A Framework for the Development of an ECG Simulator
for Health Professionals






Tracy Paul Barill

Director and Trainer, Nursecom Educational Technologies

North Vancouver, British Columbia, Canada

(604) 988-5890






November 2000

©2000 Nursecom Educational Technologies






“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 learner’s 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 


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, Csikszentmihalyi’s Flow Theory and Bandura’s contributions in the areas of self-efficacy and human performance.

The Design, Development and Deployment of An ECG Simulator


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) Csikszentmihalyi’s Flow theory; 3) Bandura’s 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 leadership…is 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 innovation’s 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 innovation’s 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 innovation’s 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.


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 program’s 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 one’s 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 student’s 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 one’s capabilities for that specific task. If one’s 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 one’s 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 one’s mastery beliefs and lead to positive emotional connections with the activity of interpreting ECGs, particularly if the simulator was simple to operate. A simulator’s 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 customer’s 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 product’s 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 FAL’s 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


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 learner’s name in the message.


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 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 one’s 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 rhythm at the patient’s 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 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 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 simulator’s 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 innovation’s implementation (Godin, 2000).

The learner’s comments included “The CardiacSim offers a quick review. I feel as though I can now identify the rest of the rhythms that I don’t 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.


The ECG simulator is designed to enhance its rate of adoption by attending to Roger’s five aforementioned attributes of a successful innovation. The simulator’s 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 rhythm’s 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 Internet’s 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 learner’s 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 learner’s time.


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 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, Csikszentmihalyi’s Flow theory, Bandura’s 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.








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