Using Spaced Repetition Learning to Improve Rhythm Interpretation and Strip Documentation of New Graduate Nurses in Critical Care Units


The purpose of this project was to evaluate the effectiveness of spaced repetition learning to improve rhythm interpretation and documentation of rhythm strips in first year critical care nurses.


This was an evidence-based practice (EBP) project utilizing the Iowa Model of evidence-based practice, Kristen Swanson’s Theory of Caring and the learning theory of constructivism. Participants were new graduate nurses in critical care units of a large multiple hospital academic medical center. Three spaced education modules were the interventions developed sequential completion in a Learning Management System (LMS) on a biweekly basis after participants had completed the Rhythm Introduction Basics course. Smartsheets© automations was utilized to send notifications and reminders to participants and unit leadership regarding project inclusion and module completion. All participants received a post knowledge assessment with their results compared to the results of rhythm revalidation outcomes for established staff on the unit. Rhythm strip documentation audits were to be collected as part of normal expectations of a champion role in the units.


Rhythm identification accuracy scores for established staff were significantly higher than program participants confirming previous studies that demonstrate rhythm interpretation abilities decrease over time. There was not a statistically significant association with the use of spaced interval education and perception of rhythm documentation by participants however, there was an 8% increase in the percent of participants that agreed/strongly agreed they routinely observed their preceptors/colleagues documenting strips and a 12% increase in the percent of participants that agreed/strongly agreed they routinely document rhythm strips. Two-thirds or more of participants agreed the modules enabled them to use rhythm interpretation skills, reinforced rhythm strip documentation and the modules were a valuable learning experience. Audits of rhythm strip documentation were not consistently obtained by the Cardiac Monitor champions and were unable to be evaluated. Each micro module took less than 10 minutes per participant to complete resulting in an average of five dollars per new graduate nurse to complete.


The low accuracy of rhythm identification by participants is concerning yet reflective of many studies. Project participants had less experience than established staff. During the project, uncontrollable variables were many: COVID-19 surges, staffing strains and an organizational monitoring re-education initiative. Further examination of the rhythm strip documentation gaps revealed that 97% of staff demonstrated accurate understanding of rhythm strip documentation expectations. In discussion staff verbalized that easier access to methods of documentation would improve strip documentation. Low rhythm interpretation accuracy, positive staff reception, as well as the minimal time and costs involved in spaced repetition learning make this a viable option for reinforcing rhythm interpretation skills and unit leadership is in support of including this in developmental plans for new staff. Improving rhythm identification and documentation is an important part of patient assessment of the monitored patient providing critical data that is not easy to discern without measuring parameters. It may be interesting to explore if staff were to measure and document rhythm strips according to recommendations and policy, to what extent their rhythm identification skills would improve.