Abstract

Mnemonics (or memory aids) have been used in education and have shifted in popularity in their use over time. They have been criticised in the educational literature for being a surface learning tool. Although there is literature extoling their virtue as a memory recall device. Their use in medical education is documented and there is some literature in nursing education surrounding the use of acronyms (mostly first letter mnemonics). However, this is largely related to passing over information (handovers) rather than vital clinical information. Mnemonic use is documented in public health initiatives (Act FAST for stroke recognition, Back-2-Sleep for sudden infant death) aimed to permeate the public consciousness. Research surrounding mnemonics in nursing focuses on professional discussion articles, with a dearth of primary research within the discipline. This study challenges the orthodoxy surrounding mnemonics from their use in education, to wider nursing and public health patient safety messaging by exploring the factors that influence student nurses’ knowledge retrieval using mnemonics.
Cognitive load theory indicates that extrinsic loading of background “noise” or lack of attention can affect memory and in clinical practice, this can have fatal consequences. Selective attention theory is paramount if recognition of patient deterioration is to be timely. Within healthcare, there is an increasing focus on sepsis as a life-threatening illness, with high rates of morbidity and mortality. The challenges of early recognition and response are well documented. Human factors have highlighted that clinical decision-making relies not only on early warning scores and sepsis care bundles but also on attention to important situational “flags”, which are often missed by staff in key positions who could intervene early in the sepsis trajectory. Staff who are placed in this clinical situation are often students or healthcare assistants, charged with recording clinical observations and recognising deterioration. Educational and healthcare literature has suggested that the use of mnemonic devices as a memory aid may assist in the retrieval of clinical information in such time-critical clinical situations.
Aim
This study explores the factors associated with the retrieval of clinical information and mnemonic devices among student nurses.
Method
The underpinning philosophical approach to this study was pragmatism as defined by Dewey (1903), as a ‘real world’ understanding of the research in both educational and clinical settings was required. A mixed methods sequential design was used to gather data from a sample of 47 undergraduate student nurses on their Masters of Nursing programme, from the three branches (adult, mental health and child). The quantitative part of the study used an Objectively Structured Clinical Examination (OSCE) scoring tool to gather data at three time points: pre-examination, during the OSCE examination and 12 months post-examination. The scoring tool consisted of questions surrounding sepsis recognition, the use of a sepsis mnemonic (O2 FLUID) based on the sepsis six care bundles and a ROME mnemonic (respiratory blood gases). The ROME mnemonic was used as a control, as this was not part of the students’ taught module content. This data was used to inform the design of semi-structured interviews for the qualitative part of the study. Semi-structured interviews took place with nine participants from the Masters of Nursing programme, exploring the use and influence of mnemonics in clinical practice and on students’ professional development and their own learning.
Results
A number of statistical tests were used to analyse the quantitative results, indicating that the use of the O2 FLUID mnemonic shows higher retrieval during the OSCE examination and remains high 12 months later (for mnemonic word usage). The use of the ROME mnemonic shows poor retrieval across the three time points. Retrieval of the full O2 FLUID mnemonic was highest during the OSCE examination phase of data collection. The total knowledge scores in relation to sepsis dropping by over half at the last stage of data collection. However, the words representing each letter of the O2 FLUID mnemonic show higher retrieval levels than the first letter of the mnemonic or the details associated with it of how to undertake treatment. This is an unusual finding for a first letter mnemonic. Hierarchical cluster analysis tests revealed that science-based undergraduate degrees are a significant cluster. Clinical placements, specifically medical, surgical and paediatric placements also appeared to be a significant cluster. Within these placements, exposure to the O2 FLUID mnemonic is higher, due to the sepsis care bundles / treatment associated with its use in an acute sepsis management situation. For the qualitative strand, the semi-structured interviews were transcribed, coded, categorised and themed using thematic analysis. Three main themes emerged prior mnemonic use; the significance of the mnemonics to learning; and the role of visual learning in mnemonic use and development.
Conclusions
The findings indicate that a number of factors influence the retrieval of vital clinical information. This study found that many students valued mnemonics as active learning tools and strategies to develop their future learning and practice. Nursing students who had prior experience of mnemonic use value this learning tool. In addition, some students spoke of seeing previous septic patients they had cared for in their “mind’s eye” and used this memory as a “trigger” or “hook” when using the O2 FLUID mnemonic. However, not all students had such a memory. Therefore, this thesis recommends that instructional design for simulated mnemonics may be used as a framework to support future learning and rethinking of how mnemonics could be taught with nursing students. Future research may focus these findings more broadly in higher education contexts. The findings and reviewed literature suggest that mnemonics are a multi-dimensional learning tool, often used in a unidimensional manner. The proposed design framework is an amalgamation of simulation, metacognition, cognitive load theory and selective attention theory, encompassed in an instructional design approach. This could provide students with a facilitated “memory palace” based on a chosen mnemonic. Thus gifting students with a learning tool/ mnemonic device which can be used not only to pass summative examinations but to save lives, by maximising accurate and timely recall of vital clinical information in clinical settings.