Capability of Emergency and Critical Care Nurses in Electrocardiogram Interpretation: A Mixed-Methods Systematic Review

Abstract

Background

Electrocardiogram (ECG) interpretation is a time-critical competency for emergency and critical care nurses. Accurate recognition of life-threatening arrhythmias and ischemic changes is essential for timely intervention and improved patient outcomes. However, evidence suggests substantial variability in nurses’ ECG interpretation capability across clinical settings.

Objective

This study aimed to systematically synthesize evidence on the competency of emergency and critical care nurses in ECG interpretation and to identify factors influencing performance.

Methods

A mixed-methods systematic review was conducted. Databases including PubMed/MEDLINE, Scopus, Web of Science, Science Direct, and Google Scholar were searched from inception to March 2025. Empirical studies assessing ECG interpretation knowledge and skills among registered nurses in emergency or critical care settings were included. Quality was appraised using the Mixed Methods Appraisal Tool (MMAT).

Results

The synthesis revealed that while nurses possess foundational knowledge, proficiency in identifying complex arrhythmias and acute myocardial infarction remains inconsistent. Performance is significantly influenced by years of specialized experience, frequency of exposure to cardiac monitoring, and the level of advanced life support training. According to Benner’s framework, a majority of practitioners function at the novice or advanced beginner stages, highlighting a gap between clinical requirements and actual competence.

Conclusion

This review demonstrates that ECG interpretation capability is a developmental skill requiring targeted institutional support. The researchers recommend the implementation of simulation-based longitudinal training and standardized competency assessments. Furthermore, nursing leadership should prioritize mentorship programs to bridge the gap between theoretical knowledge and expert clinical practice, thereby enhancing patient safety in high-acuity environments.

Keywords

emergency nursing critical care nursing electrocardiogram interpretation competency systematic review

Introduction

Electrocardiogram (ECG) interpretation is a foundational diagnostic skill in emergency and critical care practice, enabling rapid identification of life-threatening conditions such as acute coronary syndromes, ventricular arrhythmias, and conduction abnormalities. Emergency and critical care nurses are frequently the first clinicians to encounter patients presenting with chest pain, dyspnea, syncope, or palpitations, placing them at the forefront of early ECG acquisition and interpretation. In time-critical contexts, timely and accurate ECG interpretation directly influences clinical decision-making, treatment initiation, and patient outcomes (Fumagalli et al., 2016; Nowbar et al., 2019).

Despite its importance, accumulating evidence indicates that ECG interpretation competency among emergency and critical care nurses is inconsistent and frequently inadequate. While ECG education is commonly embedded in undergraduate and postgraduate nursing curricula, translation of theoretical knowledge into accurate, confident clinical practice remains challenging (Goodridge et al., 2013; Ho et al., 2021). Misinterpretation of ECGs may result in delayed diagnosis, inappropriate management, or failure to recognize life-threatening cardiac events, thereby contributing to preventable morbidity and mortality (Rafie et al., 2021).

Competency in ECG interpretation extends beyond factual knowledge. Quinn (2020) Provides a useful theoretical framework through Benner’s Stages of Clinical Competence for understanding how nurses develop expertise through experiential learning, progressing from novice to expert practice. Within this framework, ECG interpretation competency reflects the integration of cognitive knowledge, psychomotor skills, clinical judgment, and professional confidence, developed through repeated exposure and contextual learning in high-acuity environments. However, existing studies often operationalize competency narrowly, focusing primarily on knowledge assessment while neglecting skills and attitudinal dimensions.

The literature presents a fragmented and heterogeneous body of evidence. Some studies report adequate theoretical knowledge but limited practical proficiency, while others identify deficits across both domains, frequently attributing gaps to insufficient training, limited clinical exposure, or lack of institutional support (Chen et al., 2022; Ng & Christensen, 2024; Rafie et al., 2021). These inconsistencies highlight the need for a rigorous systematic synthesis to clarify current competency levels, identify influential factors, and inform targeted educational and organizational strategies.

This study addresses these gaps by conducting a mixed-methods systematic review to synthesize both quantitative performance data and qualitative perspectives on ECG interpretation. By integrating these findings, the researchers aim to provide a more nuanced understanding of the mechanisms underlying competency deficits. Unlike previous reviews that focused solely on a single study design, this review employs a convergent integrated approach to evaluate the current evidence base.

The primary objective of this review is to evaluate the capability of emergency and critical care nurses in ECG interpretation and to explore the implications of these findings for nursing education and clinical practice. By aligning these findings with Benner’s framework, this study seeks to offer actionable insights into how healthcare institutions can transition their staff from basic proficiency to clinical expertise, ultimately improving the quality of care for patients with cardiac conditions.

Methods

Design and Registration

This mixed-methods systematic review was conducted in accordance with PRISMA 2020 guidelines and registered in PROSPERO (CRD420251061510).

Search Strategy

A comprehensive and sensitive search strategy was developed in consultation with a health sciences librarian to maximize retrieval of relevant studies. Searches were conducted in PubMed/MEDLINE, Scopus, Web of Science, Science Direct, HINARI, Cochrane Library, Google Scholar, and grey literature sources from database inception to March 2025.

Search terms encompassed three core concepts: 1. ECG interpretation (Electrocardiogram, ECG, EKG, 12-lead ECG, rhythm interpretation), 2. Nursing population (Emergency nurses, critical care nurses, ICU nurses), and 3. Performance constructs (Competence, capability, accuracy, diagnostic performance, interpretation skills). Search strategies combined controlled vocabulary (MeSH) and free-text terms. Full database-specific strategies are provided in the supplementary PRISMA-S file. Reference lists of included studies were hand-searched to identify additional eligible publications.

Outcome of Review

The aim of this review is to identify and synthesize the available evidence on the competency of emergency and critical care nurses in electrocardiogram (ECG) interpretation. For the purposes of this review, “emergency and critical care nurses” refers to fully qualified nurses working in high-acuity settings such as emergency departments, intensive care units, trauma units, pre-hospital emergency services, and acute care environments. The review is guided by the following key questions: 1. How is the competency of emergency and critical care nurses in ECG interpretation defined in the literature? 2. What is the current level of competency encompassing knowledge, skills, and attitudes among emergency and critical care nurses in ECG interpretation? 3. What factors influence the ECG interpretation competency of emergency and critical care nurses? 4. How is competency in ECG interpretation assessed among emergency and critical care nurses?

Eligibility Criteria

Included studies consisted of empirical quantitative, qualitative, or mixed-methods studies involving registered nurses working in emergency or critical care settings that assessed ECG interpretation knowledge, skills, attitudes, confidence, or performance. Excluded studies included reviews, editorials, commentaries, or case reports, and studies without extractable nurse-specific data. Mixed samples were included only when registered nurse data were clearly reported.

Study Selection and Data Extraction

Two reviewers independently screened titles, abstracts, and full texts. Data extraction was performed using a standardized form and verified through random cross-checking (25% of studies). Discrepancies were resolved through discussion or third-reviewer adjudication.

Quality Appraisal

We evaluated research and quality improvement projects separately, as each requires distinct appraisal tools to assess quality. For research studies, quality was assessed using the Mixed Methods Appraisal Tool (MMAT) (Hong et al., 2018). The MMAT has proven validity and reliability and was specifically developed to evaluate the methodological quality of research using mixed, qualitative, and quantitative approaches (Souto et al., 2015). The Quality Improvement Minimum Quality Criteria Set was used to assess each quality improvement project’s quality (Hempel et al., 2015). This instrument is intended to assess the caliber of projects that present implementation or quality enhancement tactics. Each article’s methodological quality was assessed independently by two reviewers (TAK and DM for QI-MQCS; AS and TL for MMAT). To increase the rigor of the quality assessment, a consensus method was used to validate both ratings. A third independent arbitrator (MA) assisted in moderating consensus where there were disagreements. Based on the quality of their methodology, no papers were disqualified from the review. and also the following standards were used to choose the factors that were found: First, equivalent operational definitions were used in the original research; second, similar association metrics were found and documented in two or more studies demonstrating a similar direction; and third, these components were documented in at least two studies demonstrating a persistent trend. Following a careful analysis of the retrieved data, the results were narratively presented.

Data Synthesis

Utilizing a data-based convergent synthesis approach (Hong et al., 2018), we combined the results of qualitative and quantitative research. We employed a modified deductive qualitative content analysis for qualitative investigations (Elo et al., 2014), which included organizing the study findings into subcategories and categories, coding, and recurrent assessment of the findings. In order to facilitate systematic synthesis alongside qualitative data, we coded extracted results for quantitative research instead of the entire text.

Based on the goals of our review, a coding matrix was created. Two reviewers (TAK and DM) coded two quantitative research, and two more reviewers (TL and AS) coded two qualitative studies as part of a pilot coding process to guarantee reliability. Before full-scale coding, codes were discussed, improved, and finished in a collaborative manner. The finalized coding scheme was then iteratively applied to the remaining investigations by a single reviewer (MA).

Following classification, pertinent content was arranged in the coding matrix into categories and subcategories. Consensus on codes, subcategories, and categories was reached through frequent team talks, guaranteeing a thorough and open synthesis of the results from all included investigations. With this method, we were able to maintain the methodological differences between qualitative and quantitative data while summarizing trends across research types.

Results

Study Selection and Identification

The systematic search yielded 3,298 records across PubMed, HINARI, Google Scholar, Web of Science, Science Direct, and the Cochrane Library. Following the removal of 2,848 duplicates and the screening of titles and abstracts, 75 full-text articles were evaluated for eligibility. Ultimately, 18 studies met the pre-established inclusion criteria and were included in this review. The selection process is detailed in the PRISMA flow diagram (Figure 1).

Figure 1.

PRISMA flow diagram of the search strategy and study selection process

Characteristics of the Included Studies

Study characteristics are summarized in Table 1. The majority of the 18 included studies employed a cross-sectional design (n = 15), with one qualitative study, one randomized controlled trial (RCT), and one comparative survey. Geographically, the research spanned Saudi Arabia (n = 3), Jordan, China, Malaysia, Ethiopia, Egypt, and a multi-country study involving the US, Canada, and Hong Kong. Settings included emergency departments (ED), intensive care units (ICU), and cardiovascular units, with sample sizes ranging from 32 to 2,013 participants. Most studies (n = 17) assessed baseline competency, while only one Funk et al. (2017) evaluated an educational intervention.

Table 1.

Summary of Quality Appraisal Results, Presenting Individual MMAT and QI-MQCS Scores for Each Included Study

Author (Year)	Study design	Setting/sample	Instrument used	Intervention	Key findings
Aljohani (2022)	Descriptive cross-sectional	255 critical care nurses, Saudi Arabia	Self-developed questionnaire	None	Mean ECG interpretation score was 45%; rhythm management score was 14.76%.
Al-Fanboub & De Vina (2019)	Descriptive cross-sectional	65 registered nurses	Researcher-made questionnaire	None	High level of ECG knowledge and practice reported.
Amini et al. (2022)	Descriptive cross-sectional	32 staff and students, College of Health Sciences	ECG competency questionnaire	None	Mean competency score: 5.13/10; many failed to identify sinus rhythm or pathological waves.
Belay et al. (2024)	Institutional-based cross-sectional	175 adult emergency nurses, Ethiopia	Self-administered questionnaire	None	Only 5.2% competent (score ≥ 65%); 80.9% were not competent.
Buluba et al. (2023)	Quantitative cross-sectional	257 emergency nurses, China	ECG knowledge tool	None	70.9% showed low knowledge; only 9.3% answered all questions correctly.
Chen et al. (2022)	Cross-sectional descriptive	196 ER nurses	Literature-based questionnaire	None	38.8% had poor competency despite an average score of 0.78%.
Chamiso et al. (2024)	Quantitative cross-sectional	338 hospital nurses, Saudi Arabia	Pretested questionnaire	None	15.4% had good knowledge; only 9% demonstrated good ECG practice.
Chauhan (2020)	Descriptive study	75 voluntary staff nurses	Researcher-made questionnaire	None	12.8% had poor knowledge; 37.1% had average; rest had good ECG interpretation knowledge.
Ayasreh et al. (2024)	Descriptive cross-sectional	257 emergency nurses, Jordan	ECG interpretation competency questionnaire	None	Only 6.43% had prior ECG training; mean score was 4.35/10.
Funk et al. (2017)	RCT with crossover	2,013 nurses across US, Canada, and Hong Kong	Two-part observation checklist	Yes	Post-intervention, significant improvement in knowledge scores (from 48.2 to ∼70).
Kadush et al. (2023)	Cross-sectional	56 nurses, 5 hospitals in Al-Ahsa, Saudi Arabia	Validated checklist	None	46.2% identified ECG axis correctly; 48.7% identified P-R interval.
Mohammed Ali et al. (2022)	Cross-sectional	100 nurses, ICU unit, Egypt	Structured questionnaire and observation	None	90% had unsatisfactory ECG knowledge; 9.5% had unsatisfactory ECG practice.
Jamanhari et al. (2023)	Cross-sectional	255 nurses, National Heart Institute, Kuala Lumpur	Pilot-tested questionnaire	None	92.7% had good ECG knowledge; 68.2% had good ECG practice.
Rahimpour et al. (2021)	Comparative descriptive cross-sectional	170 (105 emergency nurses, 65 EMS personnel)	Researcher-made questionnaire	None	Nurses scored 6.65/10; EMS personnel scored 4.07/10.
Kashou et al. (2023)	Cross-sectional	105 healthcare staff	Questionnaire on ECG knowledge and practice	None	97.4% had good knowledge; 7.2% had good practice.
Ho et al. (2021)	Comparative survey	Nurses at a cardiovascular congress	Self-reported questionnaire	None	28% electrode misplacement; 82.1% rated their ECG competency 8–10 out of 10.
Nickasch (2016)	Qualitative	One hospital	None	None	Nurses were unable to interpret ECGs confidently; emotional and knowledge barriers identified.
Yaqoob et al. (2023)	Descriptive cross-sectional	Nurses in various hospitals	12-item validated questionnaire	None	Most nurses had suboptimal ECG interpretation competency, but CCU nurses scored better.

Methodological Quality Appraisal

Quality assessment was performed using the Mixed Methods Appraisal Tool (MMAT) and the Quality Improvement Minimum Quality Criteria Set (QI-MQCS). Among the 16 quantitative studies, methodological quality varied, with 11 rated as low (0–3/5) due to inadequate confounding control and nonresponse bias reporting. Conversely, qualitative and mixed-methods studies demonstrated high quality (4–5/5). The five quality improvement projects met 10–15 of the 16 QI-MQCS criteria, indicating moderate-to-high quality. No studies were excluded based on quality; results informed the overall synthesis.

Syntheses of Quantitative and Qualitative Studies

All quantitative and qualitative studies were analyzed collectively using a qualitative content analysis approach, and the synthesized findings are presented jointly. Table 2 summarizes the synthesis results, including the identified categories and subcategories.

Table 2.

Synthesis Findings of all Included Studies

Category	Sub-categories
Definition of Competency	Emergency Nurses’ competency in ECG interpretation
Factors influencing competency	Individual factors: Age, gender, previous working experience
	Professional factors: Exposure, prior education, confidence, comfort, perception
	Organizational factors: Type of unit/hospital, practice patterns
Competency Assessment	Type, duration, and frequency of assessments Content of assessment tools Validity and reliability of competency tools
Knowledge and Skills Related to Competency	Knowledge of ECG interpretation Skills in ECG lead placement and continuous monitoring Attitudes toward ECG interpretation

Definition and Assessment of Competency

In this review, ECG interpretation competency is defined as the integration of cognitive (knowledge), psychomotor (skills), and affective (judgment) domains required to identify arrhythmias, understand clinical implications, and intervene under high-pressure conditions. Included studies operationalized this through standardized knowledge tests, clinical simulations, pre/post-intervention evaluations, and self-reported confidence scales.

Modality, Content, and Frequency of Assessment

Structured, paper-based tools were the predominant assessment method (Amini et al., 2022; Belay et al., 2024), focusing primarily on waveform identification (P, QRS, T) and abnormalities such as pathological Q waves or AV blocks (Kadush et al., 2023). In contrast, observational or practical assessments such as direct evaluation of rhythm recognition and lead placement were rare (Aljohani, 2022; Jalal & Salih, 2024; Jamanhari et al., 2023). Furthermore, the frequency and duration of assessments were inconsistent; most studies utilized one-time cross-sectional evaluations, limiting insights into long-term skill retention.

Validity and Reliability of Assessment Tools

Very few studies explicitly reported the psychometric validity or reliability of their assessment instruments. While some tools were adapted from standardized versions, specific psychometric properties were often not discussed (Belay et al., 2024). Other studies integrated self-reported confidence or perception-based measures but lacked standardized skill (Aljohani, 2022; Malk et al., 2018). Notably, several authors did not report any validation process (Amini et al., 2022; Ayasreh et al., 2024), raising concerns regarding the consistency, accuracy, and global benchmarking of nursing competency evaluations across different clinical settings.

Skills in Lead Placement and Continuous Monitoring

Technical skills defined as motor abilities developed through practice (Kim et al., 2017), are vital for accurate ECG interpretation. Incorrect lead positioning can obscure ischemic changes, potentially delaying critical treatment. Two studies evaluated interventions aimed at improving these competencies: Fålun et al. (2020) demonstrated that a two-part online education program led to sustained improvements in lead placement and ST-segment analysis for up to 15 months. Similarly, Ros et al. (2022) found that educational interventions significantly enhanced precordial lead placement accuracy. Despite these quantitative successes, a significant gap exists in qualitative literature regarding nurses’ lived experiences and perceptions of skill development in this area.

Attitudes Towards ECG Interpretation

Nurses’ clinical performance is significantly influenced by a spectrum of attitudes, ranging from emotional barriers to setting-specific engagement. Negative dispositions, including anxiety and low self-efficacy, often stem from a lack of formal training and lead to reduced motivation (Buluba et al., 2023; Nickasch, 2016). A recurring “competency mismatch” was identified where high self-perceived ability (82.1%) contrasts with significant technical errors in practice (Kashou et al., 2023). Conversely, structured education consistently fosters positive shifts in confidence and professional disposition (Funk et al., 2017; Tahboub & Regulation, 2018). These attitudes are further modulated by the clinical environment; for instance, nurses in coronary care units demonstrate higher prioritization and proficiency compared to those in general or ICU settings, where role ambiguity can lead to disengagement (Jalal & Salih, 2024; Mohammed Ali et al., 2022; Yaqoob et al., 2023).

Factors that Influence Emergency Nurses’ Competency in ECG Interpretation

Nurses’ competency is shaped by an interplay of educational, professional, and organizational factors. Education and training emerged as the most critical determinants; formal, recent ECG training is strongly correlated with higher knowledge scores and diagnostic accuracy (Funk et al., 2017; Nora et al., 2024). Clinical experience and setting also play vital roles; nurses in coronary or emergency units with frequent exposure to cardiac monitoring significantly outperform those in medical-surgical wards (Rahimpour et al., 2021; Yaqoob et al., 2023). Conversely, departmental role ambiguity, such as delegating ECG tasks to technicians or cardiologists in some ICU settings, can diminish hands-on experience and skill retention (Chamiso et al., 2024; Mohammed Ali et al., 2022). Furthermore, psychological factors, specifically the overestimation of one’s abilities, may foster complacency and hinder further learning (Ros et al., 2022). Finally, institutional support, including access to mentorship, learning materials, and structured in-service programs, remains a less frequently reported but essential requirement for sustaining proficiency (Coll-Badell et al., 2017; Fålun et al., 2020). Targeted educational initiatives are therefore vital to bridging these multi-dimensional competency gaps.

Discussion

This review demonstrates that emergency and critical care nurses’ ECG interpretation competency remains inconsistent globally, with significant gaps between theoretical knowledge and practical application. Guided by Benner’s framework, findings suggest that many nurses remain at novice or advanced beginner stages for ECG interpretation, lacking the experiential reinforcement necessary to achieve proficient practice.

Educational interventions, particularly those incorporating simulation and repeated assessment, were consistently associated with improved performance and confidence. However, the predominance of knowledge-based assessments and limited use of validated tools undermine confidence in current competency evaluation practices, a concern also noted by Buluba et al. (2023).

Definition and Scope of Competency

The term “competency” was variably defined across the studies, with many equating it primarily with ECG knowledge (Ayasreh et al., 2024; Belay et al., 2024). However, according to Mrayyan et al. (2023), true competency encompasses a combination of knowledge, skills, and attitudes observable in the nurse’s ability to perform clinical tasks. Similar to the findings in the review by Chen et al. (2022), the majority of studies included in our review failed to incorporate skills and attitudes into their conceptualization or assessment of ECG competency, underscoring a significant gap in both clinical practice and research.

Knowledge Gaps in ECG Interpretation

Consistent with previous literature (Lee et al., 2024; Stiell et al., 2020; Çıkrıkçı Isık et al., 2020), our review found widespread knowledge gaps among emergency nurses. Knowledge levels varied significantly, with many nurses failing to identify life-threatening arrhythmias or ischemic changes. These findings align with those of Au (2023), who also reported that inadequate ECG knowledge was linked to delayed recognition and intervention in acute myocardial infarction (AMI) cases, thus increasing the risk of adverse outcomes.

Skills and Practical Application

Several studies have highlighted the disparity between emergency nurses’ theoretical ECG knowledge and their practical interpretation skills. Despite moderate to high knowledge levels, practical competency often remained low. For instance, Amini et al. (2022) found that although emergency nurses achieved a mean ECG competency score of 5.13 out of 10, many were unable to correctly identify basic rhythms such as sinus rhythm or pathological waveforms. Similarly, Ayasreh et al. (2024) reported that among 257 emergency nurses in Jordan, the average competency score was only 4.35 out of 10, with just 6.43% having received prior ECG training, highlighting a lack of practical exposure.

Other studies further reinforced this gap. Belay et al. (2024) revealed that only 5.2% of emergency nurses in Ethiopia were found competent in ECG interpretation, with over 80% falling below the competency threshold. Likewise, Chamiso et al. (2024) reported that just 9% of nurses demonstrated good ECG practice, despite 15.4% having good theoretical knowledge. These findings underscore that having ECG knowledge does not necessarily equate to accurate or confident clinical application.

Moreover, Ros et al. (2022) observed that 28% of nurses misplaced ECG electrodes, even though 82.1% rated themselves highly (8–10 out of 10) in ECG competency, pointing to a discrepancy between perceived and actual skills. Rahimpour et al. (2021) Shared similar concerns, noting that although 97.4% of participants had good knowledge, only 7.2% demonstrated good practice. Taken together, these findings align with earlier research by Chen et al. (2022) which emphasized that knowledge alone is not a reliable indicator of practical competency. The persistent gap between theoretical understanding and clinical application highlights the need for regular, skill-based training and competency assessments in ECG interpretation.

Attitudinal Factors and Confidence

Attitudes towards ECG interpretation emerged as a critical, yet underexplored, domain of competency. Studies reported low confidence and motivation among nurses, especially in non-cardiac units (Nickasch, 2016). These findings echo those of Chen et al. (2022), who highlighted the demotivating effects of perceived irrelevance or scope-of-practice ambiguity. Negative attitudes were often linked to poor training and low self-efficacy, which in turn undermined the application of knowledge and skills in clinical practice. However, educational interventions, such as those by Wang et al. (2013), have been shown to improve not only knowledge but also motivation and confidence, suggesting that attitudes can be shaped with the right support.

Implications for Nursing Education and Clinical Practice

Findings highlight the need for competency-based ECG education that integrates theory, simulation, and real-world application. Nursing curricula and continuing professional development programs should align ECG training with stages of clinical competence, emphasizing skill acquisition, clinical judgment, and confidence building. Healthcare institutions should implement standardized competency assessments, mentorship programs, and ongoing refresher training to sustain proficiency.

Strengths and Limitation

This systematic review possesses several key strengths. First, the use of a mixed-methods design allowed for a comprehensive synthesis that captured both the objective knowledge scores (quantitative) and the nuanced clinical experiences of nurses (qualitative). Second, the application of Benner’s Stages of Clinical Competence provided a robust theoretical framework to categorize and analyze the developmental trajectory of ECG interpretation skills. Finally, the use of the Mixed Methods Appraisal Tool (MMAT) ensured a rigorous evaluation of the methodological quality of the included studies.

However, several limitations must be acknowledged. The primary limitation is the significant heterogeneity observed across the included studies, which utilized diverse assessment tools and scoring systems, thereby precluding a formal meta-analysis. This variation in study context ranging from high-resource urban emergency departments to specialized intensive care units may influence the generalizability of the findings. Additionally, while the search strategy was comprehensive, the inclusion of only studies published in English and Amharic may have introduced language bias. Lastly, the cross-sectional nature of most included studies limits the ability to draw causal inferences regarding the impact of specific educational interventions on long-term competency retention.

Conclusion

This systematic review reveals significant variability in ECG interpretation proficiency among emergency and critical care nurses, with many practitioners remaining at novice or advanced beginner levels. While foundational knowledge is common, critical gaps persist in identifying complex arrhythmias and acute ischemic changes, directly impacting patient safety. To bridge these gaps, we recommend establishing a uniform definition of nursing-specific ECG competency and implementing standardized, simulation-based training frameworks within both academic curricula and professional development. Institutional leadership must prioritize resource allocation for regular competency assessments to maintain proficiency. Future multicenter research should focus on evaluating the efficacy of diverse training modalities and establishing direct correlations between nursing ECG expertise and clinical patient outcomes to enhance the quality of cardiac care.

Supplemental Material

Supplemental Material - Capability of Emergency and Critical Care Nurses in Electrocardiogram Interpretation: A Mixed-Methods Systematic Review

Supplemental Material for Capability of Emergency and Critical Care Nurses in Electrocardiogram Interpretation: A Mixed-Methods Systematic Review by Tsegaamlak Kumelachew Derse, Desalegn Mitiku Kidie, Addisu Simachew Asgai, Tadios lidetu, Yideg Abinew Kebede, Asaye Worku Agegn, Misganaw Alelign Getie, and Moges Tadesse Abebe in Sage Open Nursing.

Supplemental Material

Supplemental Material - Capability of Emergency and Critical Care Nurses in Electrocardiogram Interpretation: A Mixed-Methods Systematic Review

Supplemental Material

Supplemental Material - Capability of Emergency and Critical Care Nurses in Electrocardiogram Interpretation: A Mixed-Methods Systematic Review

Footnotes

Acknowledgments

The authors would like to thank the authors of the included primary studies, which were used as sources of information to conduct this systematic review and meta-analysis.

ORCID iDs

Tsegaamlak Kumelachew Derse

Addisu Simachew Asgai

Ethical Considerations

Ethical approval was not applicable for this systematic review and meta-analysis study.

Author Contributions

Tsegaamlak Kumelachew Derse: Conceptualization, Methodology, Formal analysis, Data curation, writing original draft, Writing review & editing

Desalegn Mitiku Kidie: Methodology, Data curation, Screening and selection of studies, Writing review & editing

Addisu Simachew Asgai: Data extraction, Quality appraisal, Writing review & editing

Tadios Lidetu: Investigation, Data extraction, Writing review & editing

Yideg Abinew Kebede: Quality appraisal, Validation, Writing review & editing

Asaye Worku Agegn: Investigation, Data interpretation, Writing review & editing

Misganaw Alelign Getie: Data synthesis support, Visualization, Writing review & editing

Moges Tadesse Abebe: Supervision, Methodological oversight, Writing review & editing

All authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship and approved the final manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The original contributions presented in the study are included in the article/supplementary material, and further inquiries can be directed to the corresponding author.*

Supplemental Material

Supplemental material for this article is available online.

Appendix

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