比較單循環和雙循環教學回饋技巧的品質：混合研究設計

Abstract

背景：教學回饋（debriefing）已逐漸被視為臨床護理教學中促進新進護理師學習與深化臨床思維的重要策略，引導新進護理師進行反思、整合經驗與建構專業認知的核心過程，對提升臨床判斷力與應變能力具有關鍵性影響。教學回饋包含「教師主導的單循環方式」以及近年來結合Kolb的學習循環理論，強調透過經驗分享（Experience）、反思（Reflection）、概念化（Conceptualization）與計畫（Plan），即簡稱為ERCP，其模式所發展出師生互動的雙循環教學回饋技巧（double-loop debriefing）。目前缺乏研究以新進護理師和護理臨床教師的觀點比較此兩種教學回饋技巧的品質。 目的：以量性研究探討某醫學中心之新進護理師、護理臨床教師及資深護理師比較單循環與雙循環教學回饋技巧在臨床教學成效上的看法。採用詮釋現象學（Interpretative Phenomenological Analysis, IPA）方法進行深入訪談，旨在理解護理臨床教師與新進護理師於實際教學歷程中對單循環與雙循環教學回饋技巧在臨床教學的主觀經驗。 方法：本研究採混合研究方法順序解釋性設計（mixed-methods sequential explanatory design），第一階段以前瞻性觀察性研究法（prospective observational design），以DASH（Debriefing Assessment for Simulation in Healthcare）問卷方式蒐集新進護理師、護理臨床教師及資深護理師老師共159位，對於單循環與雙循環教學回饋技巧應用於教學成效的觀點。第二階段質性研究設計，採用立意取樣（purposive sampling），應用詮釋現象學方法，個別訪談深入探索參與者在應用及接受雙循環教學技巧歷程中的主觀經驗，進一步補充量化結果背後的行動脈絡與情感歷程。 結果：第一項量性研究的結果顯示，應用雙循環教學回饋技巧於臨床教學後，新進護理師、護理臨床教師及資深護理師對於教學回饋品質分數皆有顯著提升，達統計顯著水準（P < .01或P < .001）。其中，以新進護理師組提升幅度最為明顯、資深護理師組次之，且護理臨床教師自評教學回饋技巧亦呈現正向提升。第二項質性研究的結果呈現出新進護理師和護理臨床教師對於單循環和雙循環教學回饋技巧、成效和優缺點看法是相似的，可歸納出：單循環教學回饋技巧主題共6項主題(及14項次主題)：護理臨床教師運用動機(時間急迫、新進護理師個性、下班生活品質考量、加深記憶)、以老師為中心之教學(服從老師的教學)、教學策略(直接提供建議)、優點(適用於環境適應)、缺點(注意力難以集中、缺乏雙向溝通、缺乏自我反思、未達學習目標)、溝通情緒(不被允許表達自我、新進護理師被動溝通方式及負向感受)。雙循環教學回饋技巧共7項主題(及19項次主題)包括：護理臨床教師運用時機（雙方已建立良好關係、新進護理師已有基礎能力後）、以新進護理師為中心之教學（護理臨床教師與新進護理師相互溝通過程、夥伴為基礎的學習）、教學策略（護理臨床教師提問策略、護理臨床教師引導新進護理師反思學習過程、正面鼓勵與回饋、經驗分享）、優點（提升學習成效：促進新進護理師主動學習的態度、提升專注與記憶、認知整合、準確分析問題促進行為改善、增加學習效率）、優點（產生正向情緒：成就感、同理心）、其他優點（願意留任單位、可節省整體教學時間）及缺點（討論花費時間長、負向情緒）。 結論：新進護理師、護理臨床教師及資深護理師認為雙循環教學回饋技巧能促進教學成效，以及新進護理師和臨床教師的正向溝通，和正向情緒。護理教學中教學回饋的品質，不僅增進新進護理師的參與度與反思能力，更提升護理臨床教師之自我覺察與教學專業成長，進而改善整體教學氣氛與學習動機。雙循環教學回饋不僅是一種技巧，更是一種強調正向互動的關係、師生的理解和同理心與重構學習經驗的教育方式。建議未來持續監測其在臨床實務中的落實情形，並發展系統化教學訓練模式與提問策略工具，結合護理核心價值與臨床照護目標，深化護理教育之實務性與專業性。

Background: In recent years, debriefing has increasingly been recognized as a critical strategy in clinical nursing education for promoting learning and deepening clinical reasoning. More than just a review of clinical events, debriefing serves as a core process that guides novice nurses in reflection, experience integration, and the development of professional understanding. It plays a vital role in enhancing clinical judgment and adaptability. However, in many clinical teaching settings, the debriefing process remains predominantly single-loop and teacher-centered, focusing on knowledge transmission and error correction. Novice nurses often take on a passive role, with limited opportunities for autonomous thinking and meaningful engagement. This unidirectional interaction may hinder the development of critical thinking skills and dampen learning motivation and the ability to apply knowledge in practice. In contrast, double-loop debriefing-such as the ERCP (Experience-Reflect- Conceptualize-Plan) model-emphasizes dialogic interaction between teacher and learner, encouraging novice nurses to revisit their experiences, explore diverse perspectives, and co-construct new courses of action. This approach has gradually attracted attention in clinical education practice. However, its effectiveness in real-world clinical environments, its impact on teaching relationships, and its contribution to learning outcomes remain underexplored and require further empirical and interpretive investigation. Purpose: This study aimed to compare the practical application and educational experiences of single-loop and double-loop debriefing strategies in clinical teaching. From the perspectives of multiple clinical roles-novice nurses, clinical nursing instructors, and senior nursing staff-the study sought to evaluate how different debriefing methods influence the quality of the debriefing process. Specifically, the research aimed to determine whether double-loop debriefing could enhance clinical teaching interactions, foster reflective thinking among novice nurses, and promote mutual trust and dialogue between teachers and learners. Furthermore, the study explored how clinical instructors reconstruct their teaching beliefs and professional roles through the application of double-loop debriefing, addressing the challenges of implementing deep reflection and collaborative learning within a fragmented and high-pressure clinical work environment. Methods: This study adopted a mixed-methods sequential explanatory design. In the first phase, a prospective observational design was employed to collect quantitative data using the Debriefing Assessment for Simulation in Healthcare (DASH) questionnaire. A total of 159 participants-including newly recruited nurses, clinical nursing educators, and senior nurse preceptors-were surveyed regarding their perceptions of the effectiveness of single-loop and double-loop feedback strategies in clinical teaching. The second phase employed a qualitative research design using purposive sampling. Interpretative Phenomenological Analysis (IPA) was applied to conduct individual in-depth interviews, aiming to explore participants’ subjective experiences in applying or receiving double-loop feedback techniques. This qualitative inquiry served to contextualize and enrich the quantitative findings by uncovering the underlying action processes and emotional trajectories. Results: The quantitative findings indicated that the implementation of double-loop feedback strategies in clinical teaching led to a statistically significant improvement in perceived teaching feedback quality among newly recruited nurses, clinical nursing educators, and senior nurse preceptors (P < .01 or P < .001). Among these groups, the newly recruited nurses exhibited the most substantial improvement, followed by the senior nurse preceptors, while the clinical nursing educators also reported positive self-evaluations regarding their feedback delivery skills. The qualitative results revealed that both newly recruited nurses and clinical nursing educators shared similar perceptions regarding the characteristics, effectiveness, and pros and cons of single-loop and double-loop feedback strategies. For single-loop feedback, six major themes and fourteen subthemes were identified:(1) Motivations for using the strategy (time constraints, personality of the novice nurse, consideration of work-life balance, reinforcing memory), (2) Teacher-centered instruction (nurses expected to comply with instructors), (3) Teaching strategy (direct advice-giving), (4) Advantages (suitable for facilitating environmental adaptation), (5) Disadvantages (difficulty maintaining attention, lack of bidirectional communication, insufficient self-reflection, failure to achieve learning goals), and (6) Communication and emotional dynamics (suppressed self-expression, passive communication styles, and negative emotional responses in novice nurses). For double-loop feedback, seven major themes and nineteen subthemes emerged: (1) Timing of application (after a trusting relationship has been established, or when the novice nurse possesses foundational competence), (2) Learner-centered instruction (mutual dialogue between educator and nurse, partnership-based learning), (3) Teaching strategies (the educator’s use of questioning techniques, guiding reflection on the learning process, positive reinforcement and feedback, experience sharing), (4) Cognitive and behavioral advantages (enhancing proactive learning attitudes, improving concentration and memory, facilitating cognitive integration, promoting accurate problem analysis and behavioral change, improving learning efficiency), (5) Emotional benefits (increased sense of achievement and empathy), (6) Other advantages (increased willingness to remain in the unit, reduced overall instructional time), and (7) Disadvantages (spending a long time on discussions, potential for negative emotional experiences). Conclusion. Integrating quantitative data and qualitative insights, this study confirms that double-loop debriefing significantly enhances the quality of debriefing in clinical nursing education. It increases novice nurses' engagement and reflective capacity while fostering clinical instructors’ self-awareness and pedagogical growth. The approach improves the overall learning atmosphere and student motivation. More than a set of procedures, double-loop debriefing embodies an educational philosophy centered on relationship-building, understanding, and experiential reconstruction. Future research and implementation efforts should focus on monitoring its integration in clinical practice, developing systematic training models and questioning strategies, and aligning these efforts with core nursing values and clinical care goals to further advance the depth and professionalism of nursing education.