http://doi.org/s10.33698/NRF0147  –  Jasveen Kaur, Sunita Sharma, Ajit Avasthi

Abstract: Electroconvulsive therapy (ECT) is defined as a medical procedure in which a brief electrical stimulus is used to induce a cerebral seizure under controlled conditions. It often works when other treatments are unsuccessful and is choice of treatment for psychiatric patients. Nurses have a major role to play for clients receiving ECT. Nurses need to perform various tasks before ECT, during ECT and post ECT. So, it may create confusion among nurses and is time consuming. A nursing management checklist is a type of informational job aid used to reduce failure in performing nursing activities by ensuring consistency and completeness in carrying out a nursing task. The process of checklist development was divided in various phases making use of Delphi technique. Checklist constituted of 114 items divided under sub-headings of pre, during and post ECT. The content validity was checked by Delphi technique. Reliability of checklist was ensured by internal consistency. Value of Cronbach’s alpha (unstandardised) was 0.86. The inter-rater reliability was assessed by computing Cohen’s kappa coefficient (k=0.94) and developed tool was found reliable. The developed checklist will help nurses to check whether all necessary pre, intra and post ECT nursing tasks are being done for patients undergoing ECT. It will save time and avoid confusions regarding work; hence, it will reduce errors and help nurses in providing better patient care. The developed nursing management checklist for ECT being valid and reliable, it is recommended to use this checklist for patients who are undergoing ECT in Psychiatry ward. The feasibility of checklist can also be checked in other Psychiatry units where patients receive ECT.

Key words

Electroconvulsive Therapy, Nursing management, Checklist

Correspondence  at:

Jasveen Kaur

No. B-XII/269-270, Rama Street, Khanna(Distt-Ludhiana)

Email: jasveen@rocketmail.com

Introduction

A mental illness is a disease that causes mild to severe disturbance in thinking, perception and behavior.1 According to the World Health Organization (WHO), 1 in every 4 people, or 25% of individuals, develop one or more mental disorders at some stage in life. Presently, 450 million people globally suffer from mental disorders. About 2-5% of India’s population suffers from some form of mental or behavioral disorders.2 The treatment of mental disorders include various forms of Psychotherapy, Psychiatric medications, and other practices like Electroconvulsive therapy (ECT).3 ECT is one of the most controversial procedures used to treat mental illnesses for over 70 years.4 ECT is a medical treatment for severe mental illness in which a small, carefully controlled amount of electricity is introduced into the brain. This electrical stimulation, used in conjunction with anaesthesia and muscle relaxant medications, produces a mild generalized seizure or convulsion.5 Today, an estimated 1 million people worldwide receive ECT every year, usually in a course of 6-12 treatments administered two or three times a week.6 The UK’s National Institute for Health and Clinical Excellence (NICE) guidelines recommend ECT for patients with severe depression, catatonia, or prolonged or severe mania.7

Electroconvulsive therapy is treated like a minor surgical procedure that requires preoperative preparation and postoperative care.8 A trained nurse with relevant experience must be present at each stage of the treatment- before, during and after ECT.9 There is a long history of nursing practice in the area of Electroconvulsive therapy (ECT). There is extensive literature on the issues raised by this particular treatment but there is little research into what nurses should actually be doing while working with patients receiving ECT.10It is imperative that a psychiatric nurse takes overall responsibility for the administration of the ECT. He or she is responsible for record-keeping and plays a key role in monitoring standards and auditing protocols.11

Nursing care starts as soon as the patient and family are offered ECT as a possible treatment option. Nurses need to assess and implement the pre-treatment plan prior to ECT, prepare and monitor the patient during the actual procedure and observe and interprete patient responses after ECT  with recommendations for changes in the treatment plan as appropriate.9 Burns and Stuart Gail W. (1991) have written that nurse’s multifaceted role in ECT is enacted by providing education and suppor t, performing pre-treatment assessments, monitoring the procedure, and observing and interpreting post treatment patient responses. 12

APA guidelines suggest that nurses should identify the equipment and medicines to be available in administering ECT. APA guidelines recommend that before, during and after completion of ECT treatment certain information needs to be documented. It includes baseline vital signs, medication given prior to treatment, during treatment, and in the recovery area, seizure duration and presence of adverse effects or complications.13 Matthew V. and Barry D. (1994) opined that nursing services attempting to develop standards for their own facilities will find limited literature specific to nurses’ role in Electroconvulsive therapy (ECT). From 1966 to December 1994, there were only 19 publications in American nursing journals that provided a specific focus on nurses’ role in ECT. Only one of these articles reported research findings. While the APA Task Force on the Practice of ECT has addressed educational needs of nursing and technical elements of the procedure, there are no current existing specific standards for nursing practice in ECT.14

In 2008, the World Health Organization (WHO) published guidelines identifying multiple recommended practices to ensure the safety of surgical patients worldwide and safe surgery checklists came into practice. When used appropriately and consistently, pre- procedure checklists enhance patient safety and care efficiency.15

WHO has given guidelines for safe surgery checklist. But there is no such checklist for ECT for nurses i.e. a checklist for all necessary things which are required to be done by nurses for patients before, during and after ECT. A single ECT check list can avoid confusions regarding nursing care activities which need to be done, which activities are already done or which activities are left for patients undergoing ECT. It can reduce common nursing errors and will save time.Therefore, for improving the quality of patient care it can become an evidence based tool for the best practices in the field of Psychiatric nursing. So, the present study was undertaken to develop a checklist on nursing management of patients undergoing ECT.

Objective

 To develop a check list on nursing management of patients undergoing Electroconvulsive Therapy.

Methodology and results

 The study was conducted in the Psychiatry ward of the Nehru Hospital, PGIMER, Chandigarh in the months of August- September 2011. A methodological research design was adopted to carry out the present study. The study was divided into four phases with different steps.

Phase I- Preliminary preparation of checklist

 It further included 3 steps. In step- 1, literature was reviewed related to ECT and Nurse’s role in ECT. In step- 2, related content was analysed and various related aspects were pooled together. In step- 3, first draft was prepared and items were categorised under 3 subheadings: Pre ECT, During ECT and Post ECT.

Phase II- Validation phase of first draft and subsequent drafts

 It constituted 3 steps. In step-1, panel was selected comprising of 11 experts from the field of Mental Health Nursing, Psychiatry, Anaesthesia and Biostatistics. The first draft of tool was circulated among 11 experts from above stated fields. In step-2: The modified Delphi technique was used to validate the draft. All the panelists were requested to give their valuable suggestions pertaining to the content, accuracy of information, the item order i.e. organization and sequence of the items. The suggestions given by panelists were incorporated to generate the second draft of the tool and similar two subsequent rounds were conducted with same panelists until the common consensus was obtained. In step-3, as per the experts’ opinion, the modifications in the checklist were made.

Phase-III- Testing feasibility of tool

 After third Delphi round, ECT checklist- III was made which constituted of 91 items under sub-headings of Pre ECT (items no. 1-63), During ECT (items no. 64-74) and Post ECT (items no. 75-91). Pilot study (first try out) was done with new formulated Check list-III on 5 patients undergoing ECT admitted in Psychiatry ward, PGIMER, Chandigarh. It was found feasible to use nursing management checklist for ECT. The language of items was clear & understandable. Changes were made in the sequence of items after pilot study. After pilot study, Nursing management checklist for ECT – III was distributed among panelists for fourth Delphi round to get final draft of checklist which was sub-divided into Pre ECT (items no. 1-63), During ECT (64-74) and Post ECT (75-91).

Establishment of Inter-rater Reliability of the Checklist by Cohen’s Kappa

 The inter-rater reliability was calculated by using Cohen’s Kappa coefficient ‘k’. This coefficient indicates the degree of agreement between the pair of raters. Each patient was rated by the nurse researcher and one of M.Sc. nursing student in the ward at same time independently during pilot study.

Table 2 shows the agreement level between rater 1 and rater 2 at a given point of time for 5 patients. There were 490 items that were marked as yes by both rater 1 and rater 2 and 55 items that were marked as no by both raters. There were 15 items which were marked as yes by rater 1 and no by rater 2 and 10 items were marked as no by rater 1 and yes by rater 2. Rater 1 marked yes for total 505 items and no for 65 items. Rater 2 marked yes for total 500 items and no for 70 items. Cohen’s kappa value came out to be 0.94 (k=0.94). Generally, Kappa value of 0 .7 or greater indicates acceptable reliability. Hence, the tool was found to be highly reliable.

Table 2- Inter-rater agreement for all items of nursing management checklist for ECT

  RATER 2  
Yes No Total for Rater 1 Kappa

(P-value)

R A T E R

1

Yes 490 15 505  

 

0.94(<0.0001)

 

No

 

10

 

55

 

65

  Total for Rater 2 500 70  

 

Phase IV- Try out

 In step-1, Draft prepared after the fourth Delphi round was tried out on 30 ECTs. The clients undergoing ECT who were admitted in Psychiatry ward, PGIMER, Chandigarh were selected as subjects for the study. Ethical approval for the study was obtained from the Ethical Committee of the Institution. Written permission was taken from the Head of the Psychiatry Department and Sister Incharge for the study in the Psychiatry

Table 1- Reliability analysis of nursing management checklist for ECT by Cronbach’s alpha for Pre ECT preparation of patient

Items of checklist Scale Mean if Item Deleted Corrected Item-Total Correlation Cronbach’s Alpha if Item Deleted
PRE-ECT

i) Preparation of patient-

a)      Preliminary preparation

1.   Checking conditions

2.   Blood investigations

3.  Urine investigations

4.   Fundus examination

5.  ECG

6.  Chest X Ray

7.  Explanation of procedure

8.   Informed consent

9.    PAC b)Routine Preparation

10.  NPO status

11.  Reviewing vitals

12.   Withholding medication 13.Changing morning

medicine time

14.  Oil free scalp

15.  Removing metal objects & valuables

16.  Changing into loose dress

17.  Vitals recording

 

 

113.10

 

 

0.68

 

 

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

 

0.86

0.86

0.86

0.86

 

0.86

0.86

 

0.86

0.86

112.97 0.64
113.73 0.48
113.80 0.65
114.73 0.59
113.03 0.24
113.50 0.26
112.83 0.63
113.97 0.66
113.90 0.58
113.90 0.11*
114.03 0.41
113.07 0.56
113.53 0.52
113.43 0.36
113.03 0.13*
112.73 0.36

Ward. The researcher explained the purpose of the study and written informed consent was obtained from the subjects. The average time taken to fill this nursing checklist was 15- 20 mins. The checklist was filled by nurse researcher by using observation technique. The data collection was done in the month of August- September 2011. In step- 2, to find out internal consistency and reliability of the present tool

Cronbach’s alpha (unstandardised) was used. Table 1-3 describe reliability analysis of nursing management checklist for pre ECT preparation of patient (1-17), preparation of articles (18-54) and nursing responsibilities (55-63) respectively. Table 4 describes about reliability analysis of during & Post ECT items (64-91). There were total 114 items in the checklist and overall Cronbach’s alpha coefficient of present tool was 0.86 which indicated reliability and internal consistency of tool. (Ideally Cronbach’s alpha coefficient should be > 0.70). Corrected item to total correlation was applied on 114 items of tool, it showed that 106 items of tool had item score to total score correlation between 0.2- 0.8. (the optimal value for item to total correlation should be at least 0.2-0.8) whereas 8 items in the tool had item score to total score correlation < 0.2 showing their incompatibility with the overall tool (Table-1). To check the individual contribution of items, each item was deleted one by one to see the changes in the value of Cronbach’s alpha coefficient. It was found that for 112 items, the value of Cronbach’s alpha coefficient remained same which indicated all of these 112 items were contributing in the tool. Inspite of deleting items having item to total correlation less than 0.2, the value of Cronbach’s alpha did not increase. Hence these 8 items were also contributing for the reliability of tool. This indicated that all the 112 items were contributing for the reliability of the tool. It means tool was internally consistent by taking all 112 items. It was observed that two items ampoule cutter and kidney tray (under Pre ECT preparation of articles) showed increase in value of cronbach’s alpha i.e. 0.87 but these items were not deleted as these items were considered important by experts and required for pre ECT preparation. So, these 2 items were also retained in the checklist.

 

The final draft of nursing management checklist for ECT is divided under subheadings of Pre ECT (items 1-63), During ECT (items 64-74) and Post ECT (items 75- 91). Pre ECT is further subdivided into preparation of patient constituting items under subheadings preliminary preparation (items 1-9) and routine preparation (items 10- 17). Further Pre ECT is subdivided into preparation of articles (items 18-54) and nursing responsibilities constituting items under subheadings immediately before shifting the patient to ECT room (items 55- and on ECT table (items 60-63). So, the final draft of developed nursing management checklist for ECT comprised of 114 items in total which is found to be reliable and

Table 2- Reliability analysis of nursing management checklist for ECT by Cronbach’s alpha for Pre ECT preparation of articles

Items of checklist Scale Mean if Item Deleted Corrected Item- Total Correlation Cronbach’s Alpha if Item Deleted
ii) Preparation of articles/equipment    

0.32

0.19*

0.49

0.46

0.64

0.48

0.66

0.28

0.24

0.26

0.64

0.46

0.62

0.24

0.63

0.56

0.68

0.28

0.41

0.46

0.52

0.36

0.33

0.36

0.32

0.68

0.64

0.56

0.65

0.59

0.24

0.26

0.13*

0.36

0.38

0.28

0.41

0.59

0.66

0.64

0.26

0.66

0.36

0.24

0.26

0.64

0.86

0.45

0.37

0.57

0.42

0.44

0.23

0.26

0.57

0.31

0.36

 

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.86

0.87

0.86

0.86

0.87

18. Resuscitation tray containing

18.a) ET tube

113.70
18.b) Oral airway 113.97
18.c) Laryngoscope 114.03
18.d) Facemask 113.67
18.e) Magill forceps 113.33
18.f) Bains circuit 112.67
18.g) Ambu bag 113.58
19. Emergency medications

19.a) Inj Atropine

112.59
19.b) Inj Adrenaline 113.67
19.c) Inj Avil 112.97
19.d) Inj Calcium gluconate 113.59
19.e) Inj Dopamine 113.423
19.f) Inj Dexamethasone 112.70
19.g) Inj Esmolol 113.87
19.h) Inj Hydrocor tisone 112.83
19.i) Inj KCl 113.97
19.j) Inj Lorazepam 113.90
19.k) Inj Furosemide 113.90
19.l) Inj Midazolam 114.03
19.m)Inj NTG 113.07
19.n) Inj Phenytoin 113.53
19.o) Inj Soda bicarbonate 113.43
20. Bed sheet 113.03
21. Draw sheet 112.73
22. Biomedical waste buckets 113.70
23. Defibrillator 113.10
24. Cardiac monitor 112.97
25. B.P. apparatus 113.73
26. B.P. cuff and pulse oximetry 113.80
27. ECT machine 114.73
28. Boyle’s apparatus 113.03
29. Oxygen cylinder 113.50
30. Tongue depressor 112.83
31. Mouth gag 113.97
32. Suction machine 113.90
33. Suction catheter 113.90
34. Bowl of water 114.03
35. Pair of Gloves 114.03
36. EEG and ECG electrodes 113.67
37. Cotton swabs 113.33
38. Jelly for EEG electrodes 112.67
39. Jelly for ECG electrodes 113.58
40. Jelly for ECT electrodes 112.59
41. IV stand 113.67
42. IV cannula 112.97
43. Infusion set 113.59
44. Normal saline 113.23
45. Injection tray 114.73
46. Syringes 113.03
47. Inj Glycopyrrolate 113.50
48. Inj Thiopentone 112.83
49. Inj Succinylcholine 113.97
50. Ampoule cutter 113.90
51. Micropore tape 113.90
52. Spirit swabs 114.03
53. Kidney tray 113.07
54. Preparation of injections of required dilutions 113.53

* Items in the tool which shows item to total correlation <0.2 Overall reliability is 0.86(Unstandardised Cronbach’s alpha)

Table 3- Reliability analysis of nursing management checklist for ECT by Cronbach’s alpha for Pre ECT nursing responsibilities

 

Items of checklist Scale Mean if Item Deleted Corrected Item- Total Correlation Cronbach’s Alpha if Item Deleted
iii)Nursing Responsibilities      
a) Immediately before shifting the patient to ECT room 5             5      .      
Checking equipments in ECT room

56. Confirming NPO status

113.43 0.14* 0.86
57. Emptying bladder before ECT 113.03 0.36 0.86
58. Accompanying patient from ward to ECT room 112.73 0.32 0.86
59. Making patient comfor table

b) On ECT table

113.70

113.97

0.18*

0.64

0.86

0.86

60.    Checking vitals

61.    Applying electrodes

114.03 0.56 0.86
62. Applying B.P. cuff and probe 114.73 0.65 0.86
63. Star ting IV line 113.90

114.03

0.59

0.24

0.86

0.86

  • Overall scale mean is 08
  • * Items in the tool which shows item to total correlation <0.2
  • Overall scale mean is 08 & Overall reliability is 0.86 (Unstandardised Cronbach’s alpha)

 

Table 4- Reliability analysis of nursing management checklist for ECT by Cronbach’s alpha (During ECT & Post ECT)

Items of checklist Scale Mean if Item Deleted Corrected Item- Total Correlation Cronbach’s Alpha if Item Deleted
DURING ECT

64. Administering Inj Glycopyrrolate

113.07

113.53

113.43

113.03

112.73

113.70

113.97

114.03

113.67

113.33

113.54

 

112.67

113.58

112.73

114.03

114.03

113.67

113.33

112.67

113.58

112.59

113.67

112.97

113.59

113.23

112.70

113.87

114.03

113.67

113.33

112.67

0.26

0.63

0.36

0.48

0.28

0.41

0.59

0.52

0.36

0.33

0.67

 

0.36

0.32

0.48

0.64

0.19

0.46

0.64

0.16*

0.56

0.24

0.24

0.26

0.14*

0.46

0.62

0.24

0.34

0.56

0.64

0.46

 

0.86

65. Administering Inj Thiopentone 0.86
66. Applying B.P. cuff on another arm 0.86
67. Administering Inj Succinylcholine 0.86
68. Inser ting mouth gag 0.86
69. Recording duration of seizures 0.86
70. Checking whether seizure duration is adequate 0.86
71. Deflating cuff 0.86
72. Checking for immediate side effects 0.86
73. Recording of any emergency medication given 0.86
74. Recording vitals 0.86
POST ECT

75. Removing electrodes

 

0.86

76. Removing mouth gag 0.86
77. Suctioning 0.86
78. Inspecting mouth for any injury 0.86
79. Checking vital signs 0.86
80. Assessing patient’s level of consciousness 0.86
81. Shifting patient in ward on trolley 0.86
82. Placing the patient in left lateral position 0.86
83. Continuing IV line & oxygen (for 15-20 mins) 0.86
84. Checking & recording vital signs every 30 mins 0.86
85. Checking status a)responding to commands 0.86
85. b)gag reflex 0.86
85. c)orientation 0.86
85. d) headache 0.86
86. Giving reassurance 0.86
87.   Ensuring patient gets something to drink after 2 hrs & then to eat

88.   Giving routine medicines

0.86

0.86

89. Removing IV cannula 0.86
90. Checking for immediate post ECT side effects 0.86
91. Documentation 0.86

Discussion

Electroconvulsive therapy (ECT) is a procedure in which electric current is passed through the brain, deliberately triggering a brief seizure. It often works when other treatments are unsuccessful.16 So, still ECT is being choice of treatment in various Psychiatric settings. Nurses working with patients who are undergoing ECT have a major role to play.17 NALNECT (National Association of Lead Nurses in ECT) has given a list of competencies a nurse should possess who is working with patients undergoing ECT.18 So, nurses need to do lot of activities for patients before, during and after ECT which creates confusion at times and important things can be missed. A nursing management checklist on ECT can be helpful to reduce confusion, save time and for better patient outcome.

There is no such checklist available for nurses. So, the present study was undertaken to develop such a nursing management checklist on ECT for patients undergoing ECT in Psychiatry ward, PGIMER, Chandigarh. Initially the in-depth review of literature was done and preliminary draft of ECT checklist was made. The preliminary ECT checklist draft was further refined by using the Delphi technique. Delphi technique is an iterative process designed to combine experts’ opinion into group consensus. It is a method for structuring a group communication process. The classical original Delphi used four rounds. However, this has been modified by many to suit individual research aims and in some cases it has been shortened to two or three rounds.19 The current study also had a total of four rounds to develop a final version of nursing management checklist for ECT.

The Phase I was preliminary preparation of nursing checklist in which literature was reviewed and different items related to nursing management pre, during and post ECT were selected and pooled together in the form of pool. In Phase II, content validity was established with Delphi technique. The best number of panelists for a Delphi exercise has not been determined. The number is generally governed by number of respondents needed to constitute a representative pooling of judgements. A panel consisting of about 10 experts is probably ideal, but more than 10 may be used if desired.19 In present study, there were total 11 experts from fields of Psychiatry, Psychology, Mental Health Nursing, Anesthesiology and Biostatistics in all Delphi rounds. Three Delphi rounds were undertaken and modifications were made as per the suggestion given by the experts. In Phase III, a pilot study was carried out and developed checklist was administered on 5 subjects who had undergone ECT in Psychiatry ward, PGIMER, Chandigarh to ensure the feasibility of checklist.

It was important to check inter-rater reliability of checklist as this checklist was being developed for nurses and will be used by different nurses in ward. Cohen’s Kappa can be used for checklists that require decisions between mutually exclusive categories such as yes/no. This coefficient indicates the degree of agreement between the pair of raters. Generally, Kappa’s value of 0 .7 or greater indicates acceptable reliability.20 So, for the present study the inter-rater reliability was calculated by using Cohen’s Kappa coefficient ‘k’.

Cohen’s Kappa value came out to be 0.94 (k=0.94) suggesting checklist was highly reliable which was consistent with two studies which have Kappa’s value greater than 0.7. In one study Francis et al used Cohen’s Kappa to find out inter-rater reliability of Palliative Performance Scale. The mean Kappa was 0.71 suggesting the reliability of the tool.21 Gowers et al also used Cohen’s Kappa to find out inter-rater reliability of Health of the Nation Outcome Scales (HoNOS) that routinely measure outcomes for adults with mental illness. The mean Kappa was 0.77 suggesting reliability of the tool.22 As there were certain modifications after the pilot study, a fourth Delphi round was undertaken. In Phase IV, checklist prepared after fourth Delphi round (Pre ECT- 83 items, During ECT-11 items and Post ECT- 20 items) was tried on 30 subjects who had undergone ECT admitted in Psychiatry ward, PGIMER, Chandigarh. Observation method was used to collect the data.

Reliability is best appreciated as a measure of the consistency of recorded observations. It is necessary component of validity (the strength of connection between observations, methods and applicable conclusions) because unreliable methods cannot be valid. Cronbach’s alpha can be used to assess internal consistency of tool. Generally, Cronbach’s alpha value of 0 .7 or greater indicates acceptable reliability.20So, the internal consistency of the checklist was ensured by Cronbach’s alpha.

In present study, Cronbach’s alpha coefficient of 114 items in checklist was 0.86 which indicated internal consistency of tool which was consistent with two studies which have Cronbach’s alpha value > 0.7.20 In one of the studies William et al also used Cronbach’s alpha to find out reliability of short form of Chinese version of Anxiety Scale for children. The Cronbach’s alpha coefficient of their tool was 0.83 suggesting the reliability of the tool.23 Another study by Yeng et al used Cronbach’s alpha to check reliability of 32-item Hypomania Checklist (HCL-32) in a clinical sample with mood disorders. The Cronbach alpha coefficient of their tool was 0.83 suggesting the reliability of the tool.24

Leung et al used Cohen’s Kappa & Cronbach’s alpha to assess inter-rater reliability and internal consistency of World Health Organization Mental Disorders Checklist for use in a tele health clinic in Hong Kong. The inter-rater reliability was (Kappa=0.88) and internal consistency reliability was (Cronbach’s alpha = 0.83) suggesting reliability of the tool.25 which was consistent with findings of present study having Cronbach’s alpha= 0.86 and Kappa= 0.94 It is concluded that developed nursing management checklist on ECT is reliable, valid and covers all the important nursing activities and responsibilities which nurses need to perform before, during and after ECT for patients undergoing ECT. It is recommended to use  this checklist by nursing professionals to save time, avoid confusions & errors, and to provide better care to patients undergoing ECT in Psychiatry ward.

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