Nurses with the following characteristics were eligible to participate in this study:

Inclusion criteria.

1) Staff nurses above 20 years of age, from both the genders.

2) Nurses who had a qualification at least three years general nursing diploma.

3) Full-time employee.

4) Registered Nurses who had at least six months of experience dealing with cardiac patients.

Exclusion criteria.

1) Nurses who were not registered with the Pakistan Nursing Council.

2) Registered Nurses working in the non-cardiac Intensive Care Unit of the ICU.

Independent variables.

1) Age

2) Years of experience

3) Novice Nurses

4) Expert Nurses

5) Specialization

6) Professional Qualifications

Dependent variables.

1) Level of knowledge

2) Level of practices

The data were collected using two instruments, which were designed by the primary investigator with the help of literature. The knowledge was assessed through a questionnaire, which was based on 50 multiple-choice questions. The knowledge questionnaire was divided into six sections: cardiac physiology, cardiac diseases, cardiac catheterization and PCI procedure, ECG interpretation, complications of cardiac catheterization and PCI procedure, and cardiac medications. The participants were given one hour to complete the knowledge questionnaire.

To assess practices, an observational checklist was utilized by the data collectors. This checklist was based on post-cardiac catheterization care standards and was developed with the help of literature. It composed of 20 components and the data collectors were had to fill it after observing each participant. Each participant was observed thrice, on three consecutive days, except for holidays; with three different patients in the morning and evening shifts. The purpose of frequent and long-term observations was to minimize the “hawthorne effect” [10] .

The participants were recruited using universal sampling technique after taking permission from the nursing manager and the area head nurse. The list of all eligible participants was obtained. Based on their willingness and voluntarily participation, all the participants were recruited from different units, which included the Coronary Care Unit (CCU), Male Higher Dependency Unit (MHDU), Female Higher Dependency Unit (FHDU), Male General Ward (MGW), Female General Ward (FGW), and the Day Care Unit (DCU). Since the study setting was a philanthropic organization, and all the care provided was free of cost, therefore, the ratio of patients coming from different regions of country was high. However, due to the limited cardiac designated beds, they utilize non-designated beds regardless of the unit. Hence, patients undergo cardiac catheterization stay in all these units.

Study Bias: To the best of researchers’ knowledge, this study had no potential bias.

A total of 79 nurses were working, at the time of the study, in the target units, where cardiac patients were taken care of, but, only 70 nurses (89%) were able to participate in this study. The sample size was calculated through the National Statistical Service & Sample Size Calculator. The total number of nurses who were working in the cardiac units was taken as population, which were calculated as being 79 participants. The confidence level was set at 95% and the level of significance was less than 0.05. The proportion of knowledge was taken as 53% by referring to the study conducted by Shini, Paul, and Smitha (2018) who evaluated the effectiveness of the nursing care protocol on knowledge and practice among staff nurses, regarding the management of patients undergoing coronary angioplasty. The sample size was 65 participants, and an additional 10 percent attrition rate was included in the sample. Finally, the total sample size comprised of 72 participants. Two participants refused to take part in this study once they understood that their practices will be observed. So, the total sample size included 70 participants.

After approval from the Ethical Review Committee (ERC), Karachi, and the Institutional Review Board (IRB), the study tool was reviewed by eight experts, who were approached based on their experience and qualification in the discipline of cardiology. The panel included six medical experts and two nursing experts. Out of the six medical experts, two were consultant cardiologists, of which one was a professor, having more than 10 years of experience in the field of cardiology, two were cardiology residents, having more than four years of experience in the relevant field, and two were medical officers, one of whom was an SMO, having more than eight years of experience in cardiology. Out of the two nursing experts, one was a nurse specialist in cardiology, having more than five years of experience, and one of them was a Head Nurse (CCU), who had three years of relevant experience. A four-point ordinal likert scale was utilized to evaluate the content validity of each of the 50 questions. The relevancy and clarity of the questions were assessed in relation to the study topic. The eight experts had to give scores on a scale in the following format. 1 = not being relevant, 2 = somewhat relevant, 3 = quite relevant, 4 = highly relevant; the same scoring was used for clarity. Scores of 3 and 4 were considered acceptable, while scores of 1 and 2 required further modifications. Finally, results from the eight experts were quantified and the CVI of the study tool was calculated, which was 0.98 for relevancy and 0.98 for clarity. For the reliability of the study instruments, Cronbach’s alpha was calculated using SPSS which was found to be 0.87. Hence, based on the results of CVI and Cronbach’s alpha, it was evident that the study instruments were valid, clear, and reliable for the study context.

Pilot testing of the tool was done on 7 participants (10% sample size) after the CVI calculation. The purpose of pilot testing was to examine the tool’s utility and its weaknesses. No significant suggestions were reported during the process of pilot testing.

The collected data were entered and analyzed using the statistical package for social sciences (SPSS) version 20, this was done by the primary investigator and the data input operator. Once the data collection was complete, it was checked for any inconsistencies. Descriptive and inferential statistics were used to analyze the data. Mean and standard deviation were calculated for continuous variables, whereas proportions and frequencies were calculated for categorical variables. The nature of the relationship between the level of knowledge and practices were compared using the independent t-test and chi-square test [11] . These comparisons were done between expert and novice nurses, between nurses who have different levels of qualification, between nurses with and without having cardiac diploma, and between male and female nurses. The difference between three practice observations was analyzed using the repeated measures ANOVA test [12] . P-value of less than 0.05 was considered significant. The study was adherent to the strengthening of the reporting of observational studies in epidemiology (STROBE) statement.

The confidentiality of the study participants was maintained throughout the study. All the data files were locked in cabinets and all the soft copies were kept protected by a password, to which no one had access except the primary investigator, thesis supervisor, and the thesis committee members.

A total of 70 nurses, who had more than six months of experience dealing with cardiac patients, were recruited for this study. Table 1 describes the demographic characteristics of the study participants, including their age, gender, qualification, specialization, professional experience, and the respective departments where they worked. The mean age of the participants was 26.8 + 5.3 years and the age range was between 20 - 48 years. Furthermore, a total of 32 nurses (45.7%) were between 25 - 29 years of age. In terms of gender, a total of 41 participants (58.6%) were males, whereas, 29 (41.4%) were females. Qualification analysis showed that 40 nurses (57.1%) had a diploma in general nursing and 22 (31.4%) had a post RN BScN degree, whereas only eight nurses (11.4%) were BScN degree holders. With regard to specialization, half of the nurses (50%) had a diploma in cardiology, whereas the remaining 50% did not.

Table 2 shows that the mean experience of the nurses was 3.86 + 3.7 and the range of experience was between 1 - 19 years. It also shows that 38 nurses (54.3%) were experts, whereas 32 nurses (45.7%) were novices. Findings related to different departments indicate that 30 nurses (42.9%) were from the Female Ward, 20 nurses (28.6%) were from the Male Ward, 16 nurses (22.9%) were from the CCU, and only four nurses (5.7%) were from the Day Care Unit.

One of the major outcomes of the study was to assess the level of knowledge among nurses, regarding patient care following cardiac catheterization. The knowledge tool comprised of 50 questions. Each question was given a score of one and the total score was 50. The mean knowledge score was 27.2 + 6. The minimum knowledge score was 16, whereas the maximum knowledge score was 46. Knowledge was categorized into three levels: inadequate, adequate, and excellent knowledge levels. A total of 38 nurses (54.3%) showed adequate knowledge scores, 28 nurses (40%) had inadequate knowledge scores, while only four nurses (5.7%) reached up to the excellent knowledge level (see Table 3).

The mean knowledge related to cardiac physiology was 4.8 + 2.4. The minimum knowledge score was zero, whereas the maximum was 10. A total of 31 nurses (44.3%) showed inadequate knowledge scores, 28 nurses (40%) obtained adequate knowledge scores, and 11 nurses (15.7%) got excellent knowledge scores related to cardiac physiology. The mean knowledge related to cardiac pathology was 7 + 1.4. The minimum knowledge score was four, whereas the maximum was 10. A total of 39 nurses (55.7%) attained adequate knowledge scores, two nurses (2.9%) got inadequate knowledge scores, whereas 29 nurses (41.4%) got excellent knowledge scores related to cardiac pathology.

Similarly, in terms of knowledge related to common electrocardiogram interpretation, the mean knowledge was 1.5 + 0.9. The minimum knowledge score was zero, whereas the maximum was three. A total of 34 nurses (48.6%) scored adequate knowledge and 28 nurses (40%) showed inadequate knowledge, whereas only eight nurses (11.4%) had excellent knowledge related to the interpretation of common electrocardiogram strips.

In analysis of knowledge related to the procedure, the mean knowledge was 6.8 + 1.3. The minimum knowledge score was four, whereas the maximum was 10. A total of 47 nurses (67.1%) attained adequate knowledge scores, three nurses (4.3%) acquired inadequate knowledge scores, whereas 20 nurses (28.6%) got excellent knowledge scores related to procedural awareness.

In the knowledge related to procedural complications, the mean knowledge was 3.4 + 1.8. The minimum knowledge score was zero, whereas the maximum was nine. A total of 52 nurses (74.3%) acquired inadequate knowledge scores, 16 nurses (22.9%) got adequate knowledge scores, whereas only two nurses (2.9%) had excellent knowledge scores.

The mean knowledge related to cardiac pharmacology was 5 + 1.8. The minimum knowledge score was one, whereas the maximum was nine. A total of 37 nurses (52.9%) got adequate knowledge scores regarding cardiac pharmacology, 26 nurses (37.1%) obtained inadequate knowledge scores, whereas seven nurses (10%) achieved excellent knowledge scores related to cardiac pharmacology (see Table 4).

Difference in knowledge scores between age categories was analyzed using one-way ANOVA. To have a better understanding, the age brackets were divided into five groups, which included: 20 - 24, 25 - 29, 30 - 34, 35 - 39, and >39. In all, there were 24 participants in the first age group, with a mean knowledge score of 26.2 + 6.6, there were 32 in the second age group, with a mean knowledge score of 27.1 + 6.3; in the third age group with a mean knowledge score of 29.6 + 5.3; and five and three in the fourth and fifth age groups, with a mean knowledge score of 28.2 + 10.4 and 29.3 + 7.5, respectively. There was no statistically significant difference in the knowledge scores between these age groups, as the p-value was 0.78 (see Table 5).

To identify the difference between the knowledge scores of male and female nurses, the t-test of two independent samples was utilized. The mean knowledge score of male nurses was 27.8 + 6.3, whereas for female nurses it was 26.2 + 6.9. Therefore, no statistically significant difference was found between the knowledge scores of male and female nurses, as the p-value was 0.31 (see Table 6).

P-value was calculated using the ANOVA test, with level of significance at P < 0.05.

P-value was calculated using independent t-test, with level of significance at P < 0.05.

One of the study outcomes was to compare the knowledge scores of nurses with specialization, i.e. diploma in cardiology. For this comparison, the t-test of independent samples was used. The mean knowledge score of nurses having specialization was 28.5 + 6.5, whereas it was 25.8 + 6.4 for nurses without specialization. The current finding was statistically insignificant. Therefore, it was concluded that there was no difference between the knowledge scores of nurses with and without specialization (see Table 7).

The difference in the scores of the knowledge subcategories between nurses with and without specialization was compared using the t-test for independent samples. The mean knowledge score in cardiac physiology among nurses having specialization was 5.2 + 2.4, whereas the same among nurses without specialization was 4.4 + 2.4. There was no statistically significant difference between the knowledge scores of both groups, as p-value was 0.19.

Similarly, the mean knowledge score in cardiac pathology among nurses having specialization was 7.2 + 1.5, whereas those without specialization had a mean score of 6.9 + 1.4. There was no significant difference between the knowledge scores of both the groups, as the p-value was 0.52.

On the contrary, the mean score of procedural knowledge among nurses having specialization was 7.1 + 1.3, whereas this was 6.4 + 1.3 among nurses without specialization. There was a significant difference in the scores of procedural knowledge between nurses with and without specialization, as the p-value was 0.02.

On the other hand, the mean knowledge score of procedural complications among nurses having specialization was 3.6 + 1.7, whereas the mean knowledge score in procedural complications among nurses without specialization was 3.2 + 1.8. There was no significant difference in the scores of procedural complications between nurses with and without specialization, as the p-value was 0.39.

P-value was calculated using independent t-test, with level of significance at P < 0.05.

In the same way, the mean knowledge score in cardiac pharmacology among nurses having specialization was 5.3 + 1.7, whereas the same in the cardiac pharmacology of nurses not having specialization was 4.7 + 1.8. Hence, no significant difference was found between the knowledge scores of both the groups, as the p-value was 0.19 (see Table 8).

The difference in knowledge scores of nurses with different qualifications was analyzed using the chi-square test. Three types of qualifications were observed during analysis, i.e. BScN, Post RN BScN, and Diploma in General Nursing. Out of the eight BScN nurses, seven nurses attained adequate knowledge scores, one nurse got inadequate knowledge scores, whereas no BScN nurse reached up to the excellent knowledge scores. Similarly, out of 22 Post RN BScN nurses, 10 nurses obtained adequate knowledge scores, nine nurses acquired inadequate knowledge scores, whereas only three nurses attained excellent knowledge scores. In the same way, out of 40 diploma nurses, 21 nurses got adequate knowledge scores, 18 nurses got inadequate knowledge scores, whereas only one nurse obtained excellent knowledge scores. The current findings suggest that there was no statistically significant difference in the knowledge scores of nurses having varying qualifications, as the p-value was 0.14 (see Table 9).

The knowledge scores of procedural complication and cardiac pharmacology were found to be significantly different among nurses with varying qualifications, as the p-values were 0.015 and 0.012, respectively. Whereas, the rest of the knowledge subcategories were found insignificant when compared with different qualifications (see Table 10).

The comparison of knowledge scores among nurses in different departments was done using the chi-square test. The overall knowledge scores were compared for all these departments. Out of 16 nurses from CCU, 12 nurses got adequate knowledge, four nurses obtained excellent knowledge scores, whereas the number of inadequate knowledge scores was zero. Likewise, out of 20 nurses from GMW, eight nurses acquired adequate knowledge scores, 12 nurses attained inadequate knowledge scores, whereas no participant reached up to the excellent knowledge level. Similarly, out of 30 nurses from GFW, 14 nurses got adequate knowledge scores, 16 nurses achieved inadequate knowledge scores, whereas no one obtained excellent knowledge scores. Lastly, out of 4 nurses from DCU, all of them got adequate knowledge scores. There was a statistically significant difference between the knowledge scores of nurses working in different departments, as the p-value was 0.00 (see Table 11).

P-value was calculated using independent t-test, with level of significance at P < 0.05.

P-value was calculated using the chi-square test, with level of significance at <0.05.

P-value(s) was calculated using chi-square test, with level of significance at <0.05.

P-value was calculated using the chi-square test, with level of significance at <0.05.

The difference in the scores of knowledge subcategories between the nurses of different departments was analyzed using the chi-square test. The knowledge score of cardiac physiology was significantly different among all the departments, as the p-value was 0.00. On the contrary, there was no significant difference in the scores of cardiac pathology among all the departments, as the p-value was 0.41. However, when compared, the scores of procedural knowledge, procedural complications, and cardiac pharmacology were found to be significantly different in all the departments except for Cardiac Pathology, as the p-values were 0.03, 0.00, and 0.00, respectively (see Table 12).

The second major outcome of the study was to assess the practices of nurses regarding patient care following cardiac catheterization. In the analysis of three time practice observations, the mean practice score was 10.3 + 2.2. The minimum practice score was 6.3, whereas the maximum score was 15.6. This shows that the majority of the nurses (87.1%) were carrying out unsatisfactory practices, whereas only nine (12.9%) nurses were carrying out satisfactory practices (see Table 13).

Difference in the practice scores of participants with regard to their demographic characteristic was determined using the chi-square test and one way ANOVA. No significant difference was found in the mean of all age groups, as the p-value was 0.25 (see Table 14). The results were found to be significant when the practice scores were compared on the basis of qualification, as the p-value was 0.05. So, there was a significant difference between practice scores of nurses, who had BScN, Post RN BScN, or Diploma in general nursing. Surprisingly, the findings were found to be insignificant when the practices of participants were compared with their specialization status and their experiences, as the p-value was 1.0 and 0.93, respectively. On the contrary, the results were found to be significant when the practice scores of participants working in CCU and different departments were compared, using chi-square, as the p-value was 0.00 (see Table 15).

The difference in three time practices was analyzed using the repeated measures ANOVA. The value of Mauchly’s test of sphericity was 0.90, which indicated that there was no violation of sphericity. The mean of all the three observations (n = 70) were 10.1, 10.3, and 10.2, respectively. The findings of three time practices revealed no mean difference in all three observations, as the p-value was 0.403 (see Table 16).

P-value(s) was calculated by using chi-square test with level of significance at <0.05.

P-value was calculated using One Way ANOVA, with level of significance at <0.05.

P-value(s) was calculated using chi square test, with level of significance at <0.05.

P-value was calculated using repeated measures ANOVA, with level of significance at <0.05.

The difference in three time practice observations within departments was analyzed using the repeated measures ANOVA. The value of Mauchly’s test of sphericity was >0.05 which indicated that there was no violation of sphericity. No difference was found between the three time practice observations within each of the departments, as the p-value was >0.05 (see Table 17).

The frequency of obtaining the vital signs was analyzed, using descriptive statistics in SPSS. The analysis of observations of vital signs indicated different practices in each of the observations. The standard of vital sign monitoring following cardiac catheterization used in literature and in other quality health care setups was set as: For first hour, vitals should be obtained every 15 minutes. For the second hour, every 30 minutes then every hour till the fourth hour.

Surprisingly, the findings of this study indicated that in all the three observations, the majority of nurses were not obtaining the vital signs as described above, but the duration of vitals was adopted according to the protocol used in their respective departments. The duration of Blood Pressure (BP) measurement, Heart Rate (HR), and oxygen saturation varied from 1st to 6th hours. A total of 69 nurses (98.6%) were obtaining BP as per the standard set by their department. Most of the times, the heart rate and oxygen saturation were monitored in the fourth hours and their frequencies were 42 and 44 times, respectively (see Table 18).

Descriptive statistics were utilized to determine the catheter site assessments. The findings were explored by taking the average of all the three observations for catheter access site assessment upon receiving the patient in the unit. A total of 54 nurses (77.1%) assessed the access site upon receiving the patients in their respective unit. Out of 54 nurses (77.1%), assessments of 33 nurses (47.1%) were consistent in all the three observations. Unexpectedly, 16 nurses (22.9%) did not assess the catheter access site even a single time, out of the three observations (see Table 19).

The frequency of assessing the catheter access site following catheterization was checked through descriptive statistics. The findings showed that 32 nurses (45.7%) did not check the catheter access site, even a single time, in their entire shift. However, 28 nurses (40%) assessed the catheter access site only once, in their entire shift. Moreover, eight nurses (11.4%) assessed the access site every three hours, whereas only 2.9% (n = 2) nurses assessed the access site every two hours, in their entire shift.

P-value was calculated using the repeated measures ANOVA, with level of significance at <0.05.

Descriptive statistics, frequencies.

Descriptive statistics, frequencies.

In the same way, the frequency of palpating the distal pulses was also determined through descriptive statistics. The findings revealed that nine (12.9%) nurses checked the distal pulses once in their shift, whereas only one nurse (1.4%) checked the distal pulses, every two hours. Surprisingly, 60 nurses (85.7%) did not check the distal pulses, even a single time, in their entire shift (see Table 20).

The association between practice and overall knowledge scores was analyzed, using the chi-square test. When practice scores were evaluated with overall knowledge, the findings showed that nurses who scored as excellent and adequate in knowledge were better at carrying out satisfactory practices, whereas those nurses, who received scores showing inadequate in knowledge, were found carrying out unsatisfactory practices. Hence, with these findings, it can be concluded that there is an association between good knowledge and satisfactory practices, as the p-value was 0.00 (see Table 21).

With regard to association between practices and knowledge of cardiac physiology and cardiac pharmacology, the findings indicate that nurses who scored inadequate in knowledge were carrying out unsatisfactory practices. Whereas, those nurses, who scored as adequate and excellent in knowledge were found better at carrying out satisfactory practices, as the p-values were 0.001 and 0.006, respectively. The association turned out to be positive when analyzed for practices and knowledge about procedural complications as the p-value was 0.00 (see Table 22).

Some important findings were also found during analysis. The different responses of the nurses and their practices were compared. Initially, nurses who were aware of the signs of thrombus formation were compared, whether they knew where to palpate the pulses or not. The findings suggested that, out of the 20 nurses who were aware of the signs of thrombus formation, nine nurses did not know where to palpate the pulses as compared to those 11 participants who knew that. On the other hand, nurses who were not aware of the signs of thrombus formation were 50 in number, out of which 40 did not know where to palpate the pulses, whereas 10 participants knew. The findings remained significant, as the p-value was 0.00. It can be concluded that there is a difference in the knowledge of nurses who were aware of the signs of thrombus formation and they knew where to palpate the pulses, as compared to those who were unaware of the signs of thrombus formation and they did not know about the site of pulse palpation (see Table 23).

In this analysis, a comparison was carried out to see how frequently nurses who were aware of the signs of thrombus formation assessed the distal pulses of patient after cardiac catheterization. The findings indicated that, out of the 20 participants who were aware of the sign of thrombus formation, 15 nurses did not check the distal pulses even a single time in their entire shifts, whereas five participants checked the distal pulses once in a shift. Whereas, out of the 50 nurses who were not aware of the signs of thrombus formation, 45 nurses did not check the distal pulses even a single time in their entire shift, whereas four participants checked the distal pulses once in a shift, and one participant checked the distal pulses every two hours. The findings remained insignificant, as the p-value was 0.136 (see Table 24).

Practices of participants who were aware and unaware of the reasons for obtaining serum creatinine levels after cardiac catheterization were also compared, to see whether they monitored urine output, despite knowing the risk of developing Dye Induced Nephropathy (DIN), or not. The findings showed that out of the 31 participants who were aware of the reasons for obtaining serum creatinine levels after cardiac catheterization, only 12 participants monitored the urine output, whereas 19 participants did not check. In the same way, out of the 39 participants who were not aware of the reasons for obtaining serum creatinine levels after cardiac catheterization, 34 participants did not check the urine output, whereas 5 participants monitored the output. The finding was statistically significant, as the p-value was 0.01 (see Table 25).

Descriptive statistics, frequencies.

P-value was calculated using the chi square test, with level of significance at <0.05.

P-value was calculated using the chi square test, with level of significance at <0.05.

P-value was calculated using chi square test, with level of significance at <0.05.

P-value was calculated using the chi-square test, with level of significance at <0.05.

P-value was calculated using chi-square test, with level of significance at <0.05.

The strengths of the current study are as follows:

1) The study is easily replicable.

2) This study had gender equality, which evidently has benefits for patient care.

3) The study tool was designed and validated according to the Pakistani context, by conducting a pilot test.

4) The CVI for the study tools was 0.98. The content clarity and inter-rater reliability was also ensured by eight expert reviews, of whom six were medical and two were nursing experts.

5) The practices were observed thrice, in three different time periods, through three different data collectors. Each participant was observed for 21 hours, cumulatively. This study employed 1470 hours of observation, for 70 participants.

6) Post hoc power analysis was done which was found to be 99.9%.

7) The study has attempted to minimize the Hawthorne effect through frequent and long duration of observations.

This study has a few limitations, which are as follows:

1) Considering the scope of the master’s thesis, only one tertiary care hospital was selected as a study setting.

2) Due to frequent and long durations of observations, only 70 participants could be recruited as a sample.

3) The attitude of nurses towards the practices could not be examined due to limited time.