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Title: Enhancing Nursing Student Clinical Reasoning: Teaching Thinking
through Debriefing
Article Type: Original Research
Keywords: Debriefing: Clinical Reasoning: Baccalaureate Nursing
Education: Simulation; Multi-site Research
Corresponding Author: Dr. Mary Beth Kuehn, Ed.D.
Corresponding Author's Institution: St. Olaf College
First Author: Mary Beth Kuehn, Ed.D.
Order of Authors: Mary Beth Kuehn, Ed.D.; Jone Tiffany , DNP ; Diana
Neal , PhD ; Heidi Meyer, MSN ; Lynnea Meyers , MSN ; Susan G Forneris,
PhD
Abstract: Abstract
Background: Debriefing as a key component of simulation creates
opportunities for nurse educators to guide students in reflection and
dialogue to "think like a nurse" for development of clinical reasoning
skills for future practice. The purpose of this pilot study was twofold;
1) determine if students' clinical reasoning skills improved with use of
a structured debriefing strategy and 2) confirm research design and
methodology to operationalize future full-scale study.
Method A pretest-posttest quasi-experimental design was used with a
convenience sample of 30 nursing students across four institutions.
Clinical reasoning scores were obtained using the Health Sciences
Reasoning Test prior to and three weeks post simulation.
Results: Health Sciences Reasoning Test raw scores increased; however,
the difference was not statistically significant.
Conclusion: Study findings support the following 1) use of the DML
strategy to enhance nursing students' clinical reasoning skills and 2)
use of the design and methodology to move forward with full scale study.
Title of Paper: Enhancing Nursing Student Clinical Reasoning: Teaching Thinking Through
Debriefing
Contact Information for corresponding author: Mary Beth Kuehn, EdD, RN, PHN
St. Olaf College
1520 St. Olaf Ave
Northfield, MN 55057
Cell: 507-390-2431
Presentations July 2013: Sigma Theta Tau International Nursing Research Congress, Podium presentation:
Enhancing Clinical Reasoning: Teaching Thinking Through Debriefing, Prague, Czech
Republic.
June 2013: International Nursing Association for Clinical Simulation and
Learning Conference, Pre-Conference Course Offering: Original Research, Enhancing
Clinical Reasoning: Teaching Thinking Through Debriefing, Las Vegas, NV.
April 2013: Bethel University Nursing Research and Practice Symposium. St. Paul, MN.
Enhancing Clinical Reasoning: Teaching Thinking through Debriefing.
March 2013: Sigma Theta Tau Annual Meeting, Chi-At-Large chapter. Enhancing Clinical
Reasoning: Teaching Thinking through Debriefing.
The information contained in this manuscript has not been submitted to any other journal, is not
currently being reviewed by any other journal, and there are no financial interests to disclose
from either author.
The study in this manuscript was part of a multi-site research study. The conception, design of
study, acquisition of data, analysis and interpretation were all completed by the research team
listed as authors in this manuscript.
Cover Letter
Enhancing Nursing Student Clinical Reasoning: Teaching Thinking Through Debriefing
Corresponding/Primary author: Mary Beth Kuehn, EdD, RN, PHN Assistant Professor of Nursing, St. Olaf College 1520 St. Olaf Ave, Northfield, MN 55057 USA Cell: 507-390-2431 [email protected]
Additional authors:
Jone Tiffany DNP, MA, RNC
Program Director, CAPS Degree Completion Nursing Program Associate Professor of Nursing, Bethel University 3900 Bethel Dr. St. Paul, MN. 55112 USA Phone: 651.638-6837 [email protected]
Diana Odland Neal, PhD, RN Minnesota Intercollegiate Nursing Consortium (MINC) Director St Olaf College Nursing Department, Chair Associate Professor of Nursing, St. Olaf College 1520 St. Olaf Avenue, Northfield, MN 55057 USA Office Phone: 507-786-3349 or 507-786-3265 [email protected]
Heidi Meyer, MSN, RN, PHN Associate Professor of Nursing, Gustavus Adolphus College 800 W. College Avenue, St. Peter, MN 56082 USA (507) 933-6094 [email protected]
Lynnea Myers, MSN,RN, CPNP, PHN Assistant Professor of Nursing, Gustavus Adolphus College 800 College Avenue West, St. Peter, Minnesota 56082 USA Phone: 507-933-6127 [email protected]
Susan Gross Forneris PhD RN CNE CHSE-A Associate Professor, Department of Nursing Henrietta Schmoll School of Health, St. Catherine University 2004 Randolph Ave, St. Paul, MN 55105 USA Office: 651.690.6674, [email protected]
*Title Page (with author details)
Enhancing Nursing Student Clinical Reasoning: Teaching Thinking Through Debriefing 1
Abstract
Background: Debriefing as a key component of simulation creates opportunities for nurse
educators to guide students in reflection and dialogue to “think like a nurse” for development of
clinical reasoning skills for future practice. The purpose of this pilot study was twofold; 1)
determine if students‟ clinical reasoning skills improved with use of a structured debriefing
strategy and 2) confirm research design and methodology to operationalize future full-scale
study.
Method A pretest-posttest quasi-experimental design was used with a convenience sample of 30
nursing students across four institutions. Clinical reasoning scores were obtained using the
Health Sciences Reasoning Test prior to and three weeks post simulation.
Results: Health Sciences Reasoning Test raw scores increased; however, the difference was not
statistically significant.
Conclusion: Study findings support the following 1) use of the DML strategy to enhance nursing
students‟ clinical reasoning skills and 2) use of the design and methodology to move forward
with full scale study.
*Blinded Manuscript (without author details)
Enhancing Nursing Student Clinical Reasoning: Teaching Thinking Through Debriefing 2
Acknowledgments: Dr. Kristina Dreifurest for providing training on use of the DML
strategy. Sigma Theta Tau International Chi-Chapter at large – Funding, Debra L. Spunt-
Funding
Key words: Debriefing, Clinical Reasoning, Baccalaureate Nursing Education, Simulation,
Multi-site Research
Key points:
1. Structured debriefing engages learners to positively enhance clinical reasoning by
emphasizing reflection and dialogue and students‟ ability to explain their thinking.
2. Debriefing is a pivotal component of the simulation process for student learning.
3. Faculty development is crucial to ensure consistency in debriefing.
.
Enhancing Nursing Student Clinical Reasoning: Teaching Thinking Through Debriefing 3
Enhancing Nursing Student Clinical Reasoning: Teaching Thinking Through Debriefing 1
Introduction 2
Nursing practice is not only knowledge, but the application and synthesis of that 3
knowledge situated in context. Future nurses need to be prepared to practice in a radically 4
changing and complex patient environment (Institute of Medicine, 2010). How nurses are 5
educated and oriented to thinking in practice is receiving well-deserved attention in the literature. 6
There is a need for more innovative and transformative strategies that guide nurses in the use of 7
nursing knowledge and science (Benner, Sutphen, Leonard, & Day, 2010). Educational 8
strategies need to focus on enhancing clinical reasoning through a learner-centered approach that 9
guides thinking through the use of reflection and dialogue to make an inferential link between 10
thinking and doing (Forneris & Peden-McAlpine, 2007, 2009). 11
The use of simulation in nursing education provides opportunities to practice clinical 12
reasoning skills in a controlled environment (Jeffries, 2007). Debriefing, as a component of 13
simulation, engages the learner and is utilized to positively enhance clinical reasoning by 14
emphasizing reflection and dialogue (Jeffries, 2007; Decker, 2007; Lasater, 2007, Dreifurest, 15
2010, Chronister& Brown, 2011). Debriefing has been discussed as the most important 16
component of simulation to develop clinical reasoning skills in nursing students (Jaeger, 2012). 17
Simulation-based learning experiences should include a planned debriefing session using 18
evidence-based debriefing methodologies based on a structured framework for debriefing 19
(INACSL Board of Directors, Standard VI, 2011). 20
Dreifuerst‟s (2010) work is concentrated on debriefing. Drawing on the reflective 21
practice literature (Schon, 1987), Dreifuerst‟s Debriefing for Meaningful Learning (DML) 22
focuses on a debriefing methodology using reflection and dialogue to enhance clinical reasoning 23
Enhancing Nursing Student Clinical Reasoning: Teaching Thinking Through Debriefing 4
skills. The results of her research supported DML enabling students to reflect on and practice 24
their clinical reasoning in a more contextual way (Dreifurest, 2009). The debriefing process 25
helped students to reconstruct current understanding with new meaning and more readily transfer 26
their learning to new situations(Dreifurest, 2010; Facione & Facione; 2006; Lasater, 2007; 27
Schon, 1983; Tanner, 2006). This paper reports findings of a multi-site pilot study conducted by 28
the Minnesota Consortium for Nursing Educational Research (MCNER) that utilized DML as a 29
reflective, dialogical debriefing strategy following a geriatric simulation experience to evaluate 30
the impact on students‟ clinical reasoning skills (Dreifuerst, 2010). 31
Background 32
Debriefing as a teaching strategy is integral for learning to occur in simulation (Cantrell, 33
2008; Decker, 2007; Dreifurest, 2009; Fanning & Gaba, 2007; Mould, Andrusyszyn & 34
Goldenberg, 2004; Shinnick, Woo, Horwich & Steadman, 2011). Debriefing is a type of guided 35
reflection, facilitated by faculty to allow students to question and dialogue about their 36
knowledge, skills and actions immediately following a simulation experience (Decker, 2007). 37
This teaching strategy provides an opportunity for students to process, reflect and receive 38
feedback immediately following the simulation and helps students integrate the experience and 39
create a connection to future clinical practice (Cantrell, 2008). 40
Reflection and dialogue through debriefing provides students an opportunity to connect 41
classroom theory to “real-life” practice. Engaging students in opportunities that assist them to 42
develop their critical thinking and clinical reasoning will positively impact patient care outcomes 43
(Benner et al., 2010: Decker, 2007; Decker et al., 2013; Driefuerst 2010; INACSL Board of 44
Directors, 2011, Pesut & Herman, 1998; Tanner, 2006). Nurse educators are shifting to more 45
active, engaging teaching strategies such as simulation to assist students to use clinical reasoning 46
Enhancing Nursing Student Clinical Reasoning: Teaching Thinking Through Debriefing 5
skills for understanding patient situations and transferring this understanding to other patient 47
encounters (Forneris & Peden-Mcalpine, 2007; Lasater, 2007; Tanner, 2006). 48
The importance of a structured debriefing method for effective student learning is cited 49
in the literature (Brackening, 2004; Driefuerst, 2009; Driefuerst, 2012 and Kuiper, 2008). The 50
International Nursing Association of Simulation and Clinical Learning (INACSL) developed and 51
revised standards for best practice in simulation (2013).Standard VI specifically focuses on using 52
a standardized debriefing process to promote the transfer of knowledge, skills and attitudes to 53
create future practitioners who provide safe, quality patient care (Decker, et al, 2013; INACSL 54
Board of Directors, 2011). Three specific criteria in this standard address faculty preparation, 55
faculty role and a structured format to facilitate clinical judgment, reasoning and reflection 56
(Decker, et al. 2013). Dreifurest (2010) created a structured debriefing method using the DML to 57
address these three INACSL criteria. 58
Most of the research in simulation to date has centered on student satisfaction and 59
efficacy not on student learning outcomes. Other simulation research has studied the 60
development and implementation of simulation while primarily excluding the debriefing 61
component (Flanagan, Clavisi & Nestel, 2007; Brackenreng, 2004). Jeffries (2005, 2012) 62
maintains that the process of debriefing is equally as important as simulation. Specifically 63
lacking is simulation research that focuses on the use of debriefing in simulation to enhance 64
student clinical reasoning (Mariani, Cantrell, Meakim, Prieto & Dreifurest, 2013). A more 65
thorough understanding of the debriefing process and debriefing methods will contribute to 66
evidence-based teaching to enhance faculty development and ultimately create positive student 67
and patient outcomes (Dreifurest, 2009). 68
Enhancing Nursing Student Clinical Reasoning: Teaching Thinking Through Debriefing 6
The DML method utilizes a consistent process to guide student reflection and 69
dialogue throughout the simulation or clinical experience. Bybee et al (1989) educational model 70
E-5 underpins the DML. The model was further adapted into the E-6 DML guide for faculty. 71
DML incorporates the E-6 components: engage, explore, explain, elaborate, evaluate, extend and 72
structures the process to help students‟ reflect-in-action, reflect-on-action and reflect-beyond 73
action to develop clinical reasoning skills to impact patient encounters. The ultimate objective is 74
to help the students “think like a nurse” (Dreifurest, 2010). 75
This multi-site pilot study was adapted, in part, from Dreifuerst‟s (2010) dissertation 76
research. The overall purpose was to address the gap in simulation research focused on the 77
impact of simulation and debriefing on enhancing students‟ clinical reasoning. This pilot study 78
explored the effect of the DML, as a structured reflective debriefing tool, on clinical reasoning 79
for senior baccalaureate nursing students across four colleges of nursing. Through the pilot 80
study, researchers were also able to explore the consistency of research procedures and 81
standardize faculty debriefing across sites. 82
Theoretical Underpinnings 83
Theoretical underpinnings guiding Dreifuerst‟s Debriefing for Meaningful Learning is 84
derived from three main theories; 1) constructivist learning theory; 2) the Reflective Cycle; and 85
3) Finks Interactive Learning Cycle. Constructivism (Dewey, 1933, Knowles, 1979, Piaget, 86
1972) focuses on how people learn; the underlying premise is active learning. Learners 87
experience situations and reflect upon them to create new understanding based on their current 88
knowledge. The learner then constructs new or revised meaning based on this contextual activity. 89
The Reflective Cycle also provides foundation and is derived from the work of Gibb‟s et 90
al. (1998) experiential learning theory based on Kolb‟s learning theory (1984). Simulation is the 91
opportunity for practice. Reflection upon that practice encourages students to create meaning 92
Enhancing Nursing Student Clinical Reasoning: Teaching Thinking Through Debriefing 7
from their learning. Debriefing for Meaningful Learning (DML) creates the opportunity to 93
intentionally reflect in a staged way to decipher the contextual patient experience by analyzing 94
actions with rationales, perceptions and future actions. 95
Finally, Fink‟s (2003) Interactive Learning Cycle helps lay a foundation as a model 96
consisting of six components acting together to create significant learning. Two elements, human 97
dimension and caring are incorporated into the simulation experience. Simulation incorporates 98
fidelity to create a sense of realism for the learner. Practicing caring and human dimension in a 99
safe simulation environment provides an avenue for internalizing these concepts with the goal of 100
transferring this learning into nursing practice. 101
Purpose 102
The primary aim of this pilot study was to evaluate the impact of a faculty-facilitated, 103
student driven, guided reflection teaching method (DML) to enrich students‟ development of 104
clinical reasoning skills during a geriatric simulation experience. A secondary aim of this pilot 105
study was to validate a multi-site approach to ensure consistency with procedures across four 106
sites, obtain a rough estimate of effect size, reduce variability in the measures, and examine the 107
reliability and validity of results in comparison with Dreifuerst‟s study. Lessons learned from the 108
pilot study were used in preparation for a full scale study. 109
The following research question guided this study: 110
Does the use of the Debriefing for Meaningful Learning (DML) strategy positively impact the 111
development of clinical reasoning skills in undergraduate nursing students? 112
Methodology 113
Setting/sample. The pilot study was conducted at four Midwestern, liberal arts 114
colleges/universities with baccalaureate nursing programs. Following IRB approval at each 115
college/university, a convenience sample of 30 senior level nursing students, who had completed 116
Enhancing Nursing Student Clinical Reasoning: Teaching Thinking Through Debriefing 8
an adult health, medical-surgical course volunteered to participate and were enrolled in this 117
study. 118
Research Design. A quasi-experimental, pre-test, post-test, repeated measure research 119
design was used is this pilot study to assess student nurses‟ clinical reasoning in simulation using 120
Dreifuerst‟s Debriefing for Meaningful Learning (DML) model. Faculty were trained in the 121
debriefing strategy by Dr. Dreifurest, to enhance consistency in the debriefing procedure (2010). 122
The research team also developed faculty debriefing guides for each scenario to create more 123
uniformity and consistency in the debriefing with students. The pilot study occurred during the 124
first month of a senior level community health nursing course. (See Figure 1- Study Timeline) 125
Method. The simulation experience incorporated the National League for Nursing‟s 126
(NLN) Advancing Care Excellence for Seniors (ACES) Millie Larsen geriatric simulation. The 127
simulation focused on an unfolding three scenario case featuring a geriatric patient experiencing 128
complications from dehydration a urinary tract infection and a complex transition process 129
(Reese, 2010). The case was adapted to include a patient fall and polypharmacy issues. Each 130
scenario engaged students in 20-minute clinical interactions followed by a 40-minute debriefing 131
sessions. The entire simulation experience unfolded during one 3-hour simulation lab. The 132
simulation scenarios were specifically scripted for faculty and actors to ensure reliability of 133
student cueing and consistency in performance. All students completed the simulation at their 134
home institution or familiar simulation centers. 135
The DML method was the study intervention. Faculty guided the debriefing allowing 136
students to determine the flow and direction of the discussion. 137
Instruments. The Health Sciences Reasoning Test (HSRT) was used to assess clinical reasoning 138
skills of the students. The HSRT measures high stakes reasoning and decision-making. (Facione 139
Enhancing Nursing Student Clinical Reasoning: Teaching Thinking Through Debriefing 9
& Facione, 2006: Facione & Facione, 2008). This test is used specifically to assess clinical 140
reasoning of students‟ and practitioners‟ in health science disciplines. Currently, the HSRT is the 141
instrument of choice for educational research (Facione, P.A. & Facione, N.C., 2006) The HSRT 142
overall internal consistency reliability estimates for the HSRT (Kuder-Richardson – 20) ranged 143
from 0.77-0.84 with an overall internal consistency of 0.81 (Facione, P.A. & Facione, N.,C. 144
2008 ). A KR-20 score above 0.70 indicates a high level of internal consistency (Nunnally, 145
1978). Content and construct validity were established by comparing test items to the Delphi 146
report (American Philosophical Association, 1990). 147
The HSRT is a 33 item, multiple choice exam that can be administered in 50 minutes. 148
The HSRT test items are set in clinical and professional practice contexts. Through HSRT, 149
students draw inferences, make interpretations, analyze information, identify claims and reasons 150
and evaluate the quality of the arguments. The HSRT measures six individual aspects of clinical 151
reasoning including: analysis and interpretation, inference, evaluation and explanation, deductive 152
reasoning and inductive reasoning providing an overall clinical reasoning score. Scores have 153
been found to predict successful professional licensure and high clinical performance (Facione, 154
Facione & Winterhalter, 2010, p. 11).Two versions of the HSRT were administered to eliminate 155
test item familiarity. 156
Results. A paired sample T-test was conducted to compare HSRT pre-test and post-test 157
means scores. The purpose was to identify a change in mean scores from pre-test to post-test. All 158
students (n=30) in the convenience sample demonstrated a visible difference between pre-test 159
and post-test scores (Table 1) but the change was not statistically significant as the p value was 160
0.237. (Table 2) Therefore, we can‟t conclude that there is a statistically significant difference between 161
Enhancing Nursing Student Clinical Reasoning: Teaching Thinking Through Debriefing 10
the mean HSRT scores and utilization of the Debriefing for Meaningful Learning Strategy. Due to a 162
small sample size, no control group was used in the pilot study. 163
To discern the statistical relevance of this difference between mean scores, a Wilcoxon 164
Signed Ranks Test was performed. A Wilcoxon Signed Ranks Test accounts for variability 165
when there is data without a normal distribution. Dreifurest (2010) also struggled with normalcy 166
in her study. The Wilcoxon Signed Ranks Test showed statistical relevance for the difference in 167
the change in HSRT mean scores from pre-test to post-test, though the difference was not 168
statistically significant. 169
Both Dreifuerst‟s study and the pilot study had mixed results. Dreifurest concluded that 170
there was no statistical difference between the experimental and control group HSRT data , 171
except when the change in total HSRT scores were compared. Like Dreifuerst‟s study, this pilot 172
was able to replicate a visible change with increased HSRT scores from pre-test to post-test. 173
However, unlike the Dreifurest study, this change was not significant. 174
Discussion 175
Debriefing is an essential component of simulation and helps students to apply learning. 176
Results of the study, although not significant, demonstrated improvement in students‟ post-test 177
scores on the HSRT. A larger sample size would have increased the probability of having a 178
normal distribution of data as well enhanced size of the effect. 179
This pilot study embraced the DML strategy. The associated nursing programs are 180
anxious to use this structured, debriefing approach to augment nursing curricula and assist in 181
enhancing student clinical reasoning skills. Students provided comments about their simulation 182
learning experience using the DML debriefing strategy (See Figure 2 – Student comments) 183
Enhancing Nursing Student Clinical Reasoning: Teaching Thinking Through Debriefing 11
The DML model: (1) engages students in a learner centered approach to teach them how 184
to think within the context of patient care; (2) uses reflection and dialogue to improve thinking 185
and transfer learning to new but similar practice situations essential for positive patient 186
outcomes; (3) provides a standardized method of debriefing for faculty to follow to create a 187
positive learning environment. 188
Lessons from the pilot study were valuable in developing the full scale study. The pilot 189
assisted in (1) determining that a full scale study is realistic; (2) integrating Debriefing for 190
Meaningful learning methodology into the current curriculum; (3) refining the recruitment 191
protocol to include discussing the potential benefits of the research project (improving clinical 192
reasoning skills and adding participation in a study to student resumes) to encourage more 193
students to take part in the study; (4) re-evaluating the timing of the HSRT‟s to emphasize the 194
possibility for a longitudinal change in clinical reasoning; (5) realizing that we need enough 195
students to demonstrate an effect and a control group;(6) establishing a timeline and resources 196
for the orientation, simulation time for the three scenarios and debriefing; (7) ascertaining the 197
importance of timing of the study (Saturday mornings during the school year did not entice 198
student participation) and incorporate into a course and (8) developing consistency with the 199
debriefing methodology, which is crucial, but one of the most challenging parts of the study (as 200
the literature states: debriefing is highly variable and dependent on faculty preparation and 201
training). The following changes to the research methodology and implementation were derived 202
from lessons learned with the pilot study: decrease the number of faculty debriefers, practice 203
using the DML faculty guide as a group and create clear, concise faculty templates for the 204
scenario. Use of templates will increase inter-rater reliability. 205
Limitations 206
Enhancing Nursing Student Clinical Reasoning: Teaching Thinking Through Debriefing 12
There are several potential study limitations. First, students at each site had completed an 207
adult health, medical/surgical course using simulation learning experiences; however; each 208
baccalaureate nursing program‟s curricular design and associated simulation experiences are 209
unique. Selection bias was an additional limitation to this study. Students who volunteered to 210
participate may not have been representative of the population from each academic institution. 211
Also, the HSRT was created for the assessment of healthcare professionals and not specific to the 212
discipline of nursing. Furthermore, the test was designed to measure clinical reasoning in 213
healthcare situations over time and may not have been specific enough to measure change in 214
clinical reasoning skills over a single semester. 215
Other limitations of the pilot study included a small sample size, lack of a control group 216
and variations in debriefing by faculty. The small sample size limited generalizability of the 217
findings. This small sample size and lack of a control group may have prevented a statistically 218
significant difference in HSRT pre-test and post-test scores. The variability of debriefing styles 219
of faculty as well as student familiarity with faculty may have also influenced the findings. To 220
eliminate this bias, faculty did not act as the debriefers or role players for their students. 221
Future research 222
MCNER researchers will proceed with plans for a full-scale study in the fall curriculum 223
in a senior public health nursing course. Plans for the future study include: (1) ensuring a larger 224
sample size to increase generalizability of the results and improve normalcy of data distribution; 225
(2) adding a control group that would receive the traditional debriefing method of the institution; 226
(3) considering additional measures to secure students‟ perceptions on the quality of their 227
debriefing experience similar to Dreifuerst‟s study (DASH-SV and DMLSQ) and (4) focusing on 228
consistency of debriefing ( faculty preparation and training) is crucial to ensure a positive 229
Enhancing Nursing Student Clinical Reasoning: Teaching Thinking Through Debriefing 13
learning environment for nursing students to enhance clinical reasoning skills. Future research to 230
determine if the DML method of debriefing positively enhances clinical reasoning skills of 231
baccalaureate nursing students is needed. 232
Conclusion 233
Debriefing is shown to be a key component in simulation and focuses on reflection and 234
connection of past and future learning (Babenko-Mould, Andrusyszyn & Goldenberg, 2004; 235
Cantrell, 2008; Decker, 2007; Dreifurest, 2009; Fanning & Gaba, 2007; Shinnick, Woo, Horwich 236
& Steadman, 2011). This pilot study demonstrates use of the DML as a method of debriefing in 237
a multi-site study utilizing a geriatric simulation. Although the major findings from the study are 238
not statistically significant (Student HSRT pre and post-test mean scores), feedback from both 239
faculty and students involved in the simulation and debriefing scenarios highlight the impact of 240
the DML on students‟ reflection and engagement in the debriefing process. Lessons learned from 241
this study are being used to inform a future study exploring use of the DML method and its‟ 242
relationship to clinical reasoning. Results of that study are forthcoming. 243
244
Enhancing Nursing Student Clinical Reasoning: Teaching Thinking Through Debriefing 14
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Table 1. Paired Sample Health Sciences Reasoning Test- pre-test and post-test means
HSRT version n Mean (SD) Std. Error Mean
Pair 1 VAR 00006-Pre-test Prior to DML
30 20.76 (3.63) .66382
VAR 00008- Post-test after DML
30 21.43 (3.83) .70088
Table(s) 1 and 2
Table 2. Results of Paired T-test on HSRT means prior to and after DML methodology (N=30)
Mean Std. Deviation
Std. Error Mean
Lower 95% confidence level of the difference
Upper 95% confidence level of the difference
t df Sig (2-tailed)
Pair 1 VAR00006-00008
-.66667 3.02100 .55156 -1.79473 .46139 -1.209 29 .237
Figure 1: Study Timeline
1 week prior to simulation – students took version 1 of the Health Sciences Reasoning Test
(HSRT)
Prior to the simulation – students completed preparation materials including reading about the
simulation objectives, purpose, performance expectations and a short description of the scenario;
review of diagnoses, pathophysiology, medications and nursing interventions; and readings about
Geriatric Syndromes.
The morning of the simulation, the students began with a 1- hour pre-brief session orienting them
to the Debriefing for Meaningful Learning methodology and tool (DML).
After the DML orientation session the students were randomly assigned the role of primary
nurse, secondary nurse, safety sentinel or documenter. When not participating in one of the roles,
students participated as observers. The students changed roles for each part of the three-scenario
unfolding simulation.
Three weeks following the simulation, the students took version 2 of the HSRT. Six to Eight
weeks following the simulation, the students took version 1 of the HSRT a second time.
Figure(s)
Enhancing Nursing Student Clinical Reasoning: Teaching Thinking Through Debriefing
Figure 2: Open-Ended Comments from Participants
“You know in debriefing how the professor usually led the discussion around certain
highlights of the events that happened during the simulation scenario (while the students
are usually feeling really bored)? Well….basically we used data gleadned during the
scenario to create a pseudo-concept map on the marker board with the instructor as the
“scribe” while we drew verbal connections between the data and the patient’s story that
they “came in with.”
“This type of simulation debriefing is more intuitive, collaborative and uses critical thinking
more than the current traditional way they debrief. You leave seeing how to apply things
learned in simulation to other scenarios in real life settings. At least that is the
goal…..and that is what I left with.”
“This type of debriefing kept me awake and engaged in the process. With the old way it felt
like the teaching was talking at us. With this they engaged US in the process”
“I had to really think and stay engaged with the professor because I knew they would ask me
questions about my thinking.”
Figure(s)
