Contribution d'un débriefing au jugement clinique d'étudiants infirmiers lors de simulations de détérioration du patient

This manuscript-style thesis presents a mixed-methods study that aimed to evaluate the contribution of a reflective debriefing to nursing students’ clinical judgment in patient deterioration simulations. Following the Medical Research Council’s guidance (2008), the REsPoND reflective debriefing approach was developed (manuscript I) based on a clinical judgment model (Tanner, 2006) and a theory of reflection and experiential learning (Dewey, 1938/1997, 1910/2007). The theory underpinning this intervention postulates that reflecting on a simulated care experience with a deteriorating patient could improve nursing students’ clinical judgment. The study used a sequential explanatory design (Creswell and Plano-Clark, 2011). It started with a quantitative randomized controlled trial to compare the effect of the REsPoND reflective debriefing approach with the Plus-Delta evaluative debriefing approach (manuscript III). In a critical care course, undergraduate nursing students (n = 119) were randomized to either approach. They participated in four simulations where a patient was deteriorating due to hemorrhage, sepsis or trauma. The sepsis scenario was repeated twice in the same day. The debriefings occurred after the hemorrhage scenario and the first sepsis scenario. To measure the debriefings’ effect on students’ clinical judgment, a situation awareness instrument was developed and tested for validity (manuscript II). It comprised two variables to operationalize two concepts of the clinical judgment model (Tanner, 2006) – perception and comprehension of signs of deterioration. The results showed that both debriefing approaches had similar effects across different simulation scenarios. However, students from the REsPoND group reached significantly higher scores in perceiving quantifiable signs of deterioration from the first to the second sepsis simulation than the second group. The following phase used a qualitative design to describe how the reflection process in the REsPoND approach fostered learning with respect to the two clinical judgment variables, according to students (manuscript IV). Nineteen nursing students who had experienced REsPoND and showed the greatest variation in either of the variables tested were selected to participate in individual semi-structured interviews. The data collected was then subjected to thematic analysis (Paillé and Mucchielli, 2012). Results show that students built a framework during the reflective debriefing that expressed their understanding of the simulated patient’s situation, which they then used to assess their own performance. This framework included making logical connections between the causes of deterioration, their observations during the simulation and the interventions required to address the situation. This process occurred through guided exchanges with their peers, under the guidance of a debriefer. In the last phase of the study, students who participated in the interviews were classified in four learning profiles according to their clinical judgment scores. The results from the thematic analysis were compared according to students’ learning profiles. REsPoND was found to contribute differently to students’ clinical judgment depending on (1) the value students placed on the systematic and chronologic review of the simulation through the ABCD-EFGHI assessment survey; (2) their focus either on understanding and anticipating what could happen in the simulation or on their performance during the simulation; and (3) their preference for debriefing among students, or discussing with the debriefer who could validate their reflections and answer their questions.  This study illustrated the added value of a reflective debriefing to improve nursing students’ clinical judgment in patient deterioration simulations, in comparison with evaluative debriefing. Potentially active components of REsPoND were identified, such as the systematic assessment through the ABCD-EFGHI and the social aspect of learning, which the study sheds new light on. The development and validation of a situation awareness instrument to measure clinical judgment is another valuable contribution. This study contributes to the development of knowledge regarding best practices for nursing education and post-stimulation debriefing. It is recommended that future research should address the concept of unmet expectations in the concept of noticing of the clinical judgment model (Tanner, 2006) and the influence of students’ knowledge, teamwork, and experience on clinical judgment learning.

Keyphrases: Plus-Delta, REsPoND, Simulation, Clinical judgment, Debriefing, Educational intervention, Experiment, Mixed-methods research, Nursing students, Patient deterioration, Reflection, Sequential explanatory design