2.2.1 Phenomenological design and theoretical framework.

The study employed a qualitative phenomenological design informed by van Manen’s interpretive phenomenological framework [16], which emphasizes hermeneutic understanding and articulation of essential meanings within “lifeworld” experiences. Tanner’s clinical judgment model [14] structured the interview guide around the “noticing-interpreting-responding-reflecting” continuum; its application to thematic organization occurred after inductive coding reached stabilization. The primary investigator, a female clinical educator with qualitative research training and NVivo proficiency, conducted all interviews. The semi-structured interview guide underwent review by two qualitative research experts and pilot testing to ensure question clarity and logical sequencing, with wording adjustments based on pilot feedback, adhering to established standards for reporting qualitative research [17].

2.2.2 Reflexivity and positionality.

The primary investigator’s concurrent role as RCDP implementer and interviewer necessitated attention to positionality and reflexivity throughout the study. Her programmatic investment as a clinical educator generated an a priori assumption of positive RCDP outcomes, carrying potential to shape both data collection and interpretive judgment. To bracket this preconception [18], a reflexive journal was maintained throughout data collection and analysis, documenting interpretive inclinations, emotional responses, and the reasoning underlying analytical decisions; entries were periodically reviewed to identify assumptions warranting suspension prior to subsequent interviews and coding cycles.

At the interview level, all questions employed open-ended, non-directive phrasing to minimize confirmatory framing and socially desirable responding. Prior to each interview, the investigator clarified her researcher identity and study objectives, distinguishing her investigative role from her implementation role and emphasizing voluntary participation unrelated to performance evaluation. Analytically, peer debriefing with co-authors provided critical examination of emerging thematic interpretations and challenge to potentially biased conclusions. This combination of reflexive documentation, procedural transparency, and collaborative scrutiny constitutes the primary mechanisms through which the trustworthiness of the data and interpretations was pursued [19].

2.2.3 RCDP intervention protocol.

Referencing the RCDP framework described in Tang et al. [20], a three-phase, station-based RCDP training program targeting ECG monitoring competency in CCU nursing was designed and implemented. In Phase 1, informed by expert consensus, clinical guidelines, evidence summaries, and institutional competency standards, ECG interpretation and emergency response competencies were structured into four training stations: rhythm identification and rate calculation; waveform morphology analysis of P wave configuration, QRS complex characteristics, and ST-T segment evaluation; arrhythmia classification and clinical significance assessment; and emergency response decision-making with interdisciplinary communication. In Phase 2, station-specific performance objectives were established per institutional competency criteria, with nurses engaging in repeated deliberate practice under assessor observation; immediate corrective feedback was delivered via the pause-coach-resume mechanism until each objective was achieved. In Phase 3, clinical case scenarios were embedded at each station; following foundational proficiency, complexity was progressively escalated through atypical ECG presentations and multi-task clinical scenarios, with time constraints and accuracy thresholds introduced to facilitate transition toward advanced clinical judgment.

3.2.1 Fragmented data perception.

Prior to RCDP implementation, participants demonstrated predominantly reactive and fragmented approaches to electrocardiographic monitoring that prioritized isolated numerical parameters over comprehensive clinical assessment. Participants described mechanistically focused attention on discrete monitoring elements: “Before, when I heard an alarm, my first reaction was to see which patient’s bed it was and then rush over to look at the numbers on the monitor” (P1, Charge Nurse).

3.2.2 Holistic pattern perception.

Following RCDP training, participants described a perceived transformation toward holistic pattern recognition that integrated multiple electrocardiographic elements into comprehensive clinical assessments, emphasizing overall rhythm characteristics and morphological patterns rather than isolated parametric values. Participants reported enhanced pattern recognition capabilities: “Now, when identifying an ECG abnormality, the first thing I ‘latch onto’ is no longer a single waveform, but the overall ‘rhythm’ and ‘waveform characteristics’ of the entire ECG” (P1, Charge Nurse).

Taken together, the perceptual shifts described across this theme carry meaningful implications for clinical attentiveness. Participants’ accounts suggest a reorientation of clinical gaze from the monitor as a terminal data source toward the monitor as a window onto the patient’s physiological state, reflecting a movement toward patient-centered interpretation in which rhythm recognition becomes inseparable from broader clinical awareness.

3.3.1 Mechanical matching and authority reliance.

Participants initially employed cognitive approaches characterized by rigid textbook pattern adherence and excessive dependence on senior colleagues for clinical decision-making, creating persistent uncertainty when confronting atypical presentations. Nurses described inflexible cognitive processes as pattern-matching exercises failing to accommodate clinical complexity: “My way of looking at an ECG was very mechanical, just matching it to textbook knowledge” (P3, Staff Nurse).

3.3.2 Training breakthrough moments.

During RCDP implementation, participants experienced distinct cognitive breakthrough moments facilitating transitions from mechanical rule application toward integrated clinical reasoning. These transformative experiences involved sudden recognition of previously overlooked clinical details: “When I shifted my attention from individual waves to the overall rhythm...I suddenly noticed a detail I had never seen before...At that moment, I felt the whole ECG ‘came alive’ before my eyes” (P1, Charge Nurse). These moments represented critical junctures at which participants began developing authentic clinical insight beyond superficial pattern recognition.

3.3.3 Integrating intuition and evidence.

Post-training, participants described cognitive models demonstrating sophisticated integration of intuitive pattern recognition with systematic evidence validation. Participants described balanced cognitive frameworks combining immediate impressions with systematic confirmation: “Now, when identifying an ECG abnormality, the first thing I ‘latch onto’ is an ‘intuitive judgment’ backed by ‘detailed confirmation’” (P8, CCU Specialist Nurse).

Considered across sub-themes, the cognitive evolution participants described reflects a qualitative transformation in clinical reasoning style that extends beyond technical competency. The movement from textbook matching toward intuition-anchored, evidence-confirmed judgment suggests a reported capacity to navigate clinical ambiguity with greater flexibility, experienced by participants not merely as skill acquisition but as a reconceptualization of what it means to interpret an electrocardiogram in a critical care context.

3.4.1 Hesitant and reactive responses.

Prior to RCDP training, participants demonstrated response patterns characterized by uncertainty, anxiety, and reactive behaviors reflecting insufficient clinical confidence and limited autonomous decision-making capabilities. Nurses experienced significant cognitive paralysis during complex scenarios: “When things got complicated, like several alarms going off at once, honestly, my mind would just go blank” (P1, Charge Nurse). This reactive pattern perpetuated professional insecurity cycles that participants described as hindering competency development.

3.4.2 Confident and proactive responses.

Following RCDP implementation, participants described transformed response patterns characterized by enhanced confidence, proactive clinical engagement, and clearer communication of clinical findings. Participants reported increased confidence and professional authority: “Now, I’ll say, ‘Patient in [Bed] 4’s monitor shows a coved ST-segment elevation...I recommend a doctor assess for acute myocardial infarction immediately’” (P4, Nurse Educator).

Across the two response sub-themes, the transformation participants described reflects changes in professional comportment that extend beyond technical execution. Their accounts suggest that enhanced confidence was experienced as an expanded sense of professional agency, enabling more assertive clinical communication and proactive engagement, with implications for participants’ described positioning within interdisciplinary care teams.

3.5.1 New professional identity.

Participants experienced substantial transformation in professional identity from passive order followers toward active clinical collaborators contributing meaningfully to patient care decisions. This evolution was characterized by enhanced professional confidence and an expanded sense of nursing’s contribution to patient safety: “I used to see myself as just an executor, doing whatever the doctor said. Now, I feel more like a ‘sentinel’ and a ‘collaborator’” (P1, Charge Nurse). This identity transformation was described as facilitating enhanced job satisfaction and professional engagement within challenging clinical environments.

3.5.2 Evolving ethical responsibility.

Participants described how enhanced clinical competency facilitated their expanded understanding of professional ethical responsibilities extending toward comprehensive patient advocacy and safety assurance. This described evolution encompassed increased willingness to challenge clinical decisions and accept responsibility for patient outcomes: “This new ability has changed my understanding of nursing ethics; I believe nurses are not just there to follow orders, but to think proactively and be responsible for the patient’s safety” (P1, Charge Nurse).

3.5.3 Continuous learning and mastery.

Participants described sustained commitment to professional development and continuous learning reflecting intrinsic motivation for excellence. This orientation was exemplified by aspirations toward advanced knowledge acquisition: “I feel like I’m in a rapid growth phase...To further improve my skills, I hope to delve deeper into electrophysiology to understand the pathological mechanisms behind the waveforms” (P1, Charge Nurse).

Across these three sub-themes, the professional identity transformation participants described reflects a fundamental reconceptualization of nursing’s epistemic role within critical care settings. Their accounts indicate that enhanced competency was experienced as ethically generative, expanding participants’ sense of accountability beyond task completion toward active patient advocacy, with implications for understanding how clinical training may shape not only technical skill but also the normative commitments that characterize professional practice.

4.1.1 Implications for clinical nursing education.

Participants’ accounts indicated a shift from alarm-reactive, parameter-focused monitoring toward integrated pattern recognition encompassing overall rhythm characteristics and morphological context, suggesting that training environments prioritizing isolated skill acquisition may be structurally misaligned with the perceptual orientation associated with competent clinical interpretation. Critical care units should therefore integrate RCDP training into routine staff development through simulation sessions during shift changes or downtime, using portable ECG simulators at nursing stations where experienced nurses provide immediate correction when interpretive errors occur and then resume the scenario. To cultivate this integrative perceptual capacity, units can create dedicated “ECG rounds” where nurses present challenging rhythms encountered during their shifts, with immediate group discussion that builds interpretive frameworks grounded in actual clinical exposure rather than decontextualized drill [13]. Monthly competency assessments should replace annual testing, requiring nurses to demonstrate rapid pattern recognition across common arrhythmias without relying on alarm prompts.

Participants also described a progression from mechanical textbook matching and reliance on senior colleagues toward a cognitive model that integrates intuitive recognition with systematic evidence validation, with several reporting identifiable breakthrough moments during training in which clinical reasoning became qualitatively transformed. New graduate programs should therefore extend ECG training through progressive, multi-week modules, with each stage focusing on increasingly complex rhythm interpretations using real patient cases from the unit [35]. Given that this cognitive transformation appeared to be facilitated by real-time, contextualized correction rather than deferred feedback, charge nurses should establish peer mentoring partnerships where experienced staff observe newer nurses during actual patient care [36], intervening immediately when suboptimal ECG interpretation occurs rather than waiting for shift debriefings. Staff development departments should maintain databases of actual ECG strips from unit patients, organized by complexity level, enabling targeted practice for nurses at different competency stages, while simulation labs should replicate the specific monitoring equipment used in each unit to ensure direct transfer to daily practice.

4.1.2 Implications for policy-making and healthcare system management.

Participants demonstrated a transition from hesitant, anxiety-driven responses toward confident and proactive clinical engagement, including the capacity to initiate clear diagnostic communication and recommend interdisciplinary action, suggesting that current institutional competency benchmarks may not adequately reflect the response capability that effective cardiac monitoring requires. Hospital administrators should therefore mandate minimum ECG interpretation competency standards for critical care nurses, requiring demonstrated proficiency in recognizing life-threatening arrhythmias within clinically appropriate timeframes, though nursing assessment must carefully integrate this with comprehensive clinical indicators [37]. Human resources policies should incorporate advanced ECG skills into job descriptions and performance evaluations, with salary differentials for nurses achieving specialized cardiac monitoring certifications. Quality improvement departments should track nursing-initiated emergency responses for cardiac events as key performance indicators, measuring the interval from rhythm change to appropriate intervention.

Beyond technical competency, participants described a reconceptualization of the nursing role itself, from task-oriented order execution toward active clinical collaboration, patient advocacy, and intrinsic commitment to ongoing professional development, indicating that institutional structures should be designed to sustain and reinforce this expanded professional identity rather than reduce ECG monitoring to a procedural obligation. Healthcare systems should therefore establish regional RCDP training centers where nurses from multiple hospitals can access standardized, high-fidelity simulation equipment and expert instructors. Insurance and regulatory bodies should recognize hospitals with certified ECG-competent nursing staff through reduced malpractice premiums and accreditation advantages. Management should allocate dedicated time for ongoing ECG skills maintenance, protecting training hours from reassignment to direct patient care during staffing shortages. Budget planning should include regular technology updates for ECG simulation equipment and protected educator positions to ensure consistent training quality across all critical care units.

4.1.3 Implications for future studies.

Future investigations should address several practical research needs. (1) Multi-site comparative studies should examine RCDP implementation across diverse hospital systems and international settings to establish broader implementation guidelines and assess improvements in patient outcomes across varied healthcare environments. (2) Longitudinal investigations should track individual nurses over extended periods following training to identify factors sustaining competency over time and determine optimal refresher training intervals, while examining the relationship between enhanced ECG skills and career advancement patterns. (3) Future mixed-methods designs should triangulate self-reported experiential accounts with objective performance indicators, including pre/post ECG interpretation assessments and simulation-based behavioral observation, to strengthen the evidentiary basis for competency and transformation claims.