Investigating the clinical decision-making of nursing students using high-fidelity simulation, observation and think aloud: A mixed methods research study.

Abstract

The aim of this study was to investigate nursing students' clinical decision-making by using high-fidelity simulation of a deteriorated patient scenario. A convergent parallel mixed methods research design was used consisting of quantitative and qualitative data collection. Twenty-three students completed the Health Science Reasoning Test before and after the simulation between October 2015 and June 2016. They were presented with a simulated scenario and asked to 'think aloud' during and after the simulation. The students were audio-video recorded and observations were collected by the researcher. There was a significant moderate increase in the 'deduction' and 'analysis' sub-scale scores and overall test score, suggestive of improved analytical decision-making processes through the simulation experience. Think-aloud and observation data identified that students predominantly applied 'forward' reasoning during the simulated 'patient's' deterioration, focusing mainly on cue acquisition. 'Backward' reasoning with a focus on cue interpretation was most prominent in the debriefing data, in line with the survey outcomes. Accurate cue interpretation of critical, key cues appeared more useful than the total number of cues in solving the main clinical case problem. Students learn different clinical decision-making skills during the simulation compared to what they learn from debriefing. Using observation and think-aloud methods have significant benefits for researchers seeking to optimize the evaluation of the clinical decision-making process.