A Reflective Learning Conversation Model for Active Clinical Reasoning Skills for Nurses Undertaking Critical Care Simulation-Based Courses

Background: Critical care nurses should be competent and have effective clinical reasoning skills to avoid errors in practice. Simulation-Based Education (SBE) develops nurses’ competence and clinical reasoning skills. During SBE, debriefing enhances and optimises participants’ clinical reasoning skills through guided reflection. However, the current debriefing models were established to develop general nursing clinical reasoning skills. They were not explicitly developed or evaluated to consider how different learners’ experience, seniority, and competence levels within a multicultural learning environment can impact the development of clinical reasoning skills. Based on gaps in the literature, a multimodal and multi-phasic post-simulation Reflective Learning Conversation (RLC) debriefing model was co-designed to enhance learners' clinical reasoning skills while accounting for variations in learners’ professional experience, using a range of scenarios. This study aimed to evaluate this newly co-designed debriefing model for immersive critical care SBE. Design: The study was conducted in three phases: systematic scoping review, co-design of a post-simulation reflective learning conversation debriefing model, and finally, testing the validity and reliability of the model. The co-design phase included a working group of healthcare practitioners and patients (n=18). Reliability measures were tested through mixed methods experimental and pre-test/post-test research design. The study sample consisted of a cohort of critical care nurses and advanced nurse practitioners recruited from nine governmental tertiary hospitals in Qatar (n=110) equally split between experimental and control groups, both taking part in immersive critical care SBE sessions. The data collected included questionnaire responses, focus group, subsequent direct observations, and video reviews of nurses' clinical reasoning using valid and reliable assessment tools. Descriptive and inferential statistical analyses were applied to the quantitative data. The descriptive analysis included the mean, median, and standard deviation. The inferential data analysis included Mann-Whitney/ Wilcoxon Sum tests to compare the clinical reasoning levels between the experimental and control groups. Friedman test was used to conduct repeated measures to evaluate the progress of the clinical reasoning levels within both groups. Thematic analysis was performed on the qualitative data. Results: The scoping review findings, based on 26 articles, revealed that despite the availability of several debriefing and clinical reasoning models and tools to enhance the development of clinical reasoning skills while attending SBE, these models were not explicitly developed or evaluated with consideration for variations in learners’ competence, seniority, culture, and prior exposure to SBE. A multimodal and multiphasic post-simulation reflective learning conversation debriefing model was co-designed for immersive SBE. The model included four phases incorporating: Bloom’s Taxonomy; Appreciative Inquiry; and the Plus/Delta (continuous improvement discussion) methods. It includes scripted examples to guide the simulation educators during the simulation debriefing sessions. The new model was deemed valid and reliable for critical care immersive SBE. It enabled nurses to develop clinical reasoning skills whilst considering their psychological safety and mitigating the risk of cognitive overload. The experimental group had a significantly higher level of clinical reasoning compared to the control group (p= [.608, <.001, <.001] z= [-.513, -3.729, -5.850] respectively) for three different observations. The model demonstrated Cronbach alpha and intra-class correlation coefficients of α=0.968 and α =0.972 respectively. Conclusion: A post-simulation reflective learning conversation debriefing model was co-designed and tested in the context of critical care immersive SBE sessions, considering variations in nurses’ seniority, experiences, and competence levels in a multicultural learning environment. The model was deemed to be valid and reliable for enhancing and optimising nurses’ clinical reasoning skills.