Heart Sounds Auscultation – Learning from the Nursing Perspective

Teaching Techniques

There are many techniques currently utilized for teaching auscultation of heart sounds in nursing education. The skill of identifying heart sounds and distinguishing normal from abnormal is not easily mastered. Clear objectives are needed. Effective learning requires experience, sufficient time for practice, and mentoring from an experienced practitioner¹. Typically, the use of a stethoscope is introduced in formal nursing education but the development of the skill evolves during a nurse’s continuing education and experiences². There is no substitute for direct patient contact for learning to assess heart sounds but this situation does require an experienced teacher to validate the learner’s findings.

To assist in the development of auscultation skills different techniques have been utilized in the learning environment such as classroom and textbook learning, simulator learning and computer mediated learning. One study has shown that nurses had the same success as physicians and other health care professionals in recognizing murmurs using directly recorded cardiac auscultatory events from actual patients transmitted via wireless infrared stethoscopes¹. Simulators have been used with some success but their size and portability do not always allow easy access for learning³.

Skill Development in the Clinical Setting

First, objectives should be set appropriate for the level of education and expected practice. The approach to teaching evaluation of heart sounds is different depending on the level of education, experience and the role of the nurse learning the skill. Nurses should be able to recognize normal heart sounds and the split of the second sound. Murmurs should be recognized as normal or abnormal. Nurses working in intensive care units and emergency departments require advanced skills in auscultation of heart sounds. Nurse Practitioners should aim to recognize abnormally wide splitting of the second heart sound and differentiate common murmurs such as innocent murmurs, aortic and pulmonary valve stenosis, ventricular and atrial septal defects, and patent arterial ducts. Examples of abnormal sounds will likely need to be derived from recordings, preferably in an educational and case format , e.g. –EarsOn⁴.

Second, a systematic approach is essential as it helps to develop a routine and the skills of assessment. Third, an experienced mentor will help the learner develop the skills to distinguish and identify heart sounds⁵.

Nurse Practitioners (NP) are growing in numbers as are the variety of clinical settings in which they practice. Currently, auscultation of heart sounds is taught in the clinical setting of the NP’s education and developed during practice experience. Continuing Education programs, such as conferences and teaching sessions, provide opportunity for further development of skills. A recent example is the workshop on auscultation of heart sounds by a Cardiologist at a conference of a Provincial association of NPs (Nurse Practitioner Association Conference, Wolfville NS, April 2010).

Primary Care Nurse Practitioners are required to assess and treat many patients of all ages who may require evaluation for cardiac findings. Specialty Nurse Practitioners (SNP) who work in tertiary care areas routinely utilize cardiac assessment skills and through their work further develop this skill. The practice of the SNP often includes teaching the assessment of heart sounds; thus SNPs become the resource for many health care providers such as nurses, medical students, respiratory therapists and other nurse practitioners. There is potential to build on this teaching opportunity and utilize teaching methods such as computer mediated learning tools to further evaluate the learning experience.

Assessment

Currently, the assessment of nurses’ skill with auscultation of heart sounds takes place in the clinical setting by a preceptor or instructor. This assessment is observational and on an individual level. The success of nurses participating in a research study evaluating heart sound teaching with recordings suggests that this modality deserves further study and possible application in nursing education¹. Further utilization of computerized sound assessment techniques would be worthwhile for nurses and nurse practitioners learning heart sound evaluation. At our institution, the evaluation of Nurse Practitioners involves the use of OSCE testing and increased emphasis on the assessment of heart sounds could be incorporated into this testing process.

There are thus many opportunities to improve the assessment of nurses’ abilities to evaluate heart sounds through mentoring and utilizing the available and developing electronic technologies.

Improving Teaching Programs

Incorporating more teaching on evaluation of heart sounds in nursing education and continuing education opportunities would contribute to improved development of this skill. As noted, bedside experience with real patients is considered a valuable form of learning and acquiring skill in cardiac assessment, but little data exists to validate this theory¹. A skilled preceptor is thought to be the most valuable educational tool for developing cardiac assessment skills but is often not available to the bedside nurse^6,5. It is this lack of availability of skilled preceptors to the bedside nurse that can cause learners to have a lack of confidence in their assessment skills ⁷. I believe there would be benefit from formalizing the assessment of this skill and the ongoing education for nurses and NPs. Other modalities of learning have been shown to improve cardiac assessment skills, such as heart sound simulators and audio recordings^7,1. Application to nursing education appears warranted.

The principles of adult learning indicate that as learners mature they become more self- directed, past experiences contribute to the quality of new learning and learners are motivated to learn solutions to problems⁷. These principles offer a base on which to build more effective learning experiences for nurses, incorporating mentoring during bedside assessments and simulated learning experiences.