Nurse practitioners (NPs) have been included in the redesign of primary care, demonstrating an ability to provide high-quality, cost-effective care. Increasing numbers of states allow for independent practice; about half of all NPs provide primary care in the United States (Poghosyan et al., 2016). Their increased responsibility and expanding scope of practice, in conjunction with rapid changes in health care technology, can precipitate possible gaps in NP education. In response, the family nurse practitioner (FNP) curriculum has to include skills needed to provide high-quality care in a busy primary care environment.
Electrocardiogram (ECG) interpretation is a core competency skill in medical schools, but not specifically in FNP programs. However, it is a skill and practice requirement that FNPs will use almost daily in primary care (Scheibmeir et al., 2015). One way to teach ECG interpretation in a time-saving way is through web-based, narrated e-learning modules. E-learning modules are convenient and flexible for students and offer an alternative teaching strategy. They provide self-paced learning, are flexible, and are available for review at all times until students complete the program of study. For faculty, modules can be a sustainable addition to FNP curricula as they can be made available for multiple semesters. This type of learning has been shown to increase nursing and medical students' ability to interpret ECGs but has not been examined in FNP students (Spiva et al., 2012). Therefore, the purpose of this study was to evaluate the confidence and ability of ECG interpretation in FNP students after completing an e-learning module. The research questions are as follows: 1) What is the effect of an e-learning ECG module on FNP students' level of confidence in interpreting ECGs? 2) What is the effect of an e-learning ECG module on their ability to interpret ECGs?
METHOD
This quantitative study used a pretest/posttest design with a convenience sample of students recruited through the graduate FNP program at a small liberal arts college. Institutional review board approval was obtained under exempt status. Students gained access to the e-learning module via a learning management system prior to their first clinical rotation. The module consisted of a series of three videos for a total of five hours of instruction. Topics included axis deviation, acute myocardial injury/ischemia, heart blocks, right bundle branch block, left bundle branch block, pericarditis, left ventricular hypertrophy, Wolf-Parkinson-White syndrome, atrial fibrillation, atrial flutter, ventricular fibrillation, ventricular flutter, torsades de pointe, hyperkalemia, and atrial tachycardia with aberrant conduction. Students had the entire 14-week semester to complete the module at their own pace.
Students received an information sheet informing them that participation was voluntary and that their course grade would not be impacted by participation in the study. All English-speaking FNP students entering their first clinical rotation were eligible for the study; students were invited to participate one month prior to the clinical rotation. Power analysis (G*Power 3.1) indicated a minimum sample size of 27 was required to maintain the power of the study. A p value of .05 or less was considered statistically significant.
Prior to beginning the modules, students completed three items through the university's online learning management system: the confidence in interpretation of ECGs survey, an ECG interpretation quiz, and a demographic form. The confidence scale was developed by FNP faculty; content validity was established by five NP experts who work in cardiology. The NPs rated items on a 4-point Likert scale for relevance; the content validity index for the scale was .90. Students rated the 10 items on the scale using a 5-point Likert scale; scores ranged from 10 (confident) to 50 (complete confidence), indicating that NP students perceived they had the confidence to interpret 12-lead ECGs.
The pretest/posttest ECG knowledge quiz required students to interpret 25 12-lead ECGs. The quiz was reviewed by five experts for consistency (three cardiologists/two cardiac NPs). Participants received 1 point for each item that was answered correctly, for a perfect score of 25. Students completed the confidence survey and knowledge quiz immediately after completing the module.
The sample consisted of 50 students; 92 percent (n = 46) were women. The average age of participants was 34 years (range: 24 to 58 years); their nursing experience averaged 6.6 years (range: 4 to 25 years). There was a significant increase in students' confidence on the ECG confidence questionnaire, t = 3.07(50), p < .001, at the end of the FNP clinical course (prior score, 22; post score, 46). A paired t-test indicated knowledge improved (prior score, 56 percent; post score, 88 percent; p < .001). Individual items were analyzed to identify which types of arrhythmias were most difficult. The FNP students scored lowest on the second- and third-degree heart block and the atrial tachycardia with aberrancy ECGs pre- and postmodule. These were identified as needing further clarification in clinical courses.
DISCUSSION
This self-paced ECG module emphasized common abnormal details and features of ECG that FNP students may encounter in the primary care setting. Overall, FNP students' confidence and ability to correctly identify ECGs increased after completing the series of modules (p < .0001). It should be noted that there is no previous research regarding FNP student confidence and interpretation skills similar to this study; physician and RN studies were identified.
Of the three physician studies, all identified improved ECG interpretation skills after computer-based tutorial training (Barthelemy et al., 2017; Kopec et al., 2015; Pourmand et al., 2015). Similar to this study, competency in 12-lead ECG interpretation improved significantly (p < .0001). The online training modules used in these studies focused on various types of ECG interpretation (e.g., acute myocardial infarction interpretation, ischemia, various rhythm disorders) as did this study.
Two RN studies also used a similar design. Jang et al. (2005) found undergraduate nursing students reported an increase in the ability to interpret ECGs (p < .0001) in the e-learning group compared to the traditional in-class lecture. The students also reported that an online learning module was needed in their curriculum. This study only looked at knowledge in ECG interpretation, not confidence levels. Spiva et al. (2012) evaluated undergraduate nursing students' knowledge and confidence in interpreting basic ECG strips accurately using different learning modalities. The findings are consistent with this study, indicating that traditional lecture learning is not superior to other learning modalities.
There are limitations to the study. The study took place in a small liberal arts school with a primarily female population; it would be strengthened by replication in a more diverse sample in multiple FNP programs. Students may have pursued other education modalities outside the self-paced modules during the 14 weeks of the study, which may have influenced their responses. The students were not asked how many hours the modules took to complete; time spent on the modules may have affected their scores on both the ECG test and the confidence scale. Students were tested for knowledge retention once at the end of their clinical courses; knowledge retention postgraduation was not tested.
CONCLUSION/NEXT STEPS
Enriched ECG interpretation is a core competency that may be lacking in FNP educational programs because of the nature of the all-encompassing curriculum. This study has shown an increase in confidence and ability to interpret ECGs in NP students after completing e-learning modules. Self-paced modules such as those used in this study offer an alternative to traditional teaching strategies. As the preceptor shortage continues, with clinical sites unable to offer uniform clinical skills, self-paced modules are a convenient way to fill gaps in clinical knowledge. Importantly, self-paced modules are flexible. They can be accessed anywhere, anytime to meet students' learning needs for their future clinical careers. Additional research is needed to evaluate self-paced modules as a means to fill identified knowledge gaps in NP education.
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