Drawing for Retention in Emergency Medical Services Education Part 2: Impact on Student Learning

Participants

Fourteen students enrolled in an accredited Emergency Medical Care program in the Southeastern United States participated in this study. Inclusion criteria consisted of students who had completed a 12-lead electrocardiogram (ECG) course in the semester prior to the study. Exclusion criteria included individuals who were not enrolled in the ECG course in the prior semester, individuals who did not speak English, and individuals under 18 years old. Data saturation guided the number of participants. Participant demographics are in Table 1.

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Table 1.

Participant Demographics.

Participant pseudonym	Age	Gender
Luca	23	M
Cliff	22	M
Arthur	24	M
Kathleen	22	F
Charlie	22	F
Laura	24	F
Trey	23	M
Kyle	22	M
Davis	21	M
Mike	23	M
Mandy	23	F
Jed	23	M
Ruby	22	F
Austin	24	M

Procedures

Participants were recruited through purposive sampling. A recruitment email containing study information and consent form was sent to all paramedic students who took the ECG class in the previous semester. Paramedic students who were interested in participating signed up for an interview time. The co-PI contacted potential participants to confirm inclusion criteria, answer questions, and obtain consent. Using a semi-structured interview guide, (see appendix, Semi-Structured Interview Guide) participants completed an 45 to 60-min individual Zoom interview. Interviews were recorded and transcribed. Data collection concluded upon reaching saturation, when no new information emerged, and findings aligned. A detailed overview of how DfR was taught has been published elsewhere (Thrasher & Braithwaite, 2024).

Instrumentation

A semi-structured interview guide was created based on the research questions and prior research related to using drawing as a pedagogical technique in healthcare. The interview guide was validated by three experts in qualitative methods and educational research. Using a 4-point Likert scale (1 = unclear, not relevant, or not important; 4 = very clear, highly relevant, very important), peer reviewers rated each interview question for clarity, relevance, and importance. Reviewers also provided qualitative feedback. Two individuals participated in pilot testing to ensure clarity, timing, and question flow. Data from the pilot study were excluded from the final analysis.

Data Analysis and Trustworthiness

Data were analyzed through phenomenological reduction with iterative multi-analyst triangulation. Each member of the research team independently read through the transcripts to get a sense of the whole. On the second reading, the researchers reviewed five transcripts and met to discuss common themes and subthemes to develop a codebook. The researchers then independently coded remaining transcripts. Next, the researchers reviewed each other’s coded transcripts to ensure consistency. Any discrepancies were resolved through discussion until consensus was achieved.

Trustworthiness and credibility were established through multi-analyst triangulation, as described above, peer review, and narrative accuracy member checks. Following data analysis, three peer reviewers performed an external audit. Each peer reviewer received three random transcripts and the codebook. They ensured the themes and subthemes were reflective of the transcripts and meaningful units of data were coded. Finally, participants reviewed their transcripts for accuracy to ensure their transcript was reflective of their experience. No changes were needed following this process.

Perceptions of Learning

The first theme was perceptions of learning, which described how the participants felt about learning while using the DfR pedagogical technique. This theme is described in the following subthemes: making connections, retention, and study time.

Patient Care

Patient care describes the participants’ ability to apply content they learned through drawing to their patient cases during clinical education experiences. This theme is described in the following subthemes: facilitates diagnosis, confidence, resource, and patient education.

Perceptions of Learning

In healthcare education, incorporating drawing into learning activities can enhance pattern recognition and stimulate neural pathways, thereby improving comprehension and retention of complex medical concepts (Aisha et al., 2018). As students draw, they make spatial relationships and connections, which reinforces learning and aids in the development of diagnostic skills. Additionally, engaging in drawing activates various neural pathways associated with visual processing, motor control, and memory (Raimo et al., 2021). Drawing involves kinesthetic, visual, and spatial processes and engage multiple areas of the brain (Likova, 2012). Activating multiple areas promotes neuroplasticity, which allows the brain to reorganize itself and form new neural connections leading to memory. Our results demonstrated that participants were able to make connections effectively with drawing, which led to retention. When drawing, participants noted an enhanced ability to “see” relationships between concepts and connect the information to patient care (Lyon et al., 2013; Shapiro et al., 2020). Using DfR, there is a connection between drawn images and physiological processes. In similar studies, participants learning clinical etiologies used visual representations to enhance comprehension. Through drawing, concepts are reinforced, and connections are made by associating medical terminology with rehearsed concepts and images (Reid et al., 2020). In other courses, concepts often required rote memorization; however, through drawing, terms became linked to rehearsed visual representations, enhancing retention and comprehension (Mathon et al., 2021; Reid et al., 2020). This, in turn, enabled participants to apply their knowledge more effectively in clinical patient care (Cromley et al., 2020).

In addition to making connections, drawing helped participants retain the information, which is consistent with literature (Alkhaifi et al., 2022). Drawing helps students recall information as the images reinforced the connection between visual representation and memory retention (Backhouse et al., 2017; Balemans et al., 2016). Professional students often learn through rote memorization (Kwan & Mafe, 2016). One challenge with rote memorization is students often emphasize short-term retention and may not be as effective for long-term retention and lifelong learning (Azzam, 2021). Participants reported techniques of “memorization and regurgitation” for previous content was easily forgotten once an exam had been passed, whereas drawn images were retained after the exam, which is consistent with previous research (Cromley et al., 2020).

One specific impact noted by participants was the time required to study. Participants in classes that utilized drawing as the pedagogy felt they spent less time studying with understanding and retention. Drawing was an efficient way to prepare for exams, while they previously reported “cramming” was necessary to prepare for exams in memorization heavy classes. Our participants align with the findings of other researchers (Alkhaifi et al., 2022; Gheysens et al., 2017) in that less study time was needed because they were confident in their understanding and felt they retained information from class. Participants also feel this technique will lead to the recall necessary for application in patient care, not just exams.

In addition to being more efficient, participants also reported that studying through drawing was an enjoyable process, a finding consistent with existing literature (Borelli et al., 2018). Drawing helps to organize studying as they rehearse information the way they had initially learned. Initial time investment in learning and drawing was substantial; however, their required study time for exams was reduced (Cracolici et al., 2019).

Patient Care

Healthcare professionals, including paramedics, nurses, athletic trainers, and physicians, must apply complex theoretical concepts in real-world settings. Through patient interactions, they identify disease patterns and contribute to public health efforts across various environments. Often, a knowledge to practice gap exists (Welch Bacon et al., 2024), which can have a negative impact on patient care (Shoghi et al., 2019). Active learning strategies, such as simulation, are often used to help bridge the gap; however, due to the intricate nature of waveform analysis, not all content is suitable for simulation. For paramedics, reading and interpreting ECGs is a critical skill, and students must be comfortable interpreting minute changes in waveforms. In this study, participants felt repetitive drawing of waveforms enhanced their ability to recognize patterns, facilitating quicker and more automatic interpretation, which in turn supported more efficient diagnosis. The ability to rapidly and accurately interpret ECGs has an exponential impact on patient care (Antman, 2008). In healthcare, achieving automatic and efficient decision-making is essential for delivering high-quality patient care. This proficiency is developed through deliberate practice and experiential learning, which enhance cognitive processes and facilitate rapid, accurate clinical judgments (Corrao & Argano, 2022). Expertise in pattern recognition is developed through extensive experience and deliberate practice (Loveday et al., 2013). Our results showed that participants were able to recognize patterns with different conditions on 12-lead ECGs, since they had engaged in deliberate practice of drawing waveforms of various conditions. This allowed them to automate decision making, contributing to a faster diagnosis and plan of care. Previous research shows the ability to use pattern recognition distinguishes experts from less competent clinicians (Loveday et al., 2013).

The knowledge practice gap is also impacted by confidence, which plays a pivotal role in bridging this gap (Singh et al., 2024). When clinicians feel confident in their abilities, they are more likely to apply their knowledge effectively, leading to improved patient outcomes. Conversely, a lack of confidence can result in hesitation, errors, and suboptimal care. Therefore, fostering confidence through education and training is essential for closing the knowledge-practice gap. New clinicians often lack confidence in making decisions; however, as they make more decisions and get them correct, they develop confidence (Walker et al., 2016). Confidence is a noted theme in literature associated with drawing repetition (Ainsworth et al., 2011; Backhouse et al., 2017; Reid et al., 2020). Our participants developed initial confidence when they interpreted ECG readings correctly on examinations, but their confidence increased even more when they were correct during their clinical education experiences. Clinical education experiences, or internships, are essential preparation for real-world practice, where autonomous patient care is critical, and lives depend on their decisions. Consistent with findings in the literature, participants reported that their confidence developed rapidly when preceptors validated their accurate interpretations during patient encounters (Gheysens et al., 2017). Some participants relate stories where they were able to interpret an ECG faster and with greater accuracy and in more detail than more seasoned providers, which escalated their confidence. Confidence influences healthcare professionals’ ability to perform clinical tasks effectively and increased confidence is associated with improved competence and better patient care outcomes (Singh et al., 2024).

One distinct advantage of DfR is that the drawn images serve as a lasting resource, a benefit also recognized in existing literature with anatomy drawings (Pickering, 2015). In our study, participants reported carrying their self-created notebooks in clinical settings, using them as a reference to enhance their experience and practice. Initially, they used it as a reference and soon felt confident enough to interpret without using the images in the notebook. Participants also noted sharing the notebook with field preceptors who are practicing paramedics entrusted to training participants in field intern opportunities. Preceptors often asked to see the notebook, and some asked for copies, again boosting the confidence of participants. Using the drawings as a continued resource is not well explored in the literature, and based on our results, future research should explore how DfR can be used to create lasting resources for students and clinicians.

A surprising result that emerged was our participants’ description of using drawing and their notebooks while providing patient education. Often, patients want to learn more about their condition and current health situation so they can increase their health literacy be empowered to join the decision-making process (Bhattad & Pacifico, 2022). While providing care, participants reported using their notebooks or drawing on paper to illustrate and clarify a patient’s condition. This reliance on visual representation as a teaching tool is also supported in existing literature (Mavridis, 2013; Narayanan & Shankar, 2021). Not only can this enhance patient trust, but using drawing to explain a condition to patients strengthens rapport, demonstrates competence, and fosters positive outcomes for both patients and providers (Ainsworth et al., 2011; Alkhaifi et al., 2022; Fiorella & Kuhlmann, 2020). Providing patients with written materials and simple drawings can improve their comprehension of complex medical information, leading to better health outcomes (Bhattad & Pacifico, 2022).

Overall, participants felt DfR was valuable for their learning, helped bridge the knowledge-to-practice gap, and facilitated decision-making. However, perhaps the most profound benefit of DfR is that participants attributed their ability to save patients’ lives to the knowledge gained through drawing, which they effectively applied in clinical practice (Ainsworth et al., 2011; Mavridis, 2013).

Limitations and Future Research

As with any study, there are inherent limitations. This study focused on paramedic students; however, healthcare students across disciplines need learn and apply complex topics. Future research should explore perceptions of DfR across disciplines and topics. Additionally, this study did not address patient or preceptor perceptions of performance. While our participants noted improvements in clinical practice, decision-making, and confidence, this was not directly assessed. We did not measure time saved for interpretation of ECGs, we merely explored participant perceptions of clinical application. Future research should address clinical applications of DfR. This study was conducted in the final weeks of the participants’ paramedic program, and the clinical applications were specific to clinical education experiences. Longitudinal research should explore perceptions of practicing clinicians through their transition to independent practice.