<![CDATA[Background: Electrocardiogram (ECG) interpretation places substantial demands on novice learners. Educational studies support several instructional approaches, but direct evidence for beginning a structured interpretation sequence with P-wave analysis remains absent from the included literature. Purpose: To synthesize ECG educational approaches and use Cognitive Load Theory (CLT) to propose a conceptual framework for P-wave-first rhythm interpretation that can guide future empirical testing. Methods: A systematic search of PubMed and ScienceDirect in May 2026, supplemented by manual searching, identified 15 eligible studies published between 2021 and 2026. Methodological quality was assessed using Joanna Briggs Institute (JBI) tools, and findings were synthesized narratively. The educational evidence and CLT informed a separate conceptual development step; three supplementary articles were used for contextual discussion without changing the original review sample. Results: Eleven intervention or comparative educational studies reported improvement in at least one learning outcome. Other studies described foundational knowledge gaps, educators’ perspectives, or exploratory differences in visual attention. None directly tested P-wave analysis as the first step or established that this sequence reduces cognitive load. The proposed framework uses a limited initial set of questions about atrial activity, followed by progressive integration of rhythm, rate, atrioventricular relationships, ventricular conduction, and repolarization. Conclusion: This article offers a CLT-informed conceptual framework grounded in a systematic review of ECG education. P-wave-first instruction is hypothesized to organize attention and manage the number of interacting elements considered initially; its effects on cognitive load, accuracy, retention, and transfer remain to be tested against other structured sequences.]]>
