost.

Where is the evidence to show that less cardiac arrest nurse training and education improves patient outcomes?

Did you know that:

• In the heart, electrical activity precedes mechanical activity?
• Electrical activity can occur without a mechanical response?
• The inherent rate of the AV Junction is 40-60 beats per minute?
• A lead is a single view of the heart, often produced by a combination of information from several electrodes?
• The PR Interval represents the time for atrial depolarization and the delay in the AV node?
• The T wave represents ventricular repolarization and can be elevated if electrolytes are off balance?
• Do you know what a “dig-dip” is, or what an inverted T wave means?
• The relative refractory period occurs when some of the cells are capable of responding if the stimulus is strong enough?
• Types of ventricular complexes and how to measure them, and why this is important?
• Or why these points are important to know if you are caring for cardiac monitored patients?

If you provide care to patients on cardiac telemetry and don’t know the answers to these questions, you are not alone. If you want or need further cardiac arrest and/or cardiac monitoring training, look for MNA’s Basic Life Support, Advanced Cardiac Life Support, Pediatric Life Support, and Cardiac Monitoring classes coming in 2020.

My patient’s normal heart rate and rhythm came back. He opened his eyes, looked around at a team of nurses and a physician at his bedside and asked, “What’s going on?” It was awesome.