Teaching Electrocardiography Procedure

Introduction

This assignment is based on teaching sessions conducted with peers in week seven. This paper aims to evaluate effectiveness of teaching methods; the creativity and efforts applied to improve learners skills. This discussion links to the teaching philosophy, learning theories, and teaching strategies. The key objective of this assignment is to identify those mistakes which were made in the course of the lesson and eliminate them. My colleagues and I did not make full use of existing educational strategies and some aspects of electrocardiography procedure were not made clear to the students. The paper also analyzes the literature related to teaching electrocardiography procedure; teaching strategies used and details my recommendations on how to improve future teaching sessions in the clinical environment (Tanner, 2009).

Learning electrocardiography (ECG) procedure is essential for nursing students. Electrocardiography is one of the most valuable and widely applied diagnostic tools that measure the heart’s electrical activity as waveforms. Every student must understand an ECG as a necessary investigation that gives quick diagnoses on the condition of the heart in emergency situations.

Clinical education is a necessary element in nursing practice. Imparting knowledge and clinical skills based on evidence to student nurses will empower them in terms of providing improved patient care. Clinical education in fields such as ECG procedure is necessary in improving clinical practice thereby facilitating the efficient and quality care delivery necessary for patient care. Clinical education enables nurses to improve their clinical practice, thus providing safer care to patients.

Therefore, teaching electrocardiography is the core of expanding electrocardiography procedural practice. This is because the sessions are aimed at assisting students to achieve higher standards of electrocardiography practice. They need to be consistent with the underlying clinical theories of learning, models of teaching in a clinical setting and effective principles of teaching and learning (Roberta, 2003)

Relevant Literature Review Including Pedagogies Used in Clinical Education

Learning involves the process through which knowledge is achieved. It provides meaning; and comes from experience, reading, and living life. The result of learning is growth. That is transformation in thinking, feeling or behaving. Many studies that endeavor to explain how learning occurs have been done through the years; and they been done through the lenses of disciplines such as psychology, physiology, and sociology (Vandeveer, 2005).

Findings of these studies have led to the evolution of theories that try to explain how individuals learn. A theory is developed from fact analysis in relation to one another and is then applied to explain a phenomenon. The knowledge achieved from such studies has contributed to the theoretical underpinnings for entire theoretical structures or frameworks for education (Roberta, 2003). At this stage, it is too early to jump to any conclusion about the learning styles of my partners yet, it appears to me that they are visual learners. This means that they predominantly rely on their visual memory while processing and utilizing new information. This is why it is essential to employ strategies which best suit their abilities and constructivist approach would be most suitable for them

Behavioral Theories of Learning

Behavior learning theories have been chosen for this literature review because they explain how teachers can elicit appropriate behavior in their students, in other words how to motivate them. These approaches are important for this analysis because they explain the key drivers of students conduct both inside and outside the classroom. Overall, education has been influenced more by behaviorism than any other single theory. Currently, behavioral principles continue to be used appropriately and successfully whereas others have been rejected. Behavioral foundational principles were developed by psychologists such as Pavlov, Thorndike, and Skinner.

These principles were derived from observations of learning in animals (Braungart, 2003). There were also other behavioral theorists who presented a variety of principles. However, all shared a common element: that all behavior is learned and that learning is influenced by the environment in which it happens and the rewards given to encourage it (Vandeveer, 2005). Therefore, competence in performing ECG procedure can be learned via methods advocated by behavioral theories and theorists.

Behaviorism was carried into classrooms where learning experiences were structured in a manner that would assist educators to attain goals through the development of objectives. Tyler (1979) stated that “the most useful form for stating objectives is to express them in terms which identify both the kind of behavior to be developed in the student and the content or area of life in which this behavior is to operate”. This was the foundation of behavioral objectives. Bloom et al (1956) made a classification of educational objectives that addressed the cognitive domain, “the recall or recognition of knowledge or development of intellectual abilities and skills” through the application of observable actions.

Krathwohl (1956) led efforts in the affective domain of knowledge with a behavioral inclination. The objectives here mainly focused on “an emotion, a feeling tone or a degree of acceptance or rejection; also attitudes, values, appreciations, and emotional sets or prejudices” (Krathwohl, 1956). Achievement of the objectives was assessed through highly structured, clearly delineated, and visible behaviors. Behavioral theories enable teachers and students alike to learn to construct behavioral objectives to guide teaching and identify measurable outcomes as the basis for evaluating learning.

Behavioral theoretical learning aspects are common and continue to be applied in clinical educational settings, particularly in the gaining of technical skills such as operating an electrocardiogram and making recordings. Commonly, at the start of clinical nursing education, what is important to know, experience and demonstrate is determined by the faculty. Even today, faculty still retains primary influence and authority despite increase in students’ involvement in their own learning.

Knowledge grows. That is to say, prior knowledge forms a reference point for both the assimilation of new knowledge and the application transfer of knowledge from one learning experience to another. Understanding what prior knowledge is available allows the teacher to help students connect new knowledge to old and hence improve overall understanding. Classically, technical skills are learnt as procedures, following a designed approach. The behavioral objectives, designed keenly to identify the expected learning outcomes, prescribe both the exposure of students to learning experiences and their evaluation.

The sequential procedural format of the nursing process, and the resulting nursing care plans are a direct outgrowth of behaviorism. Any activity learners participate in that follows this procedure, for instance the development of teaching plans, reflects behavioral learning theories. Written and verbal positive reinforcement provides a strong extrinsic learning reward; and rewarding the achievement of intended outcomes is a key behavioral aspect. Clinical teachers need to enhance their teaching skills to be able to produce effective outcomes.

Cognitive Theories of Learning

These theoretical approaches are vital for this discussion because they provide invaluable data about learners perception of new information. They show how learners process new facts and ideas. Most importantly with their help, we can ensure that this knowledge is converged into practice. Overall, cognitivism helps teachers to bridge the gap between mere perception of information and application.

As it has been noted earlier behavioral theorists emphasize that which is external to the learner. Conversely, cognitive theories emphasize that which occurs within the learner. According to cognitive theorists, mental processes involved in acquiring, processing, and structuring information are important aspects of learning (Braungart, 2003). They particularly identified six classes of cognitive learning ranging from simple to complex. These classes were; knowledge, comprehension, application, analysis, synthesis, and evaluation. Each class was broken down further into varying numbers of components. For instance, a knowledge-focused class may be broken into knowledge of specifics, then of ways and means to deal with those specifics, and the knowledge of the universals and abstractions associated with a given field of study.

Each level is associated with specific learning behavior, and has its own set of verbs descriptive of those behaviors, which are to be used when writing objectives (Bloom et al., 1956). Faculty formulates the appropriate objectives based on whether learning is new or constructed depending on prior learning, and the desired end point level of cognitive learning. Used verbs also give guidance for how the learning will be evaluated (Roberta, 2003).

Models of Clinical Nursing Education

Knowledge and understanding of models applicable to clinical practice empowers clinical educators to work in a manner that suits teachers, students, and patients. Models have been defined as tools for generating ideas, guiding conceptualization, and generating explanations (Young, 2002). Clinical teachers can apply relevant models of teaching to the procedure being experienced. Two approaches were used during the teaching session; traditional and constructivism.

Traditional Model

Teaching electrocardiography procedure requires careful design of an environment in which students get opportunities to build mutual respect and support for each other while they are achieving identified learning outcomes, in this case recording electrocardiography procedures. Teachers in clinical education form a crucial bridge to successful experience for students (Braunwald, 1997). Research in nursing education shows that effective medical teachers are clinically competent; are able to teach; have collegial relationships with learners and agency staff; and are friendly, supportive, and patient (Halstead, 1996).

It’s essential for the teacher to be knowledgeable and able to share the knowledge with students in a clinical setting. Such knowledge includes an understanding of behavioral and cognitive theories and concepts related to the practice of nursing, such as; recording electrocardiography procedure. Karuhije (1997) contends that attention to three teaching domains; instructional, evaluative and interpretational, facilitates achievement of the teaching skills required to enhance success in clinical settings.

The Instructional domain encompasses those approaches or strategies adopted to facilitate knowledge transfer from didactic to practicum (Norton, 1998). The Evaluative domain relates to making determinatives about performance and achievements as goals. The Interactional domain relates to relationships and interactions (Knox, 1985).

Competence in the clinical practice of nursing has been documented as being necessary for effective clinical teaching. Gaberson (1999) revealed that the best clinical teachers exhibit expert clinical skills and judgment. Expert skills have particularly been described by students to be important. They tend to describe effective clinical teaching as that which demonstrates nursing competence in a real situation (Horst, 1988). Knowing how to teach is also a prerequisite for effective clinical teaching. Wong (1988) adds that effective clinical teachers are expected to have expertise in the art of teaching. Equally important are teacher behaviors that facilitate learning and support students in their acquisition of nursing skills (McCarbe, 1985).

Brophy (1998) reveals that empirical evidence exists that correlates specific teaching methods with enhanced student learning; examples of such methods are the use of objectives, effective questioning, and responding to questions. A study conducted by Pugh (1988) revealed that preparation and the ability to explain concepts clearly and stimulate learning are also important. Other effective behaviors include being fair in evaluation, communicating expectations clearly, and providing positively timed and specific feedback (Nehring, 1990).

In the course of lesson we have tried to apply this model. Our first step was to carefully explain and describe electrocardiographic procedure. Students had be provided with concise explanation of its essence and major stages. Secondly, one of my peers demonstrated it in practice, explaining the rationale for every mechanism and action. Afterwards, each of the learners was asked specifying questions and only they moved to practical assignments.

Constructivism Model

Adoption of the constructivism approach to teaching in nursing gives nursing educators a new vision of teaching. It also parallels a paradigm shift in nursing practice from nurse centered to patient centered nursing (Bevis, 1989). In constructivist teaching, the teacher commences with the experience of the student and together they develop knowledge, skills and competencies for professional practice (Bergum, 2003).

Teachers who embrace constructivist teaching not only prepare student nurses with the substantive knowledge necessary for competent practice, but also create an environment in which students learn to think critically, practice reflectively, work effectively in groups, and access and use new information to support their practice, while modeling respect for meanings of lived experiences, learning and collaborative processes (Bevis, 2001).

Bergum (2003) envisions nursing as a dynamic, interpersonal, generative and caring practice. To be consistent with this view of nursing, teaching nursing should be a relational, generative practice that occurs formally and informally; between the student and the teacher; the student and the patient; the student and their colleagues; the student and their peers; and the student and professionals from other courses (Young, 2002). Such learning needs to occur in diverse settings including the classroom, lab, and clinical areas of hospitals as well as community sites. Teaching nursing requires facilitating a thoughtful engagement between the learners and learning materials to ensure that students gain skills and knowledge (Bergum, 2003).

Constructivism is a philosophy that can be applied successfully to clinical teaching. It bodes well in clinical teaching and learning since its central focus is the idea that students construct knowledge for themselves (Young, 2002). Students construct meaning individually as they learn. They attain this by reflecting on experiences. Under the constructivist umbrella, students make their own rules and mental models which they apply in order to make sense of their experiences. Miranda (2005) provides the guiding principles of constructivism, which include: learning as an active process, and searching for meaning.

Therefore, constructivism must commence with issues around which learners are trying to construct meaning actively; learning as a social activity associated with links to other people, such as the teachers and peers; constructivist learning that concentrates on primary concepts, not isolated facts; and understanding mental models in order to teach well (Wong, 1987). Learners use mental models to perceive the world and the assumptions they make to support those models; the learning purpose for individuals to construct their own meaning. Assessment requires being part of the learning process and gives learners information on the quality of their learning. Students need to revisit ideas, think them over, try them out, and use them in order for significant learning to occur. Finally motivation is an essential tool for learning (Miranda, 2005).

The use of the constructivist model was essential to my teaching and allowed my students to actively interact with the material system and concepts of electrocardiography. Through effective supervision, students’ were able to discuss their developing understanding and competences in carrying out electrocardiography procedure (Gaberson, 1999). During the lesson, my colleagues and I tried to reconstruct a situation which demanded the learner to act in the capacity of a nurse whereas another student acted as a patient and we tried to determine whether all standards of ECG procedure were met.

Models, Theories and Principles of Teaching and Learning

In teaching ECG procedure, five steps needed to be followed: identifying the goals and learning outcomes of ECG procedure, assessing the learning needs of students, planning ECG learning activities, guiding learners, and evaluating ECG learning and performance. However, this process was not linear; instead each of these steps influenced the others. For instance, my ECG procedure evaluation revealed data on further learning needs of the learners, which suggested the requirement of fresh learning activities. Similarly, working with students, resulted in observations on performance that altered assessment, thus, suggesting the need for different learning activities.

First, the session commenced by identifying the goals and outcomes of the ECG clinical experience. Teaching at this stage was formed of behavioral theories which addressed learning as being influenced by environmental manipulation.

This theory was carried into the classroom in a way that assisted in making learners understand the different aspects of ECG, the reasons for using ECG, emergencies which require ECG for diagnosis, how ECG is conducted in an emergency, and ECG recordings generally considered to be normal and abnormal. These learning goals and outcomes clearly provided areas of assessment, teaching guidelines, and the basis for evaluating learning. They were often expressed in the form of clinical objectives established for the entire teaching session, and specific clinical activities. Gaberson (1997) stated that learning objectives ‘may specify knowledge acquisition, development of values, and performance of psychomotor and technological skills.’

The ECG teaching objectives applied in my teaching addressed eight key areas of learning:

  • knowledge, concepts, and theories applicable to perform an ECG procedure
  • assessment, diagnoses, planning, and evaluation
  • psychomotor and technological skills
  • values related to patient care, families and communities
  • communication skills, ability to build interpersonal relationships, and skill in collaboration with others
  • leadership abilities, role behavior, and management care; accountability and responsibility on the part of the student
  • self development and continued learning

Guided by the significance of cognitive theories and the traditional approach in clinical teaching, a learning environment was designed in a way that provided students with opportunities to build mutual respect and support one another while they achieved competence in performing ECG procedure (Braunwauld, 1997). At this point I can say that not all of the tasks were carried out, in particular, we did not fully succeeded in teaching role behavior. One of the reasons is that students were not accustomed to such activities. Secondly, we should have explained their core duties in a more detailed manner.

The teaching strategy specified learning outcomes in terms of students’ competencies in demonstrating ECG procedure in full. They were able to acquire basic knowledge as to how to carry out electrocardiography procedures in an emergency situation. As postulated by Lippincott (2008), electrocardiography is one of the most essential and commonly used procedures to evaluate a cardiac arrest patient in an emergency circumstance (Braunwald, 1997). Through electrocardiography, the heart’s electrical functions can be displayed as a wave form. Electrocardiogram is able to monitor impulses moving through the conduction system of the heart producing electric currents that can be monitored on the body’s surface.

Normally, the electrodes attached to the skin can sense these electric currents and send them to an electrocardiogram; an instrument that produces a record of cardiac activity (Lippincott, 2008). At the outset of the lesson, my colleagues tried to explain these basics to the students. Certainly, many of them were already familiar with it. However, it seemed to us that we need to refresh their knowledge.

Furthermore, Braunwald (2008) states that electrocardiography can be used effectively in diagnosing several conditions of the heart. Nurses who encounter patients in emergency wards must have knowledge on the importance of electrocardiography procedure in a life saving situation. The responsibility of caring for patients with cardiovascular disorders cuts across every area of nursing practice. As a result, cardiovascular care is a rapidly growing area in nursing. Lippincott (2003) mentions cardiovascular care to be a dynamic field, with continued inventions of new diagnostic tests, new drugs and other treatments, and sophisticated monitoring equipment. Consequently, nurses need to keep up with these changing developments through relevant clinical education (Lippincott, 2008).

The students were able to demonstrate their specific abilities; and often reflected their proficiencies required to perform specific tasks on ECG procedure that I assigned them. Performance criteria were established to determine the level of learner competency in carrying out necessary ECG procedures. For instance: understanding the value of ECG in an emergency situation, assessing potential cases that require ECG attention, and interpreting the electrical activity of the heart and its recordings (Lippincott, 2008).

The Constructivism model provided me with a new vision of teaching. Students were allowed to participate in the clinical objectives and competences established for carrying out ECG procedure from simple to complex. This approach made it possible for learners to be prepared with substantive knowledge necessary for performing ECG procedure. It also created an environment where my students were able to think critically, practice ECG procedure reflectively, and collaborate in groups. Some of the outcomes were achieved by learners and I had to add others to meet individual learning needs and goals.

Student objectives were made flexible to the extent that they met essential ECG procedure objectives. Learning activities were directed by asking questions that provoked thought without interrogating them. Asking open ended questions about their thoughts and the rationale they applied for reaching at clinical decisions, enhanced the growth of their critical thinking skills. Queries were made to assess students’ grasp of relevant concepts and theories and how they were used in clinical practice (Bergum, 2003).

The key principles of constructivism were applied to create sessions which assisted students to graduate with their own ideas. For instance, they were assisted in openly sharing their ideas through discussion strategy during and after each learning session. They were free to vary their concepts whenever possible. This enabled them remember the key concepts of electrocardiography. Frequent assessments of the students enabled me evaluate their strengths and weaknesses. I conveniently asked and valued their interpretations of what they had learnt. Teaching plans were also varied effectively at some points to cope with the intelligence and cognitive abilities of students. What students provided as feedback, was not considered in a prejudiced manner; neither were judgmental comments (Brooks, 1993).

Secondly, an assessment was conducted on the learning needs of my students. The assessment was guided by cognitive theory which assisted in the formulation of appropriate objectives based on what the students had learnt. Teaching started at the level of the student. Therefore, assessments were performed based on; the present level of knowledge and skill of the students’, and other factors that may have influenced their achievement of the objectives. Data was collected to determine whether the students had the necessary knowledge and skills to carry out ECG procedure and complete the learning activities. The teacher’s assessment was important as it engaged learners in learning activities that developed their current knowledge and skills in ECG procedure competencies (Young, 2002).

Third, instruction was planned and delivered following the assessment of students’ learning needs. The plan for learning activities catered for clinical objectives and individual learner needs. Selected ECG learning activities met objectives for carrying out ECG procedure effectively. The learning activities included patient assignments where learners were engaged in a practical setting. Miranda (2005) contends that constructivism advocates for a curriculum that is related to learners’ prior knowledge and puts more emphasis on problem solving. Therefore, concentration focused on connecting between facts and fostering new understanding among learners.

They heavily depended on questions that were open-ended and encouraged dialogue between them. The Constructivist model had direct application in the ECG procedural setting, based on these facts. It centered on providing an overall approach that incorporated other theories and approaches, such as; experiential learning, reflection and problem based learning. It enabled me as the faculty to direct educational experiences to suit their clinical setting and provide learners with the opportunity to integrate their learning (Bradshaw, 2006). More so, it accorded learners responsibility to make sense of what goes on in an ECG clinical setting and motivated them to grow and nurture a deeper understanding of ECG procedure (Cobb, 1999).

Fourth, they were guided in achieving essential knowledge, skills and values for ECG practice through problem solving. Facilitation and support of the process enabled students to achieve the intended outcomes; guiding them with their learning activities. Demonstrations were made to learners and they were questioned to enhance their levels of understanding. As a skilled person in this practice, the teacher was able to: observe learners’ clinical performance, make sound judgment about their performance, plan extra learning activities when necessary, and question students without interrogating them. Observing learners as they performed the ECG learning activities enabled me to identify continued areas of learning and establish when help was needed (Gaberman, 1999).

The third session was conducted in a training class in the ECG room where learners were taught how ECG procedure is performed. They were provided with enough opportunities to perform electrocardiography procedure themselves. In collaboration with the technician on duty, learners were guided through the clinical practice. At the end of the session students were able to: examine the patient in the emergency room and understand the significance of ECG procedure in a life-saving scenario; perform an ECG as an initial step with patients who arrive with cardiovascular complications, chest pains or after an accident; interpret the electrical activity of the heart externally by using skin electrodes; and perform non-invasive procedures on patients (Lippincott, 2008).

Fifth, effective evaluation of clinical learning and performance was done on learners. The evaluation took two forms; formative and summative. Learners’ progress was monitored in regards to achieving clinical objectives through formative evaluation by way of a written examination. Demonstration of strategy was also used to ascertain their competency in clinical practice. Through formative evaluation strategies, it was possible to identify which students required additional learning and instruction, and in which areas this learning and instruction was required.

Recommendations for Improving Teaching Strategies Based on Feedback from Peer and Analysis of Literature

Based on the feedback received from peers and the analysis of the literature, the following recommendations to improve my future teaching sessions in the clinical environment were suggested. Firstly there was a need for identification of challenges learners are faced with. Comments made by my peers indicated that my teaching did not take into account the challenges the students faced. It was noted that the initial process of probing to understand my students was lacking. For instance, they may have been overburdened with family issues, language problems, financial problems, and many others. These factors impede effective clinical teaching as it heightens the fear nurses feel about making mistakes that could injure patients or even fail a program (O’Connor, 2001).

Secondly, extension of the possibilities for evaluation of learners’ performance in relation to teaching and learning objectives was also suggested. Ghazi (1988) noted that motivation for learners was sustained through strategies such as individualized learning, formative evaluations, and others. My teaching did not quite offer feedback in the areas of student strengths and potential areas of development for my students. Students were not given opportunities to evaluate their learning (O’Connor, 2001).

Thirdly, further research on effective characteristics of clinical teachers was also suggested. The analysis of related literature reveals that students judge effective teachers as those having characteristics such as being clinically competent, knowledgeable, good interpersonal relationships, and enthusiasm (Gaberman, 1999). Laurent (2001) contends that teachers, viewed by students as helpful, modeled competent behavior consistently and demonstrated a positive attitude and humanistic orientation. This will enhance responses to the needs of students.

Fourthly, collaborative planning of learning activities was suggested. It was felt that the teaching lacked this element. Learners are usually receptive to selecting from a variety of learning activities and contributing suggestions.

Finally, different methods of assessing clinical performance were recommended. Teaching strategies were limited to only a few methods of assessing clinical performance, such as discussions, lectures, question and answer, and rounds. Other important approaches involve role plays, case studies, group activities, and many others. More emphasis must be made on case management also.

Conclusion

In summary, there are minimum requirements for effective teaching and learning. These include the environment, dialogue and closure. Provision was accorded for sufficient lighting, ample seating arrangements and adequate audio-visual aids that enhanced an environment that was conducive for teaching and learning. Dialogue was conducted in a formal, clear, and logical way to ensure that students did not miss any part of it. At the end of the teaching session, sufficient time for discussion and clarifying doubts was allocated. A teaching summary was submitted at the end of the session. McTaggart (1997) contends that teaching must end with educators being in a position to submit a summary. Young (2002) also insisted that a teacher must be able to use proper teaching and learning principles in the three domains of cognitive, affective, and psychomotor.

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