A Framework for the Development of an Online ECG … · A Framework for the Development of an ECG Simulator for Health Professionals ... (ECG) interpretation. ... Making sense of

A Framework for the Development of an ECG Simulator

for Health Professionals

Tracy Paul Barill

Director and Trainer, Nursecom Educational Technologies

November 2000

2000 Nursecom Educational Technologies

Online ECG Training for the Free Agent Learner 2

Introduction

Make a better mousetrap, and the world will beat a path to your door.

Ralph Waldo Emerson

Within the education sector, private and corporate training accounts for $75 billion annually

and growing. Packer (2000) provides one explanation for this booming training industry: Changes in

technology, plus increased competition, fuel the demand for more education. Knowing how to learn

and adapt has become an invaluable skill (p. 41).

Many small training companies are entering this competitive training environment.

Competitive qualities such as imagination, speed, and a closer relationship with the learner strengthen

the positions of smaller training companies. The Internet is the great equalizer, providing an open

distribution channel for both the small and the mighty. The competitive edge is clearly with those

who offer products and services that are a best fit with the needs of the online learner.

The characteristics of the online learner may be evolving with the needs of the workplace.

Workers are now destined to experience several distinctly unique jobs through their lives. This trend,

together with a decade of downsizing, has prompted workers to increasingly focus on employability

rather than employment security (Short & Opengart, 2000, p. 60). Within this atmosphere, a new

type of learner is emerging, a free agent learner (FAL), defined as a learner who is engaged in self-

directed learning that is career specific and develops competencies that can promote employability

and career success (Packer, p. 41). The FAL wants easily accessible, fun, time-sensitive and

challenging learning opportunities (Martineau & Cartwright, 2000; Tapscott, 1998). Successful



deployment of online training activities to the FAL may also ensure a sellable product for corporate

customers.

Designing effective, efficient and engaging online training is the promised land of any

instructional designer (Milano & Ullius, 1998). In a competitive market, these features are vital yet

perhaps not enough. Attention to the deployment of training and the factors pertinent to the adoption

of each learning technology should also shape learning programs (Driscoll, 1999; Nielsen, 2000;

Rogers, 1995; Schrum & Berenfield, 1997; Surrey, 1999). With insight into the characteristics of the

free agent learner, training should be designed with a clear sense of the learners desire for rich,

contextually appropriate and time sensitive experiences (Csikszentmihalyi, 1990; Kearsley, 2000;

Surry, 1999).

Nursecom is a small training company that has entered the online training market. Committed

to satisfy the learning needs of health care professionals, Nursecom has provided programs in

advanced cardiac arrest management, dysrhythmia interpretation (The Six Second ECG), cardiac

physiology and emergency care. As a principal of this company and its primary trainer for the past

few years, I am recently involved in the instructional design, development and deployment of an

online training program in basic electrocardiogram (ECG) interpretation.

This paper presents the iterative process of instructional design and development of the online

Six Second ECG Simulator to its present point of completion. Particular focus is placed on the

literature and strategies used to develop a learning product for the free agent learner that is effective,

efficient, engaging, and utilized. As soon became evident with the instructional design of this online

training tool, the repurposing of course content the attempt to build a better mousetrap - was not

sufficient to realize success.



Instructional Design and Development of the ECG Simulator

Background

The Six Second ECG is an accredited basic dysrhythmia interpretation course held in a variety

of settings from Port Albernie, British Columbia to Iqualuit, Nunavut, Canada. The one and two day

instructor facilitated program has evolved since its inception eight years ago. Currently, The Six

Second ECG is designed with a high level of flexibility to conform to the immediate needs of the

prospective learners. The course is offered both to critical care health care professionals as a review

and to non-healthcare military personnel as an entry program.

Nursecom conducted a needs assessment, a performance analysis and a context/learner

analysis of health professionals in critical care settings. The continued need for effective training in

ECG interpretation is apparent. ECG training content should challenge the learner to correctly

diagnose dysrhythmias and to understand the clinical significance of each cardiac rhythm.

The context/learner analysis revealed several important characteristics of potential learners

and their environment. In keeping with the description of a free agent leaner, the learner is

exceptionally time conscious. Being an adult learner, the learner may be drawn towards learning that

is more experiential, that protects rather than threatens their self-esteem, and that problem solves

perceived real-world situations. The adult learner is often an independent learner, bringing past

experience continually into the realm of learning (Driscoll, 1998).

The knowledge and skill of dysrhythmia interpretation demands both a conceptual and a

procedural type of learning. ECG analysis is systematic. Making sense of the ECG rhythm requires a

solid conceptual base.



Earlier efforts developing online ECG programs were disappointing. The mantra

effective, efficient, engaging and utilized was not realized through the strategies implemented.

Heuristic and user evaluations confirmed that these ECG programs did not motivate the learner to

complete modules. After placing the online initiative on hold for a few months, researching further

literature sources and exploring successful online training initiatives, a new perspective began to

form.

These ECG training prototypes failed and would continue to fail despite revisions to their

interface. They were not engaging; nor were they readily utilized. The classroom course was re-

purposed into an online program without sufficient attention to the unique characteristics of the

online learner. In addition, the full potential of online technologies was not harnessed. Work towards

the implementation of the next prototype began based on: 1) successful deployment strategies of

other companies; 2) attention to time constraints of the learner; and 3) the combined influence of

Rogers Diffusion theory, Csikszentmihalyis Flow Theory and Banduras contributions in the areas

of self-efficacy and human performance.

The Design, Development and Deployment of An ECG Simulator

Overview

The first series of online training prototypes did not meet expectations. While much of the

literature in educational technology pointed to the benefits of online education and outlined a

prescriptive account of necessary online learning components, my experience with was less than

encouraging. Bolstering content with online technologies such as computer-mediated communication

does not in itself qualify as an engaging experience within the scope of the instructional objectives.



What components or parameters are necessary in an online training program to best promote the

utilization and the transfer of skills to the workplace? This is the crux of the matter.

Effective instructional designers seem to draw from a multitude of diverse fields to arrive at

an exceptional product that more than satisfies the needs of learners. i.e. learning theory,

communication theory, marketing, technology diffusion theory, change theory, play theory,

instructional design, human-interface design, human factors research, computer programming,

engineering, sociology, business management theory, neural physiology and psychology. While a

separate paper could address the contributions of each field of study, of particular importance in the

development of this online training prototype is: 1) Rogers Diffusion of Innovation theory;

2) Csikszentmihalyis Flow theory; 3) Banduras model linking the role of self-efficacy to human

performance; and 4) the influence of time as a separate parameter.

Diffusion of Innovations

Instructional technology is a field of innovation (Surry, 1998, p. 2). Online training

incorporates several innovations such as the Internet, web browsers, computer technology, newer

learning paradigms such as constructivism and computer-mediated communication. The diffusion of

technologies as innovations does not follow an expected trajectory. For example, the superior Beta

video format was beaten to extinction by the more convenient but technologically inferior VHS video

format (VHS could fit an entire movie on one tape whereas Beta often required two tapes). Benefits

of an innovation do not guarantee its adoption. Daniel Surry points out that adoption of an innovation,

far from being a spontaneous, hit and miss, mystical act, is, at least in theory, the result of a fairly

well defined, orderly process (p. 3). Whether an individual adopts or rejects an innovation is

dependent on a host of personal, social and technical factors (Farquhar & Surry, 1994; Norman, 1998;

Rogers, 1995; Surry, 1998; Zemke, 2000).



Everett M. Rogers is regarded as the eminent scholar in the field of diffusion theory. In the

fourth edition of his book Diffusion of Innovations, two distinct applications of diffusion theory are

applicable to the instructional design and development of the ECG simulator: 1) a broader insight of

the learner with regards to whether they are typically early or early majority adopters; and 2) the

characteristics of innovations that determine their rate of adoption (1995).

The rate of adoption of an innovation or technology often follows a Bell curve plotted with

the number of adopters over time. Diffusion research has parceled areas under the curve into groups

respective of the rate of adoption. Those first to adopt innovations are named innovators. Everett

describes innovators as having an obsession with innovations and technology. With the Internet, these

would be those who had Internet access in the first year of the World Wide Web. Early adopters are

those who adopt an innovation after the innovator. Socially, the early adopter is found to be a more

integrated part of the local social system than innovators [and] has the greatest degree of opinion

leadershipis considered by many as the individual to check with before using a new idea

(Rogers, 1995, p. 264). Innovators and early adopters account for a combined 16% of an innovations

potential market.

The early majority account for a third of potential adopters and typically are more cautious

about accepting new ideas and technologies. At the present growth of the Internet, most of those

online are considered part of the early majority. As a result, online training companies must cater to

this group, providing a product/service that meets or exceeds those already available in training

facilities. Advantages of the innovation must be clearly communicated and the friction common with

change should be minimized.

Closely tied to adopter categories are the attributes of an innovation and their influence on an

innovations rate of adoption. Rogers states, The perceived attributes of an innovation are one



important explanation of the rate of adoption of an innovation. From 49 to 87 percent of the variance

in adoption is explained by five attributes: relative advantage, compatibility, complexity,

trialability, and observability (1995, p. 206). A perceived relative advantage of an innovation

positively influences its rate of adoption. An innovations compatibility with existing practices fosters

rate of adoption. An innovations complexity is inversely related to its rate of adoption. Trialability,

the ability to try out an innovation before adopting, favorably influences rate of adoption. Finally,

observability can promote the rate of adoption by exposing others to a favorable innovation.

Once online training is perceived and respected as an innovation, diffusion theory provides

welcome direction to the qualities of the online training product. Since the market largely consists of

early majority adopters, a training program may benefit considerably from a design that is attentive to

the five attributes that influence rate of adoption. While the early adopters may be more willing to

overlook weaknesses of a product, the early majority will focus on an innovations compatibility,

trialability and level of complexity. By designing a training program according to these criteria, an

online training program is much more likely to be utilized by the learner.

Flow Theory

Don Tapscott claims that interactive learning is shifting for the free agent learner (FAL) from

learning as torture to learning as fun (1998, p. 147). Online training companies such as Ninth

House, Decision Architects and Corporate Gameware have built their training programs and their

businesses on entertaining, interactive learning games (Filipzcak, 1997). Marshall Jones, who has

studied computer games, believes that online training programs can benefit from the level of

engagement commanded by many computer games (1999).

From a business perspective, a learner who enjoys a learning experience will return again and

will feel obliged to share their experience from others. From the position as instructional designer,



learning concepts such as attention and retention are encouraged when learning is engaging and

enjoyable (Bandura, 1995). The question, then, is what conditions yield an enjoyable, memorable

experience? A decade of research by Mihaly Csikszentmihalyi resulted in a popular book called

Flow: The Psychology of Optimal Experience. While several psychological theories explain

enjoyment, Flow theory also provides guidance on how to create effective learning conditions for

Flow and enjoyment to occur.

Csikszentmihalyi believes that enjoyment is intimately related to learning, to increasing the

level of complexity in consciousness (growth) and to a sense of accomplishment. This sense of

optimal experience also seems to be cross-cultural. Enjoyment is associated with the presence of eight

major components:

1. we confront tasks we have a chance of completing

2. we must be able to concentrate on what we are doing

3. the task has clear goals

4. the task provides immediate feedback

5. one acts with a deep but effortless involvement that removes from awareness the

worries and frustrations of everyday life

6. people can exercise a sense of control over their actions

7. concern for the self disappears, yet paradoxically the sense of self emerges stronger

after the flow experience is over; and

8. the sense of the duration of time is altered; hours pass by in minutes, and minutes can

stretch out to seem like hours.

Flow, or experiential enjoyment, occurs when reading, playing sports, engaging in a chess game or

being challenged by a computer game for example.



Games are a natural fit with flow experiences. Clearly stated goals, the use of a variety of

skills, a time clock to prompt us to focus on the present, a sense of risk and rules that demand

complete involvement all seem to provide an ideal environment for an enjoyable, albeit challenging

experience (Pearce, 1998). Flow theory provides rationale for learning activities that are, or are not,

enjoyable. The first series of ECG training prototypes may have appealed to some learners but many

more would find them dry. Previous prototypes had clear goals and the means to accomplish the goals

but qualities such as learner control and program feedback was minimal.

Deciding on a simulator and game format for online ECG training follows directly from Flow

theory. By including features such as are outlined by Csikszentmihalyi within a learning environment,

the learner is more likely to enjoy the experience, retain knowledge through the experience, and share

the experience with others.

Self-Efficacy

Diffusion theory affected the efficiency and utility of the ECG Simulator. Flow theory helped

with its design, promoting a high level of engagement while indirectly strengthening the programs

effectiveness in facilitating knowledge acquisition and retention. Attention to the work of Albert

Bandura on self-efficacy offers much to increase the likelihood that the ECG training is successfully

implemented in the workplace.

Bandura, a learning theorist known for the Social Cognitive Theory of learning, sensed that a

key component was missing with his theory. Why were there significant disparities between learning

and subsequent performance? Bandura believed, as did Piaget, that learning was an inherent human

capability, even a human need. Learning, though, did not naturally lead to performance. In other

words, a person knew how to perform but chose not to perform. Bandura realized that this bridging

factor between learning and performance was not reinforcement as behaviorists claimed. Even with



substantial external or internal reinforcement, performance was often absent. Constructivism could

not explain this phenomenon adequately. Allowing for exploration and understanding on the part of

the learner and increasing probability of success with inclusion of suitable reinforcement did not

always result in improved or sustained performance. Bandura came to see this bridging factor as a

self-belief called self-efficacy.

Self-efficacy is defined as the belief in ones capabilities to organize and execute the

sources of action required to manage prospective situations (Bandura, 1986). Bandura and his

colleagues came to believe that how people behave can often be better predicted by their beliefs

about their capabilities than by what they are actually capable of accomplishing (Pajares, 2000).

Michael Jaffe describes self-efficacy:

Success raises efficacy self-evaluations and failure lowers them, especially if one is a novice

or at some early point in the learning sequence. Once established, enhanced self-efficacy tends

to generalize to other situations, though generalization effects occur most predictably in

activities that are most similar to those in which self-efficacy has been improved (1995).

Bandura (1999) and Pajares (2000) are quick to caution that self-efficacy pertains to a distinct task,

process or skill. Self-efficacy is not a personality trait. Thus, teaching must remain an individualized,

task-specific process with attention to self-efficacy important despite a students proficiency in other

domains.

Bandura proposes that there are four main influences on the development of self-efficacy:

Mastery beliefs: this is perhaps the most powerful and authentic determinant of self-

efficacy. Mastery beliefs result from successful or unsuccessful performances.

Performances that are successful lead to increased confidence in ones capabilities for that

specific task. If ones self-efficacy is directly related to whether one chooses to perform,



then one will choose to perform only those skills associated with some prior success

(Tripp, 1999);

Vicarious experiences: internalized beliefs based on observation of role models;

Social Persuasion: referred to as the weakest of all contributors to self-efficacy, verbal and

emotional coaching from others at least temporarily affects self-efficacy. Often, social

persuasion and appropriate reinforcement is an effective combination to initiate

performance. One or more acceptable experiences ensures sustained performance

(mastery);

Physiological and Emotional State: physical and emotional conditions such as anxiety,

anger, pain and pleasure will reduce or enhance self-efficacy (Jaffe, 1995).

Research into self-efficacy provides further insight into human performance. First, high self-efficacy

is strongly related to the effort one makes in accomplishing a task. Perhaps this explains why people

that are confident in their abilities work harder to completion (which then strengthens ones high self-

efficacy). Third, individuals with high self-efficacy persist in tasks longer to achieve successful

completion. Fourth, high self-efficacy is associated with stronger resilience. If people are more

influenced by their sense of self-efficacy than by their expectations of outcomes, significant attention

should be placed on the self-efficacy of learners.

An online training simulator could encourage ones mastery beliefs and lead to positive

emotional connections with the activity of interpreting ECGs, particularly if the simulator was simple

to operate. A simulators availability would be directly related to its ability to influence self-efficacy

through vicarious experiences or social persuasion. Human performance could theoretically be

enhanced by learning activities that were similar to the workplace while removing some of the

emotional behaviours such as anxiety. The concept of self-efficacy and its associate parameters point



to the potential effectiveness of an online simulator to facilitate successful interpretation of ECGs in

the workplace.

Time Parameters

Time permeates through virtually every decision, every design and every technology. Over

the past ten years, the Internet has helped to redefine acceptable time parameters. The term Internet

time has recently been coined to refer to the action/reaction cycle occurring almost instantaneously

(Grove 1999; Tapscott, 1996; Tapscott, 1998). Marketers, experts in identifying social trends, refer to

the attention economy (Drucker, 1999;Godin, 2000). Products and services that are designed to

account for a customers lack of available time have a distinct advantage.

Training and education is not immune to the influence of Internet time. A short decade ago,

training and education was offered as courses that ranged in duration from days to months with

specified start and finish dates. Today knowledge objects, anywhere/anytime learning modules, and

immediate automated performance evaluation are becoming the norm in a competitive learning

market. Surging training companies like Ninth House successfully utilize a business model that

provides short (less than 15 minutes) learning experiences online.

Seth Godin, a marketing guru, speaks of a products friction in the market (Godin, 2000). One

significant contributor to friction by most online training programs is the inordinate time demands

placed on the learner. The free agent learner wants to become knowledgeable and skilled in the

shortest period possible. An online learning program that is able to facilitate knowledge integration in

less than five minutes would fit well with the FALs expectations. Attention to time shaped much of

the design of the simulator and helped to revise the learning environment to one that is more efficient

than the first series of prototypes.



The ECG Simulator

Technology

A weakness of the first series of ECG training prototypes was their dependence on various

technologies such as dynamic HTML, JavaScript, and RealAudio that are not ubiquitous across all

web browsers. A suitable technology in the development and deployment of an online simulator for

most online learners was not available at the time that the first prototypes were released. Today, a

technology called Flash can replace the functionality offered by several tools with over 75% of web

browsers equipped with a Flash Player (Macromedia, 2000).

The ECG simulator was created with Flash 4.0 technology of Macromedia Inc. Flash is a

program generally used to create animated web pages. Two years ago, it released version 4.0 with

expanded features including the ability to create a high level of interactivity within a web page. Flash

has been bundled with both Internet Explorer and Netscape since their third generation releases. As a

result, Flash technology is almost ubiquitous for those accessing the Internet (Macromedia claims that

200 million Flash players have been distributed). Designed as a web-based multimedia development

tool, Flash applications can include text, graphics, sound, video and animations within a highly

interactive environment. Its vector-based graphics and advanced compression algorithm enables

developers to offer small applications sufficient to those with slower modems.

For the learner, Flash is often transparent. Learning applications reside within web pages. The

user may be prompted to download a newer version of Flash (i.e. Flash 5.0) if the application

warrants the functionality of the latest version. While the newest Flash 5.0 was available, the

simulator was released in Flash 4.0 to make the learning experience as smooth, frictionless and

simple as possible (Godin, 2000;Rogers, 1995). Sound was not included in the ECG simulator at this

point due to the existing diversity in the processing power of personal computers, with the



expectation that some computers would be heavily taxed with the use of sound as well. Applications

created in Flash also possess significant security features, protecting the integrity of the training

program for both the learner and the course developer.

Structure and Function

The ECG simulator took over three months and over fifty alpha versions to arrive at the beta

version released at the site http://www.skillstat.com/ECG_Sim.html. The simulator is 100k in size

and downloads through a 56k modem in about 8 seconds. Overall, the simulator functions as a

learning tool for learners who are novices with limited prior exposure to ECG interpretation.

The cardiac rhythm simulator begins with an introductory screen where the participant is

prompted to enter their name or nickname and then click Start. This introduction displays the

progress of downloading and also makes the experience more personal with later feedback that uses

the learners name in the message.


http://www.skillstat.com/6sECG_rdm.html


Figure 1. Welcome Screen

Upon clicking on Start, the next screen is displayed. This default screen is the learning mode

of the simulator. You can access either the Learn mode or the Game mode through the Option menu

title at the upper left corner of the screen. Note that the 'Start' button begins an animated sinus

tachycardia across a blank window. The Freeze button stops the rhythm and places a grid under the

rhythm for reference. For example, once frozen, the rhythm's intervals and rate can be quickly

determined. For a closer look, right click the mouse on the screen that you want magnified and

choose Zoom In. Note that resolution is not lost (the graphics are vector art rather than pixilated

images). To return to the original screen magnification, right-click again and choose Zoom Out, Show

All or 100%.



Figure 2. Display of the Learn mode.

Each rhythm named is a functional button that begins an animated cardiac rhythm of its namesake.

Note the blue box at the bottom of the screen. This is a reference window, providing brief details on

the characteristics and significance of each rhythm.

Choosing Game mode adds a few extra features to the interface. First, a time clock is docked

on the left side of the rhythm window and to the right is a scoreboard. Also find a Reset button that

begins the game anew with each click. The objective of the game or challenge is to correctly identify

as many rhythms as possible within a certain time frame. The Time menu offers three choices: one



minute, three minutes, and no limit to the time taken. The learner can choose a suitable time after

choosing Game mode for feedback at the end of the time frame chosen. Default time for a game is

one minute.

Figure 3. Display in Game mode. Note the time clock and scoreboard. Once the Start button is

clicked, the reference window disappears during the game.

In Game mode, the Freeze button will stop the rhythm and make visible the reference grid

(like Learn mode) but the time clock does not stop. After beginning the game by clicking on Start,

animated rhythms are generated randomly. Click on the appropriate rhythm name to identify the


Online ECG Training for the Free Agent Learner


19

rhythm. If the choice is correct, Correct is displayed below the rhythm names. A Correct stops the

clock. Click on Continue to continue the game and the clock. If the rhythm name chosen does not fit

the cardiac rhythm displayed, a Try Again will be displayed and the clock will continue.

If a time frame of one minute or three minutes were chosen, the game/challenge concludes at

the end of the respective time period. At the conclusion of the game, personal feedback is provided on

total attempts tried, percent correct, and the average time taken to correctly identify cardiac rhythms

along with a little personalized encouragement. Choosing Reset and then Start begins a new game.

Support is provided to the learner/user through the Help menu. The Help Index is a one-stop

web page to access various resources such as a selection of learning modules in ECG interpretation, a

quick guide to ECG interpretation, directions on using Flash and links to outside resources or the

course developer. Subsequent buttons of the drop menu allow for direct link to the respective web

page.

Time and the User-Interface

The simulator takes as little as two minutes to review ECG rhythms or assess ones

proficiency at ECG interpretation. This short time frame is in keeping with the available time of the

FAL. Time is used within the Game mode in a time clock to make the game a finite entity. By having

a time clock, learners are encouraged to fully immerse themselves in the learning/assessment activity.

Together with clearly stated game objectives and a high level of user control, the immersive nature of

the simulator potentially facilitates a state of flow or enjoyment for the learner/user.

With an activity that can be accomplished in less than a few minutes, the opportunities for

frequent visits increase. With frequent visits, learners are expected to be more successful at ECG

interpretation, thus fostering a sense of self-efficacy and the application of ECG interpretation skills

in the workplace. Note that the animated quality of the ECG simulator closely reflects an ECG



20

rhythm at the patients bedside. Realistic, repeated reinforcement promotes retention on the

knowledge and skills. The learners could cyclically assess their knowledge and knowledge gaps

(Game mode) then quickly address the knowledge gaps (Learn mode).

The interface was designed to be as simple as possible while allowing maximum

functionality. The design process strived to continually balance white space, functionality, and

simplicity to minimize complexity for the learner. By using virtually identical interfaces in Game

mode and Learn mode, the user was not required to learn a new interface. Colors were used to

highlight buttons (i.e. Start button is consistently red) and to categorize the ECG rhythms (i.e. all

ventricular rhythms are black). Flow theory, the concept of time, diffusion theory and self-efficacy

served as perceptual filters not only with the design of the interface but throughout the full iterative

process of the development of the ECG simulator.

Deployment

Deployment is an important component of instructional design and development. Instructional

designers should be mindful of the deployment strategies throughout all stages of design (Milano &

Ullius, 1998). Diffusion theory, with its description of the learner adoption qualities and the preferred

characteristics of an innovation with regards to its rate of adoption, supports deployment strategies.

The ECG simulator was created to be used. Therefore, attention to the five factors that affect rate of

adoption is vital.

The relevant advantage of the ECG simulator over the first prototype is inherent in many

features mentioned earlier. The ECG simulator closely approximates a learning program that is

efficient, effective and engaging. Pilot testing of the simulator to over sixty nurses and paramedics

yielded much insight into its design, weaknesses and strengths. While revisions are planned, the

majority of the feedback was very positive. Learners claimed to visit the simulator regularly, to be



21

able to navigate through both modes in less than a minute, to enjoy the experience and to quickly fill

in the gaps in their knowledge with regards to interpreting ECGs.

Simplicity, the opposite of complexity, was one of the main themes in the development of the

ECG simulator. Mention has already been made of the work towards a simple user interface. The

choosing of Flash 4.0 instead of the latest version favored simplicity of download. Within the web

site, access to the simulator is only two mouse clicks away. The ECG simulator is planned to expand

to include over 100 rhythms and additional features as a sellable product. By providing the basic

version, the user is able to quickly become familiar with the interface without the complexities of a

full-featured product.

The ECG simulators close resemblance to current practice enhances its rate of adoption. By

offering the simulator free, its trialability and observability are encouraged. The presence of a Share

Me button in the right upper corner enables the learner to quickly share the simulator with one or

more online colleagues. The potential dissemination by this method is exponential provided the

innovation does foster steady rates of adoption and minimal friction exists in the innovations

implementation (Godin, 2000).

The learners comments included The CardiacSim offers a quick review. I feel as though I

can now identify the rest of the rhythms that I dont see regularly. A useful tool. The ECG simulator

seems to foster a positive self-efficacy, a crucial criterion in the transfer of learning to performance in

the workplace. Other learners reported how time seemed to fly by, that they wanted to try and

better their game scores, and that the game was fun. Two learners challenged each other in a

competition for the highest accuracy of ECG interpretation and the greatest number of correctly

interpreted ECGs. All of these descriptors are in line with parameters of Flow.



22

The ECG simulator is designed to enhance its rate of adoption by attending to Rogers five

aforementioned attributes of a successful innovation. The simulators strength in creating an

engaging, positive learning experience support the direction provided by the literature with regards to

Flow theory and self-efficacy respectively.

The ECG simulator is currently in its beta version. Expected revisions include linking every

rhythms reference content with an online training module that provides sufficient depth for the

motivated learner. Each of the modules would include a smaller, tailored simulator to help the learner

retain and reinforce knowledge and skills. One of the Internets greatest strengths is in its ability to

deliver bits, connect with resources and share globally. It is this feature that is utilized in the ECG

simulator. The inclusion of a button within the interface to publish the learners score live on a web

site may be included if a new round of user testing proves this a desirable feature.

Additional challenging games will supplement the existing game. For example, the learner

could be challenged to identify other pertinent components of an ECG such as its relationship with

cardiac output, atrial kick, ST changes, myocardial ischemia and electrolyte imbalances. A separate

simulator to assess or reinforce each of these components could be developed. The full complement

of features could be included in a training program to be downloaded upon purchase. Each revision

would be designed based on principles of instructional design, diffusion theory, flow theory, and self-

efficacy with attention to the scarcity of the learners time.

Conclusion

Recently, Nursecom launched an initiative to augment its training programs with online

training programs and online learning tools. The first training program to be available online is The

Six Second ECG, a course in electrocardiogram interpretation. One hurdle facing Nursecom was to



23

provide an online learning program that was effective, efficient and engaging within the technological

constraints of the Internet. The second hurdle was facilitating the adoption of this training innovation.

Over the past few years, several prototypes were developed. The latest prototype benefited

from the failures of earlier ones together with new insight into what factors may be significant in

developing an online training program that is efficient, effective, engaging, and utilized. The

influence of Rogers Diffusion theory, Csikszentmihalyis Flow theory, Banduras work linking self-

efficacy with human performance and the important parameter of time have all provided a complex,

non-linear lens to viewing instructional design. The ECG simulator reflects a culmination of these

four factors together with the countless contributions of other fields of study towards exemplary

instructional design.

Several questions remain. From a training standpoint, are learning tools ideal for the FAL?

Are modular text and graphic learning environments a match for the career-focused professional?

Would the typical online training module benefit from the inclusion of a selection of learning games

or other engaging activities?

The ECG Simulator has enjoyed a favorable reception as a standalone learning tool and as a

technology to support the classroom workshop, The Six Second ECG. Nursecom may have found its

unique selling position: create training experiences that are effective, efficient, engaging and utilized

for the free agent learner.



24



25

References

Bandura, A. (1999). Self-Efficacy: The Exercise of Control. Freeman: New York

Beer, V. (2000). The Web Learning Fieldbook: Using the World Wide Web to Build

Workplace Learning Environments. San Francisco: Jossey-Bass Pfeiffer.

Csikszentmihalyi, M. (1990). Flow: The Psychology of Optimal Experience. New York:

Harper & Row. Dick, W. & Carey, L. (1996). The Systematic Design of Instruction (4th ed.). New York: HarperCollins Publishers.

Driscoll, M. (1998). Web-Based Training: Using Technology to Design Adult Learning

Experiences. San Francisco: Jossey-Bass Pfeiffer.

Drucker, P.F. (1999). Management Challenges of the 21st Century. New York: Harper

Business.

Equity Research (2000). Corporate e-Learning: Exploring a New Frontier. [Online]. Available

at http:///www.internettime.com.

Farquhar, J. & Surry, D. (1994). Adoption Analysis: An Additional Tool for Instructional

Developers. Education and Training Technology International, 31 (1), 19-25.

Filipzcak, B. (1997). Training Gets Doomed. Training, 38, 24-34.

Fister, S. (1999). CBT Fun and Games. Training Magazine, 36, 68-73.

Fosnot, C. (1996). Constructivism: Theory, Perspectives, and Applications. Townsend: Chicago.

Godin, S. (2000). Ideavirus. [Online]. Available at http:// www.ideavirus.com.

Gilbert, L. & Moore, D.. (1998). Building Interactivity into Web Courses: Tools for Social and Instructional Interaction. Educational Technology, 29-35.

http:///www.internettime.comhttp://www.ideavirus.com/



26

Grove, A. (1999). Only the Paranoid Survive: How to Exploit the Crisis Points That Challenge Every Company. New York: Bantam Books. Hall, B. (1997). Web-Based Training Cookbook. Toronto: Wiley Computer Publishing.

Jaffe, M.J. (1995). Media Interactivity, Cognitive Flexibility, and Self-Efficacy. [Online] http://research.haifa.ac.il/~jmjaffe/Dissert/. Jones, M. (1998). Creating Electronic Learning Environments: Games, Flow, and The User Interface. In Proceedings of Selected Research and Development Presentations at the National Convention of the Association for Educational Communications and Technology. Presented in St. Louis, MO, February 18-22, 1998

Kearsley, G. (1998). Social Learning Theory. [Online]

http://www.gwu.edu/~tip/bandura.html. Kemp, J., Morrison, G. & Ross, S. (1996). Designing Effective Instruction (2nd ed.). Columbus, Ohio: Prentice Hall. Khan, B. (1998). Web-Based Instruction (WBI): What Is It and Why Is It?. In B. Khan (Ed.), Web-Based Instruction (pp. 5-18). Englewood Cliffs, New Jersey: Educational Technology Publications. Kristoff, R. & Satran, A. (1995). Interactivity by Design. Mountain View, California: Adobe Press.

Landauer, T. K. (1996). The Trouble with Computers: Usefulness, Usability, and

Productivity. Cambridge, Massachusetts: MIT Press.

Lee, S.H. & Boling, E. (1999). Screen Design Guidelines for Motivation in Interactive

Multimedia Instruction: A Survey and Framework for Designers. Educational Technology, 19-26.

http://research.haifa.ac.il/~jmjaffe/Dissert/http://www.gwu.edu/~tip/bandura.html



27

Macromedia Inc. (2000) Macromedia Shockwave and Flash Player Adoption Statistics. [Online]. Available at http://www.macromedia.com/software/player_census/ .

Martineau, J. & Cartwright, T. (2000). FALs: Friend or Foe?. Training & Development, 54,

40-55. Milano, M. & Ullius, D. (1998). Designing Powerful Training: The Sequential-Iterative Model. San Francisco: Jossey-Bass Pfeiffer. Negroponte, N. (1995). Being Digital. New York: Alfred A. Knopf. Nielsen, J. (2000). Designing Web Usability. Indianapolis, Indiana: New Riders Publishing. Norman, D. (1998). The Life Cycle of a Technology: Why Is It So Difficult for Large Companies to Innovate. [Online] Available at http://www.jnd.org/dn.mss/life_cycle_of_techno.html.

Packer, A. (2000). Getting to Know the Employee of the Future. Training & Development, 54, 39-43.

Pajares, F. (2000). Schooling in America: Myths, Mixed Messages, and Good Intentions (Great Teacher Lecture Series). [Online] Available at http://www.emory.edu/EDUCATION/mfp/GreatTeacherLecture.html.

Pajares, F. (1999). Albert Bandura: Biographical Sketch. [Online] Available at

http://www.emory.edu/EDUCATION/mfp/bandurabio.html.

Pajares, F. (1996). Current Directions in Self Research: Self-Efficacy (Annual Meeting of the

American Educational Research Association, New York, April, 1996). [Online] Available at

http://www.emory.edu/EDUCATION/mfp/aera1.html.

Pearce, C. (1997). The Interactive Book. Indianapolis, Indiana: MacMillan Technical Publishing.

http://www.ideavirus.com/http://www.jnd.org/dn.mss/life_cycle_of_techno.htmlhttp://www.emory.edu/EDUCATION/mfp/GreatTeacherLecture.htmlhttp://www.emory.edu/EDUCATION/mfp/bandurabio.htmlhttp://www.emory.edu/EDUCATION/mfp/aera1.html



28

Rieber, L. (1996). Seriously Considering Play: Designing Interactive Learning Environments

Based on the Blending of Microworlds, Simulations, and Games. Educational Technology Research

and Development, 44, 43-58.

Rogers, E. M. (1995). Diffusion of Innovations. 4th ed. Toronto: The Free Press. Romiszowski, A. (1997). Web-Based Distance Learning and Teaching: Revolutionary Invention or Reaction to Necessity? In B. Khan (Ed.), Web-Based Instruction (pp. 25-40). Englewood Cliffs, New Jersey: Educational Technology Publications. Rothwell, W. & Kazanas, H. (1998). Mastering the Instructional Design Process. 2nd ed. San Francisco: Jossey-Bass Publishers. Schrum, L. & Berenfield, B. (1997). Teaching and Learning in the Information Age: A Guide to Educational Telecommunications. Toronto: Allyn and Bacon.

Short, D. & Opengart, R. (2000). FALs: Friend or Foe?. Training & Development, 54, 60-63.

Squires, D.(1999). Educational Software for Constructivist Learning Environments:

Subversive Use and Volatile Design. Educational Technology, 48-53.

Surry, D. (1998). Diffusion of Instructional Innovations: Five Important Unexplored Questions. Evaluative Reports, 142, 1-17.

Tapscott, D., Lowy, A. & Ticoll, D.. (1998). Blueprint to the Digital Economy: Creating

Wealth in the Era of E-Business. Toronto: McGraw-Hill.

Tapscott, D. (1998). Growing Up Digital: The Rise of the Net Generation. Toronto: McGraw-

Hill.

Tennyson, R. & Nielsen, M. (1998). Complexity Theory: Inclusion of the Affective Domain

in an Interactive Learning Model for Instructional Design. Educational Technology, 7-12.



29

Tripp, M. (1999). Perspectives on the Development and Influence of Self-Efficacy Beliefs.

[Online] Available at http://www.umm.maine.edu/BEX/students/MarkTripp/mt310.html.

Waters, C. (1996). Web Concept & Design. Indianapolis: New Riders Publishing.

Zemke, R. (2000). How Change Really Happens. Training, 37 (10), 122-126.

http://www.umm.maine.edu/BEX/students/MarkTripp/mt310.html

A Framework for the Development of an ECG Simulator for Health ProfessionalsTracy Paul Barill

IntroductionInstructional Design and Development of the ECG SimulatorBackgroundThe Design, Development and Deployment of An ECG SimulatorOverviewDiffusion of InnovationsFlow TheorySelf-EfficacyTime Parameters

The ECG SimulatorTechnologyStructure and FunctionTime and the User-InterfaceDeployment

Conclusion

Documents

A Framework for the Development of an Online ECG … · A Framework for the Development of an ECG Simulator for Health Professionals ... (ECG) interpretation. ... Making sense of