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The Importance of Repetition in Education and Competency in the Critical Care Setting

This blog post was written by Emily Rice, BSN, RN, CCRN-CMC, critical care nurse with experience precepting new nurses at a large Level I Trauma Center prior to her current role in travel nursing.

The ventilator alarms, the flashing monitors, and the crash carts in the hallway—I soaked

it all in as I stepped onto the unit for my first day in the Cardiothoracic Intensive Care Unit (CTICU). I was finally where I'd dreamt of being throughout nursing school. With a little over a year and a half of experience in the Coronary Care Stepdown Unit, I was motivated and ready to take on this new beast at one of the largest, high-acuity hospitals in my home state. That was, until report started and the unfamiliar words started flying. "Patient had a CABG x4 complicated by a graft failure with a re-sternotomy 2 days later." Furious scribbling. My preceptor sat quietly, listening and nodding. The words. Why didn’t I recognize any of them? "Patient has a CorPak with Vital HP running at a goal rate of 50 with q6 hour 100 mL flushes. WHAT?! More furious scribbling. Why wasn’t she writing anything down? "Swan in the right IJ, measuring at 67. CI has been hovering around 2.4 – 2.8." Pen down; I didn’t even know where to write this information on my report sheet. I felt a flood of anxiety wash over me. How am I ever going to know all of this? I’m going to be about as useful as an inflatable dartboard today. And in all honesty, that was a fairly accurate prediction.

As time passed, I began to understand. I took a multitude of scheduled training courses

during the remainder of my orientation—a pulmonary artery catheter class, an intra-aortic

balloon pump class, an emergent ventricular assist device (VAD)/extracorporeal membrane oxygenation (ECMO) class—and the dots began to connect. Fast forward nine months, and I was the one giving a lightning-speed report using the fancy lingo that had run me into the ground just nearly a year ago. Still, with each new device alarm I had to troubleshoot, I found myself with those same feelings of anxiety. Why can’t I remember what this means? Will my patient be okay while I figure this out? How do I fix this? It made me think just how valuable it would be to have the opportunity to take refresher courses in order to solidify the mountain of information I’d learned during orientation. I continued on, studying for and passing the CCRN examination, which helped me learn my hemodynamics inside and out, forward and backward. I was trained on every device, earned my CMC certification, and even began precepting new Intensive Care Unit (ICU) nurses. Soon after, I stepped out into the world of travel nursing. All the knowledge I’d gathered gave me the confidence to enter a new facility, complete one to two days of training, and begin working independently with critical patients. Despite this progress, that first-day feeling has stayed with me throughout my career. It has enabled me to realize the importance of repetition in learning and perfecting a skill set, and in developing confidence to recognize and manage a rapidly changing clinical situation.

Nurse educators have the ability to advocate for both patients and clinical staff by

offering additional opportunities for training after the initial orientation period, in turn fostering a culture of growth, safety, and competence. Neuroscientific studies have shown that when information and skills are learned through repetition, they are retained and recalled for longer periods of time (Zhan et al., 2018). Consider the importance of recalling what to do when an Impella placement signal falls flat, or when the continuous renal replacement therapy (CRRT) machine stops flowing due to a critical alarm and there are mere minutes until the filter clots. In the first instance of these issues, another nurse may find themselves plagued with those same feelings of stress that I experienced during my adjustment period to a high-acuity environment. By the third, fourth, or even fifth time, the nurse will know exactly what to do to efficiently and effectively manage the situation. Alternatively, rural facilities may only see certain devices once or twice per year. For example, caring for a patient who needs long-term VAD support in the community can be a beneficial learning experience, but what happens when a similar clinical scenario doesn’t arise again for another one to two years after the patient is discharged?

The concept of "spaced out learning" suggests that revisiting learned information over

time results in improved long-term learning and memorization when compared to massed repetition (Kang, 2016). An example of this is yearly competency evaluations; training requirements that are often mandatory at facilities to ensure that staff have received adequate exposure to medical support devices, procedures, and clinical scenarios throughout the year to provide safe, evidence-based patient care. Although annual competency training often elicits a collective groan among nursing staff, low levels of self-perceived competency can influence the quality of care delivered and negatively impact job satisfaction while increasing occupational resignation. Conversely, a feeling of competence improves self-confidence and decreases incidences of staff burnout (Afshar et al., 2020). Working in any ICU demands a high level of attention to detail, the ability to think critically, and the retention of large volumes of information regarding different aspects of critical care and its patient population.

In this current climate of healthcare, we're seeing patient care suffer as the ripple effects

of inadequate staffing and inadequate training besieges hospitals. With patient acuity increasing each day, it's important to have staff members able to display competence and confidence when providing care to critically ill patients. Nurse educators play a vital role in patient safety and staff improvement, and implementing these learning strategies can have a profound impact on positive outcomes and staff satisfaction in the clinical setting.


Afshar, M., Sadhegi-Gandomani, H., & Masoudi Alavi, N. (2020). A study on improving

nursing clinical competencies in a surgical department: A participatorion research.

Nursing Open, 7(5), 901-1268. https://doi.org/10.1002/nop2.485

Kang, S. (2016). Spaced repetition promotes efficient and effective learning: Policy implications for instruction. Policy Insights from the Behavioral and Brain Sciences, 3(1). https://doi.org/10.1177/2372732215624708

Zhan, L., Guo, D., Chen, G., & Yang, J. (2018). Effects of repetition learning on associative recognition over time: Role of the hippocampus and prefrontal cortex. Frontiers in Human Neuroscience, 12, 277. https://doi.org/10.3389/fnhum.2018.00277


Guest Blogger

Emily Rice

Emily is a Michigan born, Texas-transplanted registered nurse who earned her Bachelor of

Science in Nursing from Baker College in Michigan, USA. She has been working in cardiac critical care for three years, and is an active member of the American Association of Critical Care Nurses (AACN). She is currently travel nursing and previously served as a nurse preceptor to new ICU nurses during her time at Spectrum Health, a Level I Trauma Center in Michigan. In her free time, Emily enjoys snowboarding, volunteering, reading, and finding new restaurant experiences.