Investigating nursing students' clinical reasoning and decision making using high fidelity simulation of a deteriorating patient scenario

The ability of the nurse to make clinical decisions is an integral part of nursing practice and clinical competency. The shortage in clinical placement, the incidences of “failure to rescue” and the emphasis on patient's safety has driven the increased use of simulation in nursing education. Yet, there is a lack of evidence about how simulation affects students’ decision-making skills and the way in which nursing students learn how to make decisions is not well understood. The aim of this study was to investigate nursing students’ clinical decision making using high fidelity simulation of a deteriorated patient scenario. Twenty-three nursing students in the final year of their nursing degree were recruited for this investigation. A pragmatist approach and a multiphase mixed method design were adopted. The Health Science Reasoning Test (HSRT), think aloud and observations were used in phase1. A semi-structured interview was applied in phase 2 to explore the benefits of this experience on students' clinical practice. Phase 1 results showed a statistically significant improvement in the overall HSRT score post the simulation experience. The students applied both methods of reasoning, the forward and backward, in a dynamic manner to make decisions. They predominantly used the analytical type of decision making and forward reasoning to respond to a patient's deterioration. The equal application of the analytical and non-analytical types associated with a better effect on the HSRT score. The students were not always effective in cue acquisition and interpretation and these stages were affected by cognitive biases. Phase 2 revealed that simulation promoted deep learning and increased students' self-awareness. The study draws the attention to the need for a clinical simulation design that based on a theory of decision making. It proposes a framework that has the potential to enhance the effectiveness of clinical simulation in teaching clinical decision making.