Article Summary: Nursing

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January-February 2017 • Vol. 26/No. 1 15

William M. Parrish, DNP, RN, CCRN-K, CPHQ, is Coordinator, Nurse Residency Program,
Providence Health and Services, Everett, WA.
Marilyn Hravnak, PhD, RN, CRNP, FCCM, FAAN, is Professor, University of Pittsburgh,
School of Nursing, Department of Acute and Tertiary Care, Pittsburgh, PA.
Linda Dudjak, PhD, RN, FACHE, is Associate Professor, University of Pittsburgh, School of
Nursing, Department of Acute and Tertiary Care, Pittsburgh, PA.
Jane Guttendorf, DNP, RN, CRNP, ACNP-BC, CCRN, is Assistant Professor, University of
Pittsburgh, School of Nursing, Department of Acute and Tertiary Care; and Acute Care Nurse
Practitioner, Department of Critical Care Medicine, UPMC Presbyterian, Surgical Intensive Care
Unit, Pittsburgh, PA.

Impact of a Modified Early Warning
Score on Rapid Response and

Cardiopulmonary Arrest Calls in
Telemetry and Medical-Surgical Units

I
n response to the Institute for
Healthcare Improvement’s (2014)
call for hospitals to reduce the

number of cardiac arrests and sud-
den life-threatening patient events,
more than 1,500 hospitals across
the United States have implement-
ed rapid response teams (RRTs).
Healthcare systems implementing
these teams empower staff, and in
some cases patient family members,
to call a group of clinicians with
advanced assessment skills quickly
to the bedside to evaluate a change
in patient condition. Many organi-
zations implementing RRTs have
demonstrated reductions in num-
ber of cardiac arrests, mortality rate,
and critical care unit length of stay
(Maharaj, Raffaele, & Wendon,
2015).

For RRTs to be effective, organi-
zational leaders must equip clini-
cians with the knowledge and tools
to recognize patients at risk for dete-
rioration in condition. According to
Chen and colleagues (2015), RRTs
often are mobilized to the patient
bedside when an extreme alteration
occurs in one parameter of vital
sign and, in many cases, after the
patient is already in distress. Early
warning scores (EWS) or modified
early warning scores (MEWS) repre-
sent a way to detect smaller changes
in multiple patient parameters over
time, giving clinicians an earlier
indication of potential change in
condition. Early recognition of an
untoward change in patient condi-
tion is vital to early intervention,
which then can improve patient
outcomes (Mapp, Davis, &
Krowchuk, 2013).

Literature Review
A literature search was conduct-

ed using the PubMed and Ovid
databases and search terms early
warning score and modified early
warning score, limited to articles
published 2012-2014. The search
generated 361 results. Articles were
selected for inclusion if they were
available in full text in English, and
specifically addressed impact of an
EWS on RRT activations or patient
outcomes (e.g., cardiac arrest, mor-
tality rate).

A systematic review on the
impact of EWS on patient outcomes
conducted by Alam and colleagues
(2014) found an evidence gap exists
due to few multicenter trials using a
standardized scoring system. How –
ever, overall positive impact was
demonstrated on clinical outcomes.
Authors conducted a search of the

PubMed, EMBASE.com, and Coch –
ran Library databases using the
terms early warning score, hospital,
hospital setting, and adults. Seven of
532 identified references were
included because they were con-
trolled, addres sed the im pact of
EWS on patient outcomes, and
included only subjects over age 16.
Two of the seven studies demon-
strated significant reduction in pre-
implementation versus post-imple-
mentation mortality rates (5.8% vs.
2.8%; p=0.046; and 1.4% vs. 1.2%;
p<0.0001). Two additional studies in the systematic review also dem - onstrated positive trends in survival that did not reach statistical signifi- cance. One study reported an 8% increase in survival to discharge (p=0.47) and the other a 0.9% reduction in mortality (p=0.092).

McNeill and Bryden (2013) per-
formed a systematic review evaluat-

Continuous Quality Improvement

Continuous Quality Improvement

William M. Parrish, Marilyn Hravnak,
Linda Dudjak, Jane Guttendorf

To reduce the number of cardiac arrests in telemetry and medical-
surgical units, a 70-bed community hospital integrated a weighted,
aggregate, electronic modified early warning score into the elec-
tronic medical record. Impact was evaluated via a quality improve-
ment initiative.

January-February 2017 • Vol. 26/No. 116

ing the impact of RRTs on adult
patient survival. Authors originally
performed a search of Ovid Medline,
CINAHL, Cochrane Library, Web of
Science, NHS National Research
Register, NHS UK Research Network
Study Portfolio, and EMBASE for
studies evaluating the impact of an
EWS and RRTs on patient outcomes.
Studies were included if they exam-
ined adults and focused on one of
the following outcome criteria: inci-
dence of cardiac arrest, unplanned
intensive care unit (ICU) admissions,
ICU mortality, length of ICU stay,
length of hospital stay, or inpatient
hospital survival. Six of the reviewed
studies also evaluated EWS. Four
included aggregate weighted scoring
systems with multiple patient
parameters; two others used a single
parameter approach. Only one of
the included studies demonstrated
improved hospital survival rates;
however, both studies using a single
parameter system demonstrated
reduction in cardiac arrest rates, and
two of the four using multiple
parameter EWS demonstrated posi-
tive impact on unexpected deaths or
cardiac arrest calls. Although some of
the data in the review were identi-
fied as poor quality, authors conclud-
ed a whole system of scoring cou-
pled with clinical action is needed.
In addition, aggregated early warn-
ing scoring systems seemed to be
more effective than single parameter
triggering systems.

A retrospective observational
study in an academic medical cen-
ter evaluated the potential effective-
ness of a MEWS based on the vital
signs of medical-surgical patients
collected for the 48-hour window
prior to an adverse event (Ludik –
huize, Smorenburg, de Rooij, & de
Jonge, 2012). Authors used an
aggregate weighted scoring system
for vital signs. Patients were includ-
ed in the study only if they experi-
enced emergency surgery, unplan –
ned admission to the ICU, car-
diopulmonary resuscitation, or
unexpected death. Of 204 patients
meeting these inclusion criteria,
81% (n=166) experiencing an
adverse event achieved an EWS of 3
or more at least once during the 48
hours preceding the event.

Ludikhuize and colleagues (2014)
also conducted a quasi-experimen-
tal study to evaluate the degree to
which a MEWS used three times
daily, versus an EWS obtained only
when prompted by a clinical event,
impacted RRT activation at an aca-
demic medical center. Data were
collected for 3 consecutive months
on adult patients to include vital
signs and adverse events, such as
unplanned admission to the ICU or
cardiopulmonary arrest. These data
were analyzed for 372 patients who
were monitored using an EWS pro-
tocol and 432 control patients.
Authors concluded scoring occur –
red more often when used by proto-
col (70%, n=2,513) than when trig-
gered by a clinical event (2%, n=65).
Addi tionally, the rate of RRT calls
per admission on the units using
protocols were double those of
units not using protocols.

Huh and co-authors (2014) pub-
lished a retrospective cohort study
of RRT activation through the use of
an electronic aggregate weighted
EWS, compared to a clinician- or
provider-activated call prompted by
established RRT activation criteria.
Scores were calculated based on
scoring criteria built into the elec-
tronic medical record. Authors col-
lected data on all inpatient and out-
patient RRT activations in an aca-
demic medical center for 24 consec-
utive months (n=3,030), including
outcome information, such as trans-
fer to a higher level of care or death
during resuscitation. RRT activa-
tions prompted by the electronic
medical record EWS calculation
resulted in fewer ICU transfers (192
vs. 400; p=0.0000) and deaths dur-
ing cardiopulmonary resuscitation
(2 vs. 8; p=0.0000) than RRT activa-
tions by a clinician or provider.

Improvement Needs
In an attempt to decrease the

number of cardiopulmonary arrests
occurring outside the ICU, the pri-
mary author’s medical center
formed a group of nurse educators,
leaders, and nursing informatics
staff to establish a MEWS that
would provide clinical staff with an
early alert to changes in patient

condition. Before facility imple-
mentation of an electronic MEWS,
cardiopulmonary arrest and RRT
calls were initiated by a care
provider when a patient was found
to be in distress or when a signifi-
cant alteration in vital signs was
noted. For example, an RRT call
may have been initiated when a
patient care technician reported to
the primary nurse a patient was
severely short of breath during rou-
tine vital signs. While suggested
activation criteria were provided to
clinicians during introduction of
the facility RRT in 2006, no formal
warning system existed to prompt
staff of a potential change in
patient condition.

With the implementation of the
electronic MEWS on the medical-
surgical and telemetry units at the
institution, a quality improvement
initiative was launched to provide a
framework for evaluating the
impact of the electronic MEWS.
Three evaluation metrics were iden-
tified: the number of RRT calls, the
number of cardiopulmonary arrests
occurring on the noncritical care
units, and survival to discharge fol-
lowing an RRT call or a cardiopul-
monary arrest. Implementation
groups before and after MEWS
implementation were compared.

This project was conducted in a
70-bed suburban acute care facility,
which included a 36-bed medical-
surgical unit, a 26-bed telemetry
unit, and an 8-bed ICU. The MEWS
was implemented on the medical-
surgical and telemetry units, but
not in the ICU. The facility dis-
charged an average of 538 patients
per month (June-November 2014).
Approval for this quality improve-
ment project was obtained from the
hospital vice-president and admin-
istrator.

MEWS criteria (see Table 1) were
culled from the literature and
included graded parameters for
heart rate, systolic blood pressure,
respiratory rate, temperature, neu-
rologic assessment, oxygen satura-
tion after initial intervention,
and use of a supplemental oxygen
delivery device (Subbe, Kruger,
Rutherford, & Gemmel, 2001). A
plan for integration into the elec-

Continuous Quality Improvement

January-February 2017 • Vol. 26/No. 1 17

Impact of a Modified Early Warning Score on Rapid Response and Cardiopulmonary Arrest Calls in Telemetry and Medical-Surgical Units

tronic documentation system for
the facility was devised. Hospital
policies were updated to reflect the
score at which a care provider
should receive a real-time, on-
screen pop-up prompt by the elec-
tronic MEWS system to consider
calling the RRT (score of 4 or
greater, or 2 or more points above
patient’s baseline). If the pop-up
was to be received by a member of
patient care services other than the
primary nurse assigned to the
patient, that person would be
responsible for notifying the pri-
mary nurse of the alert. While the
pop-up notification directs the care
provider to consider calling the
RRT, facility policy did not mandate
RRT activation. Education on the
electronic MEWS and the scoring
system used within the electronic
medical record was provided to
medical-surgical and telemetry
patient services staff by the primary
author. Critical care nurses who
respond to RRT calls also were pro-
vided education on the system to
give them insight into the criteria;
physician providers were educated
separately in medical staff meet-

ings. In collaboration with nursing
informatics staff, the electronic
MEWS was implemented on the
medical-surgical units in September
2014 and on telemetry units in
November 2014.

Data Collection
The project consisted of a

descriptive review of pre- and post-
implementation data surrounding
implementation of the electronic
MEWS. Three months of pre-imple-
mentation data were collected for
the baseline comparison group
(June-August 2014). These data
were compared to post-implemen-
tation data collected October-
December 2014 for the medical-sur-
gical unit and December 2014-
February 2015 for the telemetry
unit. De-identified information on
RRT and cardiopulmonary arrest
calls was obtained from aggregate
data collected by the facility for
institutional reporting. All data
were de-identified and stored on
the facility’s private network. Period
incidence rates for RRT calls and
cardiopulmonary arrests (number

per 1,000 discharges) were calculat-
ed before and after implementa-
tion, and the percentage change
from baseline was reported.

Patient survival to hospital dis-
charge after RRT activation was
reported as a percentage of all
patients having experienced an RRT
call in the medical-surgical and
telemetry units; survival-to-dis-
charge for patients after a cardiopul-
monary arrest call was reported as a
percentage of all patients having
experienced cardiac or pulmonary
arrest in the medical-surgical and
telemetry units. Patients with a do-
not-resuscitate order were excluded
from the survival analysis.

Results and Limitations
The period incidence of RRT calls

before and after electronic MEWS
implementation did not differ sig-
nificantly for the medical-surgical
units or the telemetry units (see
Table 2). For the individual unit
subgroups and the combined units,
the number of RRT calls was some-
what lower in the post-implementa-
tion phase. The rate for combined

TABLE 1.
Electronic Modified Early Warning System Scoring Criteria

Score 3 2 1 0 1 2 3

Heart rate: Beats/min <40 40-50 51-100 101-110 111-130 >130

Systolic BP mm Hg <70 70-80 81-100 101-159 160-199 200-220 >220 if acute or
change from
baseline

Respiratory rate/min <8 8 9-17 18-20 21-29 >30

Temperature ˚F <95 95-100.4 100.5 - 101 >101

Central nervous system,
if changed from baseline

Acute confusion Awake and
responsive or
chronic confu-
sion

“A”

Responds
to verbal
commands only

“V”

Responds to
pain only

“P”

Unresponsive

“U”

O2 saturation after
intervention

<85% 85%-89% 90%-94% >94%

O2 delivery method High-flow nasal
cannula or trach
collar

Simple face
mask or nasal
cannula

Room air Face tent or
aerosol

Non-rebreather
or Venturi mask

Note: Adapted from Subbe et al., 2001

January-February 2017 • Vol. 26/No. 118

units was 12.54 before vs. 10.78
after implementation, representing
14% reduction in calls.

During the evaluation period, no
cardiopulmonary arrests occurred
on the medical-surgical units for
the pre- or post-implementation
periods. The period incidence of
cardiopulmonary arrest calls (num-
ber of RRT calls per 1,000 hospital
discharges) on the telemetry units
was slightly lower after implemen-
tation (1.19 vs. 1.16), which repre-
sented 2.5% reduction from base-
line (see Table 2). Hospital survival
to discharge following an RRT call
(see Table 3) did not differ signifi-
cantly for pre-implementation and
post-implementation groups for
medical-surgical units, telemetry
units, or combined unit rates.
Survival to discharge for patients
after a cardiopulmonary arrest call

(see Table 3) was the same in pre-
and post-implementation periods
for the telemetry unit (50% vs.
50%). These data could not be
reported for the medical-surgical
unit as no arrests occurred during
either phase of the project.

Sample size for the project was
small due to the type of facility and
current patient volume. Also, the
evaluation period after implemen-
tation of the electronic MEWS was
limited and the relatively small
numbers of events (RRT calls and
arrests) limited the ability to make
broad assumptions from the com-
parison group data. Ongoing,
extended collection of data sur-
rounding RRT and cardiopul-
monary arrest calls will be critical to
evaluate the impact of the electron-
ic MEWS system.

Nursing Implications
Several important points should

be considered by organizations
implementing an electronic MEWS.
First, pop-up notifications within
the electronic medical record to
alert staff to an elevated score may
not be sufficient to prompt the clini-
cian to activate the RRT. Monitoring
of follow-through of RRT activation
following clinician notification of
an elevated electronic score would
be essential in determining if the
pop-up notification is effective.
Second, data collection on how
often nurses may initiate an alterna-
tive intervention or consultation
with a medical provider in lieu of
activating the RRT in response to
notification of an elevated electron-
ic score would be helpful in deter-
mining if the electronic MEWS
impacts clinician decision making.

Continuous Quality Improvement

TABLE 2.
Rapid Response Team (RRT) Calls and Cardiopulmonary Arrest Calls per 1,000 Hospital

Discharges

Event Unit Pre-Implementation Post-Implementation Result

RRT Calls

# RRT
Hospital

Discharges

# RRT
Calls/1,000
Discharges # RRT

Hospital
Discharges

# RRT
Calls/1,000
Discharges

% Change
from Baseline

Medical-Surgical 11 1,674 6.57 9 1,615 5.57 15% ↓

Telemetry 10 1,674 5.97 9 1,727 5.21 13% ↓

Total 12.54 10.78 14% ↓

Cardiopulmonary
Arrest Calls

# Arrests
Hospital

Discharges

# Arrest
Calls/1,000
Discharges # Arrests

Hospital
Discharges

# Arrest
Calls/1,000
Discharges

Medical-Surgical 0 1,674 0 0 1,615 0 ——

Telemetry 2 1,674 1.19 2 1,727 1.16 2.5% ↓

Total 1.19 1.16 2.5% ↓

TABLE 3.
Hospital Survival: Patients* Experiencing Rapid Response Team (RRT) Calls or Cardiopulmonary Arrest

Event Unit Pre-Implementation Post-Implementation

RRT Calls*
Number (%) of patients surviving to discharge after
RRT call/Total patients experiencing RRT call

Medical-Surgical 10/11 (91%) 7/8 (88%)

Telemetry 9/9 (100%) 7/9 (78%)

Total 19/20 (95%) 14/17 (82%)

Cardiopulmonary Arrest Calls*
Number (%) of patients surviving to discharge after
arrest call/Total patients experiencing arrest

Medical-Surgical N/A (no arrests) N/A (no arrests)
Telemetry 1/2 (50%) 1/2 (50%)

Total 1/2 (50%) 1/2 (50%)

* Excluding do-not-resuscitate patients

January-February 2017 • Vol. 26/No. 1 19

Finally, given the relatively low
incidence of events (RRT calls and
cardiopulmonary arrests) during
the 3-month duration of this proj-
ect, designing a continuous quality
improvement initiative to collect
data over a longer period with a
larger sample may yield more useful
benchmarking data.

Conclusion
Although authors expected RRT

calls would increase in number fol-
lowing electronic MEWS imple-
mentation, a notable decrease
occurred. The small number of calls
during the pre- and post-implemen-
tation period made it difficult to
draw conclusions. No change in
numbers was noted for cardiopul-
monary arrest calls. Before imple-
mentation of the electronic MEWS
system, however, the project facility
did not have a formal early warning
system to guide clinicians in deci-
sion making regarding activation of
the RRT. While the project revealed
information useful to facility and
system leaders in determining the
future of the electronic MEWS sys-

tem, ongoing evaluation of the sys-
tem is needed. Develop ment and
implementation of a formal quality
improvement process for collecting,
evaluating, and benchmarking data
will be instrumental in this evalua-
tion. Addi tionally, more evidence is
needed on staff culture, education,
and hospital policy surrounding
implementation of an electronic
MEWS to determine if its use
impacts patient outcomes.

REFERENCES
Alam, N., Hobbelink, E.L., van Tienhoven,

A.J., van de Ven, P.M., Jansma, E.P., &
Nanayakkara, P.W. (2014). The impact
of the use of the early warning score
(EWS) on patient outcomes: A systemat-
ic review. Resuscitation, 85(5), 587-594.

Chen, J., Bellomo, R., Flabouris, A., Hillman,
K., Assareh, H., & Ou, L. (2015). Delayed
emergency team calls and associated
hospital mortality: A multicenter study.
Critical Care Medicine, 43(10), 2059-
2065.

Huh, J.W., Lim, C., Koh, Y., Lee, J., Jung, Y.,
Seo, H., & Hong, S. (2014). Activation of
a medical emergency team using an
electronic medical record-based screen-
ing system. Critical Care Medicine,
42(4), 801-808.

Institute for Health Care Improvement. (2014).
Early warning systems: Scorecards that

Impact of a Modified Early Warning Score on Rapid Response and Cardiopulmonary Arrest Calls in Telemetry and Medical-Surgical Units

save lives. Retrieved from http://www.ihi.
org/resources/Pages/ImprovementStor
ies/EarlyWarningSystemsScorecards
ThatSaveLives.aspx

Ludikhuize, J., Borgert, M., Binnekade, J.,
Subbe, C., Dongelmans, D., & Goos –
sens, A. (2014). Standardized measure-
ment of the modified early warning score
results in enhanced implementation of a
rapid response system: A quasi-experi-
mental study. Resuscitation, 85(5), 676-
682.

Ludikhuize, J., Smorenburg, S.M., de Rooij,
S.E., & de Jong, E. (2012). Identification
of deteriorating patients on general
wards; measurement of vital parameters
and potential effectiveness of the modi-
fied early warning score. Journal of
Critical Care, 27(4), 424.e7-424.e13.

Mapp, I., Davis, L., & Krowchuk, H. (2013).
Prevention of unplanned intensive care
unit admissions and hospital mortality by
early warning systems. Dimensions of
Critical Care Nursing, 32(6), 300-309.

McNeill, G., & Bryden, D. (2013). Do either
early warning systems or emergency
response teams improve hospital patient
survival?: A systematic review. Resusci –
tation, 84(12), 1652-1667.

Maharaj, R., Raffaele, I., & Wendon, J. (2015).
Rapid response systems: A systematic
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19, 254.

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November-December 2016 • Vol. 25/No. 6418

Bonnie Nickasch, DNP, APNP, FNP-BC, is Assistant Professor and Director, DNP Family
Nurse Practitioner Emphasis, University of Wisconsin Oshkosh, Oshkosh, WI; and Family Nurse
Practitioner, ThedaCare Physician Services, Appleton, WI.
Suzanne Marnocha, PhD, RN, CCRN, is Professor, Assistant Dean, and Pre-Licensure
Director, University of Wisconsin Oshkosh, Oshkosh, WI.
Lisa Grebe, BSN, RN, is Registered Nurse, ThedaCare Regional Medical Center, Appleton, WI.
Heather Scheelk, BSN, RN, is Registered Nurse, Intensive Care Unit, ThedaCare Regional
Medical Center-Neenah, Neenah, WI.
Colette Kuehl, BSN, RN, is Dialysis Nurse, Purity Dialysis Center, Watertown, WI.

‘What Do I Do Next?’
Nurses’ Confusion and Uncertainty

with ECG Monitoring

T
elemetry monitoring is used
on many hospital units.
Goodridge, Furst, Herrick,

Song, and Tipton (2013) identified a
need for increased education/train-
ing in cardiac monitoring for the
medical-surgical nurse who often
needs to interpret cardiac rhythms
outside a cardiac-specific unit. A
nurse’s ability to interpret a cardiac
rhythm quickly and correctly is vital
to initiating appropriate interven-
tions and key to patient safety.
Nurses often report confusion

and uncertainty due to their lack of
knowledge related to electrocardio-
graphy (ECG) rhythm identifica-
tion and intervention. Many hospi-
tal leaders have attempted to close
the knowledge gap, but no specific
evidence supported the amount
and type of training, or how often
training is needed (Costanzo, Ehr –
hardt, & Gormley, 2013; Forfa,
2013; Tai, Cattermole, Mak,
Graham, & Rainer 2012). Further –
more, gaps in registered nurse (RN)
telemetry training and retraining
identified within facilities have led
to patient safety concerns (Pecci,
2012; U.S. Department of Veteran
Affairs, 2010).

Purpose
The purpose of this qualitative

study was twofold: to identify RNs’
perceived knowledge of and ability
to respond to dysrhythmias to iden-
tify possible areas for improvement,
and to identify the type and
amount of education needed by

RNs to be proficient with ECG
rhythm analysis and patient treat-
ment (eliminate confusion and
uncertainty).

Review of Literature
A review of the literature was

completed in the following databas-
es for 2012-2016: CINAHL, Health
Source Nursing, Medline, Ovid, and
PubMed. Search terms included elec-
trocardiography, ECG, EKG, telemetry,
and dysrhythmia. The search then
was narrowed by using the addi-
tional search terms accuracy, compe-
tence, proficiency, teaching, and train-
ing.
Very little research was available

regarding evidence-based practices
designed for telemetry monitoring
by medical-surgical nurses. Thus,
authors reviewed studies in other
practice areas and also included

earlier literature. In 2004, the
American Heart Association (AHA)
recognized this lack of information
by publishing detailed standards of
care for telemetry use (Drew et al.,
2004). The AHA recommended
ECG rhythm orientation for all
nurses who have any exposure,
even infrequent, to telemetry mon-
itoring by didactic and return
demonstration. Instruction should
be based on a list of concepts under-
stood by nurses with significant
exposure to

ECG monitoring.

However, no specific recommenda-
tions were offered for nurses who
do not have significant exposure to
telemetry monitoring (e.g., med-
ical-surgical nurses). Essentially, the
AHA recommended leaders of each
hospital determine what the mini-
mum ECG proficiency should be for
all nurses. This lack of specific rec-
ommendation by the AHA could

Research for Practice

Research for Practice

Bonnie Nickasch, Suzanne Marnocha,
Lisa Grebe, Heather Scheelk, Colette Kuehl

The prevalence of telemetry monitoring is increasing on medical-
surgical units, but no evidence-based guidelines standardize nurs-
ing education. Research indicates nurses feel uncertain and report
a lack of knowledge when caring for patients with telemetry moni-
toring.

November-December 2016 • Vol. 25/No. 6 419

create confusion and increase the
likelihood that nurses, especially
nurses with minimal exposure to
telemetry monitoring, will not
receive appropriate education or
policy guidance. Notably, the AHA
has not updated this manual
despite significant increases in
telemetry usage.
Advanced cardiac life support

(ACLS) is the only education that
defines a standard of knowledge for
ECG interpretation for nurses car-
ing for adult patients (AHA, 2016).
Because telemetry monitoring is
used widely, a national standard
should be set for minimum ECG
rhythm identification and treat-
ment proficiency among nurses to
ensure patient safety.
Costanzo and colleagues (2013)

published results from their long-
standing education consortium
focused on dysrhythmia education.
Nursing educators from 14 hospitals
designed and offered a 24-hour
instructor-led, computer-based ECG
training program over 2 weeks for all
newly hired nurses with no previous
ECG education. Content included
basic anatomy and physiology, nor-
mal and abnormal rhy thms, and
ventricular pacing with appropriate
intervention. After completing the
program, participants took a 50-
question standardized test of general
ECG knowledge, rhythm identifica-
tion, and interventions. Because the
test was developed by the re –
searchers, it was given for 2 months
with the standard consortium exam-
ination that had known reliability
data. Item analysis was completed
after 2 months and two questions
were revised for clarity. Ninety-nine
percent (N=215) of participants
achieved a score of 85% or better in
no more than two attempts. Re –
searchers did not try to determine if
the increase in base knowledge trans –
lated to better psychomotor per-
formance; they also did not investi-
gate how long the increased knowl-
edge lasted without repeat educa-
tion.
Tai and colleagues (2012) con-

ducted a prospective study evaluat-
ing nurse confidence levels when
initiating defibrillation. Nurses from
the Emergency Department at a

teaching hospital in Hong Kong
attended an educational session on
defibrillation skills and identifica-
tion of rhythms in cardiac arrest.
Comparing pre-test and post-test
scores, authors found no change in
ECG rhythm identification but
noted increased nurse confidence as
well as improved decision making
and psychomotor performance on
defibrillation. Authors did not
address how long the improve-
ments lasted and when nurses
should be re-educated.
In a study by Forfa (2013), a clin-

ical educator identified a lack of
ECG rhythm recognition, interpre-
tation, and rhythm management by
nephrology RNs and subsequently
developed a review course. Fourteen
RNs completed the review course
before taking a required annual
rhythm recognition course in which
they were categorized as competent,
additional practice needed, or needs
remediation. Scores from the 2011
and 2012 annual rhythm recogni-
tion course were compared to evalu-
ate impact of the 2012 review
course. Though improvements in
scores were seen in 2012, 35.7%
(n=5) of nurses still required remedi-
ation. This suggested annual reviews
and tests may be helpful but may
not ensure continued competence.
A gap exists in the literature con-

cerning nurses’ perceived proficien-
cy in ECG rhythm analysis and
intervention. None of the reviewed
articles evaluated these variables or
offered data to inform the current
study. In particular, literature con-
cerning nurses who do not use the
education on a daily basis was lack-
ing.

Sample Selection
The study site was a 157-bed

Midwestern hospital. The research
team used a purposive sample of 11
RNs from the hospital’s medical-
surgical (n=6) and cardiac step-
down units (n=5). All RNs who had
completed orientation were invited
to participate. Managers placed
signs related to the study in com-
mon work areas to encourage staff
participation. All staff were offered
time away from the unit or paid if

not on duty so they could partici-
pate. This approach increased the
diversity of response as staff with
diverse opinions or experiences
could self-select for participation.
After 11 interviews were completed,
researchers believed data saturation
occurred and no more RNs were
interviewed.

Ethics
This study received Institutional

Review Board approval from the
University of Wisconsin Oshkosh
and the hospital in which the study
was conducted. All potential partic-
ipants were informed of the study
purpose and requirements, as well
as the voluntary nature of their
involvement, before providing con-
sent. Participants were informed
their answers would help guide
development of a new ECG educa-
tion program. They were compen-
sated for their time by the hospital
by being relieved during their paid
shifts or being paid to come to the
hospital when not scheduled to
work. Only aggregate results were
shared with hospital leaders.

Methods and Design
The literature was used as a basis

for the seven-question semi-struc-
tured interview guide used in this
descriptive qualitative study. Inter –
views were completed by two doc-
torally prepared nurse researchers
with experience in qualitative
research. Then-BSN students (now
RN authors) took notes during the
interviews. Each participant com-
pleted an informed consent and
demographic questionnaire, and
answered the semi-structured ques-
tions (see Table 1). Researchers asked
participants to be frank and honest
in their responses. Participants were
ensured all information would be
held in strict confidence, and they
were free to withdraw from the study
at any time. The interviews occurred
in a private room adjacent to the
hospital library.

Analysis
Spiegelberg’s (1975) techniques

of intuiting, analyzing, and describ-

‘What Do I Do Next?’ Nurses’ Confusion and Uncertainty with ECG Monitoring

November-December 2016 • Vol. 25/No. 6420

ing were used for data analysis. This
technique allowed researchers to
uncover emerging themes, patterns,
and insights. All interviews were
audio-recorded and transcribed ver-
batim for consistent review and
data analysis. Recordings and tran-
scribed text were reviewed once by
the entire team and twice by the
two doctorally prepared researchers.
Data were coded, concepts defined,
and emerging themes identified.
The research team focused on con-
firmability when discussing the
emerging themes. After determin-
ing the major overarching theme
and sub-themes, members complet-
ed an additional literature search to
determine if emerging themes were
congruent with past studies.

Trustworthiness
The trustworthiness of this study

was established through ensuring
credibility, dependability, conform –
ability, and transferability (Lincoln &
Guba, 1985). Organi zational leaders
noted RNs on the study units had
verbalized concerns related to safely
caring for patients with telemetry
monitoring. Researchers established
credibility via informal conversa-
tions and feedback sessions follow-
ing presentations at state and
national nursing conferences. Credi –
bility was evident when RNs attend-
ing state and national nursing con-
ferences confirmed study findings
resonated with their own thoughts,
feelings, and experiences. Several
RNs identified situations in which
staff in their agencies verbalized dis-
comfort with telemetry monitoring
due to infrequent exposure and
unclear behavioral expectations.
Dependability was demonstrated

through the researcher’s reflective
appraisal of the project. Themes
were grounded in the interviews
and literature. Although there was
congruence, limitations to this
study included a small sample size
and representation of a single geo-
graphic location. To increase de –
pendability, this study should be
replicated in other similar units
within the Midwest and beyond.
Regarding confirmability, one of

the doctorally prepared authors has
38 years of intensive care experi-

ence and has been an ACLS instruc-
tor for over 20 years. This author
has heard descriptions of clinical
RNs in the hospital and remotely
calling telemetry technicians and
intensive care RNs with questions
about rhythm interpretation and
actions for a patient’s dysrhythmia.
Additionally, the author presented
study findings at a national research
conference and received RNs’ feed-
back indicating results were similar
to issues in their hospitals. Com –
mon concerns involved having
infrequent exposure to ECG moni-
toring and feeling uncertain and
uncomfortable.
To enhance the transferability of

current study results, researchers
have included the semi-structured
interview guide (see Table 1). They
also have described sample selec-
tion, research team composition,
and data analysis. However, the per-
son who wishes to transfer the
results to a different context or set-
ting is responsible for judging how
sensible the transfer would be.

Findings/Discussions
The main overarching theme

was Confusion and uncertainty: What
should I do next? to reflect nurses’
feelings in caring for patients receiv-
ing telemetry monitoring. Re –
searchers also identified three gen-
eral subthemes regarding RNs’ use
of telemetry in treating hospitalized
patients: (a) Use it or lose it, (b)

Losing my independence: Relying on
unlicensed telemetry technicians, and
(c) Help! I am out of my comfort zone.

Overarching Theme
Nurses reported confusion and

uncertainty in caring for patients
with telemetry monitoring. Two
nurses who were considered clinical
resources and self-identified as
nurse leaders were not comfortable
with ECG analysis or what to do
when the telemetry technician
called to report a rhythm change.
As one resource nurse stated,

We don’t even look at the
strips to determine what
the rhythm is … I will flat
out ask (the telemetry tech-
nician) is this something I
should call the doctor for?
… because they (telemetry
technicians) know more
than I do … it is usually not
an RN sitting in there, but I
trust them a lot more than
I would trust myself to
know what the heck they
are talking about, because
they see it every day.

A second resource nurse noted,
“Yeah, if somebody would come to
me … and say this patient had
whatever abnormal rhythm … I
would honestly not know the
answer … my first thing would be to
call the doctor because I don’t
know.” Another clinical RN com-

Questions
1. Please share what specific education you believe is necessary to be proficient

in ECG cardiac rhythm analysis and treatment.
2. How often and what type of education would help to maintain your proficiency?
3. How many times a year on average do you care for a patient with ECG

monitoring (telemetry)?
4. Please share situations about cardiac rhythm analysis and patient treatment

that make nursing care more difficult.
5. Describe step-by-step what you would do if you receive a phone call from the

telemetry technician about a patient experiencing cardiac rhythm problems.
6. Please share what you would do if you have a question about a rhythm

analysis or patient treatment.
7. Please share any suggestions you might have to improve the ECG monitoring

and patient treatment processes here.

TABLE 1.
Semi-Structured Interview Guide

Research for Practice

November-December 2016 • Vol. 25/No. 6 421

mented, “The paper may say that
we are (proficient) but I know I for
one, and I know there are others,
we’re just not confident in it.”
Though some nurses mentioned
ACLS education and training
increased their confidence, they did
not believe extra training every 2
years was sufficient to maintain
their sense of proficiency. One
nurse stated, “It really was a waste
of time for me because once I left
the classroom, I never saw it again.”
Another nurse agreed, “The biggest
thing to me is consistently using it
in order to be proficient.”

Subtheme 1: Use it or Lose it
The most common explanation

for uncertainty was the need for
information to be used often or it
would be forgotten. Even though
some nurses were pleased their
organizations sent them through
ACLS, they believed they did not
retain the knowledge because they
did not use it often enough. One
RN stated, “For me, I feel like, if you
don’t use your skills, you lose your
skills.” This use it or lose it theme
appeared in all interviews. Every
nurse expressed a desire for more
education, more frequent use, or
both to maintain proficiency. One
nurse stated, “The class was fine,
but to be proficient, you have to use
it, and on my unit, we never use it.”
Another nurse speaking about ACLS
noted, “It’s just that when you walk
out of there, and then don’t see it
again for a long a period of time, I
think that’s where things get forgot-
ten.”
This perception may have con-

tributed to nurses’ anxiety and
worry. One nurse commented, “It’s
like not being a cardiac nurse … it’s
like, let’s go, let’s get them off the
floor, because I don’t want some-
thing to go wrong … oh my God,
they’re not gone yet.” Another nurse
seemed even more anxious, stating,
“I just feel like nursing is getting so
… they’re stretching us too thin and
no amount of teaching is going to
help, unless you use it on a multiple-
day basis.” This nurse displayed
characteristics of anxiety during this
portion of the interview, tapping her
leg and speaking quickly.

Subtheme 2: Losing My
Independence: Relying
on Unlicensed Telemetry
Technicians
This lack of knowledge likely was

the basis for nurses’ belief they were
unable to work independently.
Nurses described lack of knowledge
and confidence in how to read the
rhythms. Additionally, they often
were uncertain of a rhythm’s seri-
ousness and what to do when called
by the telemetry technician with
information about an abnormal
rhythm. This insecurity led RNs to
ask telemetry technicians for guid-
ance on what to do next, and for
help in differentiating the rhythm
as serious or relatively benign. For
example, as one nurse indicated
when the telemetry technician
calls, “I will flat out say – is this
something I should call the doctor
for?” A nurse stated, “I trust them
(the telemetry technician) a lot
more than I would trust myself to
know what the heck they’re talking
about … they see it every day.”
Another nurse said, “Granted
they’re not professional people, but
technically they know more than I
do, and I’m a professional person.”

Subtheme 3: Help: I Am Out
of My Comfort Zone
The sense of fear and panic in

the nurses’ statements was unmis-
takable. One RN explained her dis-
comfort when caring for a patient
with a dysrhythmia: “Not being a
cardiac nurse, the minute RNs (on
medical-surgical unit) hear the
patient should go, it’s like, let’s just
go, let’s get them off the floor,
because I don’t want something to
go wrong.” Similarly, another nurse
stated, “It makes me nervous when
they sit there (patients) … some-
times, it’s … a little too long for my
liking.” When describing her dis-
comfort with dysrhythmias, anoth-
er nurse said, “I don’t even feel
comfortable enough knowing what
would be considered, you know,
extremely lethal.” These statements
emphasized the need for increased
education and training for all nurs-
es working with telemetry monitor-
ing. Nurses suggested working in
small groups to discuss and think

critically about potential and past
cases. They also indicated regularly
scheduled hands-on experience in
the telemetry room (e.g., 1 hour per
month) and annual computer-
based and instructor-led training
would be beneficial. Finally, one
participant suggested rotating with
intensive care nurses would be valu-
able.

Nursing Implications
This study identified confusion

and uncertainty as notable factors
in ECG rhythm analysis and inter-
vention by medical-surgical and
cardiac step-down RNs. Findings in –
dicated nurses believe they require
more frequent training and expo-
sure in these two areas. Authors sug-
gest policies and procedures must
be developed to assist nurses in
responding to dysrhythmias appro-
priately, quickly, and confidently.
This is congruent with AHA’s rec-
ommendation that agencies should
specify the desired steps medical-
surgical RNs should take with
rhythm changes in monitored
patients (Drew et al., 2004).
To increase RN knowledge, per-

ceived proficiency, and comfort in
caring for patients with telemetry
monitoring, nurses in the study sug-
gested several modes of education be
used (e.g., online, paper and pencil,
case-based scenarios, hands-on expe-
rience with ECG rhythm strips). To
reduce reliance on unlicensed per-
sonnel, a list of resource contacts
should be developed so RNs can
obtain assistance quickly (e.g., inten-
sive care RN, cardiac RN, house
supervisor). Evidence-based hospital
standards must be developed and
disseminated to all nurses, to include
a hierarchy of resources for nurse
consultation and a step-wise process
for assessment. A format for report-
ing the dysrhythmia to the provider
could be developed to ensure com-
plete, concise communication. A
laminated card listing this step-wise
process could be attached to the
back of the RN’s name badge as a
quick reference. Color-coded, lami-
nated reference sheets also could be
stored in each patient room. In the
event of a dysrhythmia, these tools

‘What Do I Do Next?’ Nurses’ Confusion and Uncertainty with ECG Monitoring

November-December 2016 • Vol. 25/No. 6422

could ensure response consistency.

Limitations
In this qualitative study, a small

number of informed participants
shared their personal narratives.
Their answers reflected their own
experiences within their own envi-
ronments. Moreover, the study
measured only participants’ percep-
tions of proficiency related to ECG
rhythm identification, rather than
using an objective measure of
knowledge.

Recommendations for
Future Research
Future research is needed to

determine the amount of education
needed to help RNs feel comfortable
and proficient in ECG monitoring.
Additionally, perceived knowledge
and tested knowledge may not be
the same. Future studies could focus
on the optimal mode and frequen-
cy of ECG training. This content
area could be studied with a larger,
more diverse sample. Further re –
search could investigate the effec-
tiveness of case studies, as suggested
by several participants, and the
components necessary to create a
significant learning experience
from a case study.

Conclusion
Participants in this study report-

ed confusion and uncertainty re –
garding caring for patients with
ECG monitoring. They perceived
these feelings to be due to lack of
frequent exposure to monitored
patients and/or education regarding
their appropriate treatment. To
increase comfort and proficiency,
participants recommended case
reviews, more frequent online
learning, hands-on experience, and
specific step-by-step guidelines.

REFERENCES
American Heart Association (AHA). (2016).

Advanced cardiovascular life support
(ACLS). Retrieved from http://cpr.heart.
org/AHAECC/CPRAndECC/Training/
HealthcareProfessional/AdvancedCard
iovascularLifeSupportACLS/UCM_
473186_Advanced-Cardiovascular-Life-
Support-ACLS.jsp

Costanzo, A.J., Ehrhardt, B., & Gormley, D.K.
(2013).  Changing the rhythm of dys-
rhythmia education through blended
learning. Journal for Nurses in Pro –
fessional Development, 29(6), 305-308.

Drew, B.J., Califf, R.M., Funk, M., Kaufman,
E.S., Krucoff, M.W., Laks, M.M., … Van
Hare, G.F. (2004). Practice standards for
electrocardiographic monitoring in hospi-
tal settings: An American Heart Assoc –
iation Scientific Statement from the

Research for Practice

Participants in this study reported confusion and
uncertainty re garding caring for patients with

ECG monitoring.

Councils on Cardiovascular Nursing,
Clinical Cardiology, and Cardiovascular
Disease in the Young: Endorsed by the
International Society of Computerized
Electrocardiology and the American
Association of Critical-Care Nurses.
Circulation, 110(17), 2721-2746.

Forfa, M.J. (2013). Advancing nursing practice
in rhythm recognition with an e-learning
educational program. Nephrology Nurs –
ing Journal, 40(2), 159-163.

Goodridge, E., Furst, C., Herrick, J., Song, J.,
& Tipton, P.H. (2013). Accuracy of car-
diac rhythm interpretation by medical-
surgical nurses. Journal of Nurses in
Professional Development, 29(1), 35-40.

Lincoln, Y.S., & Guba, E.G. (1985). Naturalistic
inquiry. Beverly Hills, CA: Sage Publica –
tions.

Pecci, A.W. (2012). VA finds large gaps in RN
telemetry training, retraining. Health –
Leaders Media.  Retrieved from http://
www.healthleadersmedia.com/nurse-
leaders/va-finds-large-gaps-rn-teleme
try-training-retraining

Spiegelberg, H. (1975). Doing phenomenolo-
gy. Dordrecht, NL: Martinus Niijhoff.

Tai, C.K., Cattermole, G.N., Mak, P.S.,
Graham, C.A., & Rainer, T.H. (2012).
Nurse-initiated defibrillation: Are nurses
confident enough? Emergency Medicine
Journal, 29(1), 24-27.

U.S. Department of Veterans Affairs, Office of
Inspector General. (2010).  Healthcare
inspection: Telemetry monitoring issues,
VA Eastern Colorado Health Care
System, Denver, Colorado (VA Office of
Inspector General Report No. 09-01047-
69). Retrieved from  http://www.va.gov/
oig/54/reports/VAOIG-09-01047-69

Copyright of MEDSURG Nursing is the property of Jannetti Publications, Inc. and its content
may not be copied or emailed to multiple sites or posted to a listserv without the copyright
holder’s express written permission. However, users may print, download, or email articles for
individual use.

March-April 2014 • Vol. 23/No. 2 77

Mavel F. Arinal, BSN, RN, CMSRN, is Staff Nurse and Clinical Nurse Educator, Medical-
Surgical Telemetry, West Kendall Baptist Hospital, Miami, FL.

Tanya Cohn, MSN, MEd, RN, is Research Specialist, Center for Research and Grants, Baptist
Health South Florida, Miami, FL.

Carmen Avila-Quintana, BSN, RN, CMSRN, is Staff Nurse, Medical-Surgical-Telemetry, West
Kendall Baptist Hospital, Miami, FL.

Evaluating the Impact of Medication
Cabinets in Patients’ Rooms on a
Medical-Surgical Telemetry Unit

M
edication administration is
a key nurse-driven process.
Nurses spend almost 27%

of their time on medication-related
activities and over 73% of their time
on nonmedication-related activities
(Keohane et al., 2008). In addition,
nurses are responsible for 26%-38%
of medication errors in hospitalized
patients (Bates, 2007). Nationally,
36% of medication errors occurred
in the administration phase (Nation –
al Research Council, 2007). Sub –
stantial research has been conducted
to determine the causes of medica-
tion errors and the barriers to report-
ing these errors; however, there
seems to be little evidence on nurse-
initiated and implemented processes
to increase medication accessibility,
safety, and efficacy.

In April 2011, a 133-bed academ-
ic hospital opened in the southeast-
ern United States. This facility, the
first new nonreplacement hospital
in Miami, Florida, in over 35 years,
was opened as a patient- and family-
centered institution. The study hos-
pital has two medical-surgical-
telemetry units with 36 private
rooms in each unit. Each unit has
two medication rooms with individ-
ual automated medication dispens-
ing systems.

Although the hospital uses bar-
coding technology to facilitate safe
medication administration, the need
to improve this process was consid-
ered and implemented through an
interdisciplinary shared governance
approach among nursing staff, lead-
ers, and pharmacy staff. The medica-
tion administration process was
challenged by the design of the tar-
get units. For example, nurses expe-
rienced frequent interruptions in

workflow from having to walk down
long hallways to the rooms with the
central medication dispensing units.
Therefore, medication cabinets were
installed inside patients’ rooms to
help nurses with medication admin-
istration. Inside each medication
cabinet, nurses were allowed to keep
medications due for the shift and
other supplies, such as syringes,
medication cups, alcohol swabs, and
disposable needles, needed for med-
ication administration (see Figures
1a-1b). Controlled substances and
medications that need to be refriger-
ated were not stored in the medica-
tion cabinets. The goal of placing
medication cabinets in each patient
room was to increase accessibility,
efficacy, and safety of medication
administration.

Literature Review
A literature search was conducted

in collaboration with the hospital’s
library services using CINAHL and
Medline. The search included the
years 2006-2012 using different
combinations of the following
words: medication administration,

medication cabinets, nurse satisfaction
with medication administration, and
patient outcomes and care. Research
was identified regarding medication
storage, accessibility, and administra-
tion. Gaps identified in the literature
included nurses’ perceptions of med-
ication safety and efficacy with
patient-specific medication storage,
as well as how patient-specific med-
ication storage may or may not
impact medication charge accuracy
and medication errors.

Popescu, Currey, and Botti (2010)
found ward or unit design influ-
enced medication safety and quality.
Specifically, the location of medica-
tion storage in relation to the patient
could have a positive or negative
impact on the medication adminis-
tration process. For example, the
lack of readily available medications
increased the risk of late administra-
tion or omission. Furthermore, med-
ication storage in distant or central
storage sites affected medication
safety and quality by increasing the
number of distractions during med-
ication administration. Collection of
medications at distant or central
storage sites, such as automated dis-

Mavel F. Arinal, Tanya Cohn, and Carmen Avila-Quintana

Results of a pre-post survey study designed to evaluate the impact
of medication cabinets in patients’ rooms on nurses’ satisfaction
with medication administration, medication charge accuracy, and
errors are described.

Instructions for Continuing Nursing Education Contact Hours appear on page 83.

March-April 2014 • Vol. 23/No. 278

pensing cabinets, often requires the
nurse to wait in line, which in turn
may cause hurried medication selec-
tion and medication removal errors
(Mandrack et al., 2012).

Using the systematic approach of
evaluating failure modes and effects
analysis, Hull, Czirr, and Wilson
(2010) examined the medication
administration process. The authors
identified various difficulties related
to the storage and administration of
medications, including nurses’ frus-
tration over making multiple trips to
the medication room and waiting in
line to use the automated dispensing
system. This prompted them to iden-
tify workarounds that increased the
risk of errors. Specifically, Mandrack
and co-authors (2012) reported hav-
ing to wait in line increases the likeli-
hood nurses will remove more than
one patient’s medications at a time.
About 30% of nurses reported always
or frequently removing more than
one patient’s medications at a time.
Such work arounds can compromise
the safety features of medication
administration systems, allowing for
new opportunities for error and prob-
lematic work practices (Wulff,
Cummings, Marck, & Yurtseven,
2011).

Hull and colleagues (2010) placed
medication cabinets outside patient
rooms and found this intervention
decreased the number of times nurs-
es went to the automated dispensing

system to retrieve medications.
Nurses also reported the location of
the cabinets to be more convenient.
Although the authors identified
increased convenience and decreased
time to retrieve medications, they did
not evaluate nurses’ perceptions of
medication safety and efficacy or the
impact medication cabinets may
have on medication charge accuracy
or medication errors.

Given the evidence related to unit
design and nurse workarounds, a
collaboration among nursing staff,
nursing leaders, and pharmacy staff
was initiated in the two medical-
surgical-telemetry units where the
two medication rooms were a signif-
icant distance from most patients’
rooms. The medication cabinet
(Enovate Medical; Murfreesboro, TN)
was chosen and installed in each
patient’s room to simplify the med-
ication administration process. All
medication cabinets have standard-
ized numeric codes for nurse use
only to ensure safety and avoid unse-
cured medications.

Hypothesis
Because nurses are the end users

of the medication administration
system, their perception of the
process with the use of these medica-
tion cabinets was important to the
success of this innovative implemen-
tation. Authors of this study hypoth-

esized the installation of medication
cabinets in the patients’ rooms
would increase nurses’ satisfaction
with the medication administration
process without significant impact
on charge accuracy or medication-
related errors. Nurses’ satisfaction
was defined as the degree to which
facility structures and operational
policies supported the processes and
procedures of delivering medications
to patients in a safe but timely man-
ner.

Purpose
The specific purposes of this study

were to measure nurses’ satisfaction
with the medication administration
process before and after the installa-
tion of cabinets using the Medi –
cation Administration System-
Nurses Assessment of Satisfaction
(MAS-NAS) Scale (Hurley et al.,
2006). Three additional questions
were developed to expand the effica-
cy and safety assessment sections of
the MAS-NAS. In addition, hospital
data were obtained to determine if
the installation of medication cabi-
nets in patients’ rooms impacts med-
ication charge accuracy or medica-
tion errors.

Study Design and Sample

The MAS-NAS Scale (Hurley et al.,
2006) was used to compare medica-

FIGURE 1A.
Medication Cabinet

FIGURE 1B.
Medication Cabinet and Stocked Supplies

March-April 2014 • Vol. 23/No. 2 79

tion administration satisfaction of
nurses before and after implementa-
tion of medication cabinets. This
scale was developed to assist with
assessment before and after changes
in the medication administration
system; pre- and post-implementa-
tion data from individual questions
can be compared to identify prob-
lematic areas perceived by nurses
(Hurley et al., 2007). The MAS-NAS
includes three subscales: efficacy,
safety, and access (see Table 1)
(Hurley et al., 2006). Three addition-
al questions were included to
increase responsiveness and address
the intervention of medication cabi-
nets (see Table 2). The MAS-NAS also
includes seven additional post-inter-
vention questions to allow partici-
pants to compare the medication
administration process before and
after intervention. Responses are
provided on a 6-point Likert scale
from 1 (strongly agree) to 6 (strongly
disagree). Two months before instal-
lation of the medication cabinets,
the MAS-NAS and the three addi-
tional questions were distributed
during staff meetings. Approxi –
mately 2 months after the medica-
tion cabinets were installed, data
were collected with the same tools
plus seven questions to allow partic-
ipants to compare the current med-

ication administration process (med-
ication cabinets) with the previous
medication administration process
(no medication cabinets). All 75
direct-care nurses on both day and
night shifts of the two units were
invited to participate in the study.
Before installation, 39 nurses were
available for recruitment at staff
meetings; 25 (64% response rate)
returned completed surveys. After
installation, 36 nurses were available
for recruitment at staff meetings; 20
(56% response rate) returned com-
pleted surveys. In addition, medica-
tion charge accuracy data were col-
lected through the information tech-
nology department, and medication
error data from risk management.
Parti cipation was voluntary, institu-
tional review board approval was
obtained, and cover letters were used
in the informed consent process.
The cover letters included a descrip-
tion of the study purpose, necessary
actions to participate or not to par-
ticipate, and length of study partici-
pation; the letters indicated data
would be reported in aggregate.

Materials and Methods

Data collection included the
MAS-NAS with demographics. The

MAS-NAS previously demonstrated
reliability (access alpha=0.71; effica-
cy alpha=0.77; safety alpha=0.76;
and MAS-NAS alpha=0.86) and
validity (efficacy 0.50-0.80, safety
0.42-0.71, and access 0.36-0.74)
(Hurley et al., 2006). With the addi-
tion of the three questions, internal
consistency Cronbach alpha coeffi-
cients were calculated for this study
(access alpha=0.68; efficacy alpha=
0.83; safety alpha=0.82; and MAS-
NAS alpha=0.92). Because all scores,
when rounded, were at least 0.7,
internal consistency reliability for
the scale with the added questions
was acceptable.

Medication charge accuracy data
(comparison of medication charged
to a patient compared to adminis-
tered) were collected 1 month prior
to installation and implementation
of medication cabinets with the
assistance of the information tech-
nology staff. Medication charge
accuracy data were collected 1
month before installation and 6
months after installation of all med-
ication cabinets in the two units.
Medication error data (number of
medication errors) were obtained
from the hospital’s risk manage-
ment staff. This included 6 months
before installation and 6 months
after implementation of the medica-
tion cabinets. For both charge accu-
racy and medication error data, the
2-month implementation period
was not included. All data were
reviewed and medications that were
not authorized to be in the medica-
tion cabinets were removed from
both data sets (see Figure 2 for study
timeline).

Data Analysis
All survey data were entered into a

spreadsheet for review and then
exported into SPSS 19.0 (IBM Corp.,
Armonk, NY)) for analysis. All data
were converted to the same scale
based on question wording, and the
subscale scores were calculated based
on the MAS-NAS criteria. Descriptive
statistics were calculated for demo-
graphics of both data collection peri-
ods as well as the seven additional
questions on the post-installation
survey (see Tables 3 and 5). Inde –

Evaluating the Impact of Medication Cabinets in Patients’ Rooms on a Medical-Surgical Telemetry Unit

TABLE 1.
Medication Administration System-Nurses Assessment of Satisfaction

(MAS-NAS) Scale’s Subscales

Efficacy: Dependable and effective system

Safety: System components assure nurse that it is correct to administer the med-
ication.

Access: Having necessary information and medications immediately at hand

Source: Adapted from Hurley et al. (2006).

TABLE 2.
Additional Survey Questions by Subscale

Efficacy: The current system helps me to be time efficient at medication administra-
tion.

Efficacy: The current medication administration system allows simple and hygienic
storage of medication.

Safety: The current medication administration system helps keep the number of dis-
tractions I encounter low.

March-April 2014 • Vol. 23/No. 280

pendent t-tests were performed to
compare sample demographics, sub-
scale scores, and individual ques-
tions. Individual item questions were
also compared before and after
implementation to examine prob-
lematic areas that the medication
cabinets may have addressed. Charge
accuracy data were compared by
trending proportions and calculating
a z-score using Stat 12.0. Medication
error data were compared for differ-
ences using independent t-tests ana-
lyzed by SPSS 19.0.

Findings

The comparison of group demo-
graphics before and after installation
are summarized in Table 3. No statis-
tical significance was found (p=0.05),
suggesting the two independent
groups were similar demographical-
ly. The comparison of the three sub-
scales access (p=0.361), efficiency
(p=0.229), and safety (p=0.388),
along with the total score (p=0.301),
did not show a statistically signifi-
cant change in survey results before

and after cabinet installation. Com –
parison of results for the three sub-
scales did not show statistical signifi-
cance, but individual questions
within the MAS-NAS also were eval-
uated (see Table 4). Nurses’ satisfac-
tion increased after installation of
cabinets based on responses concern-
ing availability of equipment and/or
supplies needed to administer med-
ications (t(42)= 2.057, p=0.046, eta
squared 0.09). The effect size of 0.09,
a moderate effect, suggests clinical
significance. The seven additional

FIGURE 2.
Study Timeline

Before Installation of

Medication Cabinets

Installation Period
After Installation of

Medication Cabinets

June 2001 – November 2011

Medication Error Data Collection

Medication Error Medication Charge
Accuracy Data Collection

Medication Charge
Accuracy data

collection

December 2011- January 2012 February 2012 – July 2012

Variable Before (n=25) After (n=20) p Values

Sex Female 95.7% (22) Female 88.9% (15) 0.35

Male 4.3% (1) Male 11.1% (2)

Age 34.27±8.51 32.29+7.43 0.45

Highest RN degree AS/AD 41.7% (10) AS/AD 33.3% (6) 0.52

BS/BSN 50% (12) BS/BSN 61.1% (11)

MS/MSN 4.2% (1) Diploma 5.6% (1)

Years as RN 3.50 (2.15, 9.50) 3.50 (2.75, 7.0) 0.71

Hours worked per week 37.13±4.23 38.76±6.46 0.33

Shift 7A-7P 50% (12) 7A-7P 55.6% (10) 0.66

7P-7A 45.8% (11) 7P-7A 44.4% (8)

7A-7P & 7P-7A 4.2% (1)

TABLE 3.
Sample Demographics

March-April 2014 • Vol. 23/No. 2 81

Evaluating the Impact of Medication Cabinets in Patients’ Rooms on a Medical-Surgical Telemetry Unit

Questions

Before
(n=25)

Mean (SD)

After
(n=20)

Mean (SD) p Value Effect Size

1. Because of information available through the current
medication administration system, I know both the
intended actions and side effects of medications I
administer.

1.78 (1.51) 1.45 (0.69) 0.35 0.02

2. I find the drug alert feature (drug/drug or drug/food
interaction) of the current medication administration
system helpful.

1.96 (1.58) 1.25 (0.44) 0.05 0.09

3. The current medication administration system makes it
easy to check active medication orders before
administering medications.

1.43 (0.59) 1.25 (0.55) 0.30 0.03

4. The current medication administration system provides
me with information to know a medication order has been
checked by a pharmacist before I administer the
medication.

1.77 (1.19) 1.45 (0.69) 0.30 0.03

5. The current medication administration system promotes
two-way communication between clinicians (MD,
pharmacist, RN) about medication orders.

1.70 (0.82) 1.79 (0.98) 0.74 0.003

6. I have access to the systems that support medication
administration (physician’s orders, drug information) when
I need them.

1.67 (1.01) 1.65 (0.81) 0.95 0.01

7. The drug information available through the current
medication administration system is easy to get when I
need that information.

1.91 (1.20) 1.53 (0.61) 0.21 0.04

8. When I see a message that acknowledges and accepts a
known drug/drug interaction, I know that both physician
and pharmacist communicated and agreed on the order.

2.38 (1.58) 1.85 (0.93) 0.20 0.04

9. I know where all the medications I need are stored (either
on the unit or if they need to be procured from the
pharmacy).

1.92 (1.18) 1.55 (0.76) 0.24 0.03

10. The current medication administration system helps me to
be efficient at medication administration.

1.78 (0.90) 1.45 (0.61) 0.17 0.04

11. The current medication administration system makes it
easy to check that I am following the “5 rights” when I
administer medications.

1.54 (0.78) 1.30 (0.47) 0.21 0.04

12. The turnaround time for receiving medications needed
“stat” or for patients newly admitted to the unit is adequate.

2.36 (1.44) 2.35 (1.14) 0.98 0.00

13. The current medication administration system is effective
in reducing and preventing medication errors.

1.60 (0.82) 1.30 (0.47) 0.13 0.05

14. The current medication administration system is user
friendly to the nurses who administer medications.

1.92 (0.91) 1.55 (0.61) 0.13 0.05

15. The equipment and/or supplies needed to administer
medications are readily available to me.

2.08 (1.18) 1.50 (0.51) 0.05 0.09

16. Information available through the current medication
administration system helps me to know what to do
should my patient have any bad reactions from a
medication.

2.57 (1.56) 2.05 (0.95) 0.19 0.04

TABLE 4.
MAS-NAS Survey Results

continued on next page

March-April 2014 • Vol. 23/No. 282

post-implementation ques tions
showed in creased nurse satisfaction
with having the medication cabinets
(see Table 5).

Charge accuracy data before and
after cabinet installation did not
show a statistically significant differ-
ence (z=1.33, p=0.1828). The trends
of percentage of medications that
were both withdrawn (charged) and
administered are illustrated in Figure
3. Medication errors 6 months
before and 6 months after medica-
tion cabinet installation did not
show a statistically significant differ-
ence (t(10)=0.031, p=0.976).

Discussion
Findings indicate medication cab-

inets installed in each patient room
increased nurses’ satisfaction con-
cerning medication availability. The
decision to place medication cabi-
nets was driven in part by nurses’
need for more accessible medica-
tions and supplies. Data from the
post-intervention surveys also sug-
gested the medication cabinets
allowed nurses to spend more time
with their patients and thus
increased patient safety. This study’s
findings also indicated use of indi-
vidual patient medication cabinets
did not impact medication charge
accuracy or medication errors.

Study Limitations
In the initial study design, partic-

ipants were to create a personalized
code so researchers could compare
individual and group changes before
and after installation of the medica-
tion cabinets. However, despite simi-
larities in demographics, the groups
before and after installation did not
have the same participants. There –
fore, researchers used the independ-
ent t-test to compare responses to
determine if average perceptions of

the nurses were higher or lower after
the installation of the cabinets. In
addition to the standard before-and-
after questions of the MAS-NAS,
which evaluate changes between
time periods, seven additional ques-
tions on the after-implementation
survey allowed participants to self-
compare their perceptions before
and after the implementation data
collection point. Because this study
was conducted in a new hospital, 6
complete months of data for medica-

Questions
Before
(n=25)
Mean (SD)
After
(n=20)
Mean (SD) p Value Effect Size

17. I have to keep stashes of medications to be sure I have
medications I need when I need them.

3.09 (2.11) 3.28 (2.24) 0.78 0.002

18. When I see a message that acknowledges and accepts a
known drug/drug interaction, I believe it is appropriate to
give the medication.

2.92 (1.93) 2.67 (1.82) 0.67 0.004

19. The current system helps me to be time efficient at
medication administration.

2.25 (1.29) 2.15 (0.93) 0.77 0.002

20. The current medication administration system helps keep
the number of distractions I encounter low.

2.21 (1.22) 2.05 (0.89) 0.63 0.01

21. The current medication administration system allows
simple and hygienic storage of medication.

2.29 (1.16) 1.85 (0.93) 0.18 0.04

TABLE 4. (continued)
MAS-NAS Survey Results

TABLE 5.
Responses to Additional Questions: Comparison of Nurse Perceptions

Before and After Cabinet Installation (N=17)

Question Mean (SD)*

It is easier to do all the checking steps needed during
medication administration process.

1.84 (0.83)

This is a safer system for patients. 1.74 (0.73)

With the new system, it is easier to access information I need to
administer medications.

1.95 (1.22)

I am more satisfied with this new medication administration
system than with the previous one.

1.67 (0.84)

I have more time to spend with patients. 1.94 (0.87)

Medication cabinets have made the medication administration
process more efficient for me.

2.00 (1.25)

Medications are more readily available when I need them for
patients.

1.89 (1.24)

*On a 6-point Likert scale (1 Strongly Agree and 6 Strongly Disagree)

Source: Hurley et al., 2006. Reprinted with permission.

March-April 2014 • Vol. 23/No. 2 83

Instructions For
Continuing Nursing

Education Contact Hours
Evaluating the Impact of
Medication Cabinets in

Patients’ Rooms on a Medical-
Surgical Telemetry Unit

Deadline for Submission:
April 30, 2016

MSN J1404

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tact hour(s) may be printed.

Fees – Member: FREE Regular: $20

Objectives
This continuing nursing educational (CNE)
activity is designed for nurses and other
health care professionals who are interest-
ed in impact of medication cabinets in
patients’ rooms. After studying the informa-
tion presented in this article, the nurse will
be able to:
1. Explain the use of medication cabinets

in patients’ rooms.
2. Describe the results of a study to meas-

ure nurses’ satisfaction with medication
administration following the installation
of medication cabinets in patients’
rooms.

3. Discuss implications for nursing practice
based on the study results.

Note: The authors, editor, and education
director reported no actual or potential
conflict of interest in relation to this
continuing nursing education article.

This educational activity has been co-provided
by AMSN and Anthony J. Jannetti, Inc.

Anthony J. Jannetti, Inc. is a provider
approved by the California Board of Registered
Nursing, provider number CEP 5387. Licensees
in the state of CA must retain this certificate for
four years after the CNE activity is completed.

Anthony J. Jannetti, Inc. is accredited as a
provider of continuing nursing education by the
American Nurses’ Credentialing Center’s
Commission on Accreditation.

This article was reviewed and formatted for
contact hour credit by Rosemarie Marmion,
MSN, RN-BC, NE-BC, AMSN Education
Director. Accreditation status does not imply
endorsement by the provider or ANCC of any
commercial product.

tion accuracy were not available
before cabinet installation; a 1-
month baseline was used and trends
over 6 months after installation were
compared. This limits the ability to
make equal comparison between
time periods.

Implications for Practice
Findings support the premise that

nurse-initiated and implemented
processes, such as use of medication
cabinets, can increase nurses’ satisfac-
tion with the medication administra-
tion process through increased avail-
ability of supplies and medications.
Such processes also can affect patient
safety. For example, nurses in this
study perceived medication cabinets
to be safer, easier to use, and more effi-
cient for medication administration.

Findings from this study make
several contributions to the current
literature. First, findings related to
impact on charge accuracy indicate
the installation of medication cabi-
nets inside patient rooms does not
impact the accuracy of charges while
increasing nurses’ satisfaction on the
process of medication administra-
tion. Second, use of medication cabi-

nets may not affect the incidence of
medication errors. Third, use of med-
ication cabinets allows nurses to
spend more time with their patients,
in turn increasing patient safety and
supporting goals of a patient- and
family-centered institution. In sum-
mary, results suggest a nurse-driven
innovation such as medication cabi-
nets inside patient rooms supports
nurse workflow and enhances nurses’
ability to provide safe patient care.

Future Research
Possible areas for further research

in medication administration include
patients’ perception of the medica-
tion administration process. Of par-
ticular benefit could be research con-
cerning the direct impact of medica-
tion cabinet use on patient care,
including safe handling and adminis-
tration of medications. For example,
placement of a medication for an
entire shift in a medication cabinet
may reduce distractions associated
with use of a central room for medica-
tion preparation.

continued on page 119

FIGURE 3.
Charge Accuracy Before and After Medication Cabinet Installation

67.0%

69.0%

71.0%

73.0%

75.0%

77.0%

79.0%

P
e

rc
e

n
ta

g
e

o
f

M
e

d
ic

a
ti

o
n

C
h

a
rg

e
A

c
c

u
ra

c
y

Months Before and After Installation of Cabinets

July
2012

June
2012

May
2012

April
2012

March
2012

February
2012

November
2011 (Pre)*

* Data were available only 1 month before installation. Cabinet installation period was
December 2011 to February 2012.

March-April 2014 • Vol. 23/No. 2 119

Evaluating the Impact of Medication
Cabinets
continued from page 83

Conclusion
The results of this study may be used in supporting

practice changes. This research provides information that
may assist in the future development and implementa-
tion of systems that will maximize the benefits rather
than introduce more errors into the current medication
administration system. When new innovations are being
implemented, the integration of the change into practice
must support the workflow of nurses and not hinder their
ability to provide safe patient care.

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Hurley, A., Lancaster, D., Hayes, J., Wilson-Chase, C., Bane, A., Griffin,
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Hull, T., Czirr, L., & Wilson, M. (2010). Impact of medication storage cab-
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