L'évaluation de l'autonomie fonctionnelle des personnes âgées : contribution de la didactique professionnelle à la formation des travailleuses et travailleurs sociaux au Québec

Résumé : Le vieillissement démographique est statistiquement indiscutable au Québec. Ce singulier trompeur masque les différentes manières de vieillir. Pour ceux qui ne parviennent pas à vieillir en santé, les solidarités familiales, comme les solidarités institutionnelles, c’est à dire publiques viennent en principe compenser ce qu’il est convenu de désigner de perte d’autonomie. Les politiques de santé publique au Québec organisent les services de soutien à domicile sous condition d’avoir estimé la situation de la personne avec l’outil d’évaluation multiclientèle (OEMC). Il est en usage dans l’ensemble du réseau de la santé et des services sociaux, et utilisé par les professionnels dont les travailleuses et les travailleurs sociaux (TS). Or, la gérontologie est peu soutenue dans la formation initiale des TS. Nous nous sommes interrogée sur les savoirs mobilisés par les TS quand ils évaluent. S’agissant des savoirs inscrits dans la pratique, nous avons orienté la recherche dans les théories de l’activité, la didactique professionnelle et le cadre conceptuel de la médiation. Nous avons étudié l’activité de professionnels en travail social expérimentés afin d’identifier certains des savoirs mobilisés pour les rendre disponibles à la formation des étudiant (e)s en travail social au Québec. Cent-cinquante heures d’observations et vingt-deux entretiens individuels et collectifs ont été réalisés avec des intervenants volontaires du service de soutien à domicile. Les résultats préliminaires de la recherche ont été présentés lors de groupes de discussion avec les TS ayant participé à la recherche, puis avec des enseignants en travail social. Nos résultats permettent de décrire les procédures de l’évaluation dans l’organisation du service d’aide à domicile et d’en différencier le processus de l’activité par laquelle le TS évalue l’autonomie fonctionnelle de la personne. Nous constatons que les savoirs mobilisés par les TS reposent premièrement sur une connaissance fine du territoire, de l’outil d’évaluation et des institutions. Un deuxième registre de savoir concerne la conceptualisation de l’autonomie fonctionnelle par l’outil OEMC comme objet et domaine d’intervention des TS. Enfin, un troisième registre se réfère aux savoirs mobilisés pour entrer en relation avec les personnes âgées, avec leur entourage. Or, ces trois registres de savoir n’apparaissent pas dans le discours des TS et résultent de notre propre analyse sur leur pratique. L’évaluation de l’autonomie fonctionnelle analysée par le concept de médiation est révélatrice du rapport aux savoirs du TS. S’agissant de savoirs de la pratique, nous constatons que leur classification entre les catégories usuelles de savoirs théoriques ou pratiques était inopérante. Nous empruntons le vocabulaire de la didactique professionnelle : celui des invariants opératoires reliés à l’autonomie fonctionnelle et celui des schèmes d’activité reliés à l’activité d’évaluation. C’est ainsi que nous avons identifié deux moments dans l’évaluation. Le premier assemble la collecte des informations et l’analyse des données. L’autonomie fonctionnelle se décline dans des conditions d’existence de la personne sur l’axe allant de la mobilité à la cognition avec comme balises d’intervention la sécurité et l’intégrité de la personne. Dans ce processus itératif, le TS identifie avec la personne ce qui nuit à son quotidien. L’évaluation formule comment résoudre cette incidence, comment la perte d’autonomie pourrait être compensée. La collecte d’information et le raisonnement du TS est alors un mouvement itératif, les deux éléments du processus sont liés et en continu. Le second moment de l’évaluation apparait si, dans le processus itératif, le TS perçoit une dissonance. Il est essentiel d’en identifier la nature pour la prendre en compte et maintenir la finalité de l’activité qui consiste à évaluer l’autonomie fonctionnelle à des fins compensatrices. Le TS doit identifier l’objet de la dissonance pour pouvoir cerner avec la personne le besoin inhérent à la perte d’autonomie et envisager d’y remédier. La prise en compte de cette dissonance vient ralentir le déroulement de l’activité. Le raisonnement qui, jusque-là, était relié à la collecte d’informations s’en dissocie pour analyser ce qui vient faire obstacle à l’activité d’évaluation à partir de la situation. Les composantes qui génèrent la dissonance paraissent reliées à la quotidienneté, aux conditions de vie à domicile de la personne (cohérence/incohérence, refus de services, autonégligence, maltraitance, agressivité). La dissonance génère une activité plus complexe pour évaluer la situation. L’autonomie fonctionnelle se décline toujours sur l’axe mobilité/cognition avec comme balises d’intervention la sécurité et l’intégrité de la personne. Or, pour ce faire, les TS raisonnent selon trois schèmes. Dans les situations où, pour décider de la suite du dossier, il faut en référer à une norme (de service, de profession, etc.) le raisonnement est déontologique. Il est aussi des situations où le TS agit au regard de valeurs et de représentations qui relèvent de sa sphère personnelle. Nous désignons ce raisonnement d’instinctuel. Enfin, le TS peut naviguer entre ces deux orientations et choisir la voie du raisonnement clinique que nous qualifions d’éthique et se rapproche alors des pratiques prudentielles qui sont marquées par l’incertitude.

The Impact of a Simulated Clinical Experience on CEGEP Nursing Students’ Perceptions of Self-Efficacy and Achievement

Abstract : Providing high-quality clinical experiences to prepare students for the complexities of the current health-care system has become a challenge for nurse educators. Additionally, there are concerns that the current model of clinical practice is suboptimal. Consequently, nursing programs have explored the partial replacement of traditional in-hospital clinical experiences with a simulated clinical experience. Despite research demonstrating numerous benefits to students following participation in simulation activities, insufficient research conducted within Québec exists to convince the governing bodies (Ordre des infirmières et des infirmiers du Québec, OIIQ; Ministère de L’Éducation supérieur, de la Recherche, de la Science et de la Technologie) to fully embrace simulation as part of nurse training. The purpose of this study was to examine the use of a simulated clinical experience (SCE) as a viable, partial pedagogical substitute for traditional clinical experience by examining the effects of a SCE on CEGEP nursing students’ perceptions of self-efficacy (confidence), and their ability to achieve course objectives. The findings will contribute new information to the current body of research in simulation. The specific case of obstetrical practice was examined. Based on two sections of the Nursing III-Health and Illness (180-30K-AB) course, the sample was comprised of 65 students (thirty-one students from section 0001 and thirty-four students from section 0002) whose mean age was 24.8 years. With two sections of the course available, the opportunity for comparison was possible. A triangulation mixed method design was used. An adapted version of Ravert’s (2004) Nursing Skills for Evaluation tool was utilized to collect data regarding students’ perceptions of confidence related to the nursing skills required for care of mothers and their newborns. Students’ performance and achievement of course objectives was measured through an Objective Structured Clinical Examination (OSCE) consisting of three marked stations designed to test the theoretical and clinical aspects of course content. The OSCE was administered at the end of the semester following completion of the traditional clinical experience. Students’ qualitative comments on the post -test survey, along with journal entries served to support the quantitative scale evaluation. Two of the twelve days (15 hours) allocated for obstetrical clinical experience were replaced by a SCE (17%) over the course of the semester. Students participated in various simulation activities developed to address a range of cognitive, psychomotor and critical thinking skills. Scenarios incorporating the use of human patient simulators, and designed using the Jeffries Framework (2005), exposed students to the care of families and infants during the perinatal period to both reflect and build upon class and course content in achievement of course objectives and program competencies. Active participation in all simulation activities exposed students to Bandura’s four main sources of experience (mastery experiences, vicarious experiences, social persuasion, and physiologic/emotional responses) to enhance the development of students’ self-efficacy. Results of the pre-test and post-test summative scores revealed a statistically significant increase in student confidence in performing skills related to maternal and newborn care (p < .0001) following participation in the SCE. Confidence pre-test and post-test scores were not affected by the students’ section. Skills related to the care of the post-partum mother following vaginal or Caesarean section delivery showed the greatest change in confidence ratings. OSCE results showed a mean total class score (both sections) of 57.4 (70.0 %) with normal distribution. Mean scores were 56.5 (68.9%) for section 0001 and 58.3 (71.1%) for section 0002. Total scores were similar between sections (p =0.342) based on pairwise comparison. Analysis of OSCE scores as compared to students’ final course grade revealed similar distributions. Finally, qualitative analysis identified how students’ perceived the SCE. Students cited gains in knowledge, development of psychomotor skills and improved clinical judgement following participation in simulation activities. These were attributed to the « hands on » practice obtained from working in small groups, a safe and authentic learning environment and one in which students could make mistakes and correct errors as having the greatest impact on learning through simulation.

Une comparaison des journaux non structurés et des journaux structurés rédigés par les étudiants en hygiène dentaire

The Canadian Dental Hygienists Association (CDHA) has indicated that there is a need for research in education in the field of dental hygiene. It seems that when compared to the nursing profession, the profession of dental hygiene is only in the earliest stages of investigating ways of teaching critical thinking. The faculty of the dental hygiene program at John Abbott College has always valued the skill of self-assessment in the students, yet there are few specific learning activities provided whereby the students can learn how to perfect and work on this invaluable skill of self-reflection in order to better self-assess. Although self-assessment is required of the students upon the completion of each clinical experience in Clinic 1, 2 and 3, a modest amount of clinical time is allotted to reflect upon this most important skill. It appears that more could be done to prepare our students to assess their learning and clinical practice. Self-reflection as an essential element of practice has a valid place in professional education. The purpose of conducting this study was to find out whether unstructured or structured self-reflective journal writing is a sound pedagogical technique to encourage dental hygiene students’ self-assessment through self-reflection. The research design for the project was a single case study. The paradigm for the study was chosen with a purposeful selection of participants, involving twenty-seven, third-year dental hygiene students at John Abbott College. The students were arbitrarily enrolled in two sections, which for the purpose of this study were referred to as Group A and Group B. Three duplicated coded anonymous journal entries from each student were collected over a ten-week period during the Fall 2009 semester. To examine the students’ level of self-reflection, two methods were used. First a content analysis of reflective journals was used to ascertain the level and substance of the reflections from their clinical experiences with the intent of looking more specifically at the students’ self-assessment. The journal entries were coded and analyzed after the grades were submitted at the end of the school term. This was followed by the distribution of an anonymous questionnaire to the students in both sections. The responses of the questionnaire were tabulated and analyzed. An analysis was done on the data collected in order to determine whether age, education and or mother tongue of the students in both Groups A and B had an influence on their perceptions of journal writing, as well as the student’s opinions about the value of journal writing. This questionnaire included two open-ended questions to assist in gathering additional data on the student’s thoughts on writing journals. A content analysis of the qualitative data collected from the open-ended questions in the questionnaire was also analyzed. Results indicated there were very few differences in the level of self-reflection leading to self-assessment. However, students in Group B who were assigned structured journals showed more evidence of deeper learning. Taken as a whole, the journal entries clearly showed the students were involved in ‘reflection-on-action’ of their clinical experiences (Schon 1987, as cited in Asadoorian & Batty, 2005). The quality of the responses for the most part indicated the students took the time and effort to record their perceptions of their clinical experiences. It is important to note that the results do indicate that students did show a need to self-reflect and assess. The students did in fact validate the importance of reflection through journal writing, even though they did not particularly like it as an added assignment. The journals were found to be very helpful to the research in getting to know what the issues were that held the students’ attention. They explained how and to what extent the students developed relationships with their clients. It was obvious that clinicians have an impact and influence on student learning. The students value the help, role modeling, patience, encouraging words and or gestures, positive reinforcement, and understanding provided by their clinicians. This research provides some evidence that students do believe that self-reflection through structured journal writing helped them better prepare for future clinical sessions with their clients. Our goal as educators should be to encourage dental hygiene students to self-assess through written self-reflection as an established practice for deeper learning.

Apprendre à être un Leader dans un Programme de Leadership: Perceptions, Éxpérience Préalable en Leadership et Sexe de l’Étudiant

The purpose of this study was to examine whether leadership can be learned through the Community Recreation and Leadership Training (CRLT) program and how effective the program is in terms of changing the perceptions and abilities of the students. The intentions of the researcher were to discover crucial learning moments as perceived by students and to gain insights that could lead to future improvements to enhance and enrich learning in a leadership program. To continue to be a viable program and to keep step with the demands of the recreation/leisure industry and society's wide-ranging needs, this study may help to inform the program's 'action plan' for continued success. This study employed a mixed method approach to determine how college students develop effective leadership ability in a three-year Community Recreation and Leadership Training (CRLT) college career program. First, a number of statistical tests were carried out to examine the four research questions used to guide the study. The SPSS software was used to analyze the data collected. The first research question asked how perceptions of leadership change as a result of being in a three-year leadership program. This study, using the Student Leadership Practice Inventory (SLPI), compared the five SLPI leadership dimensions by year. The SLPI was administered to all the first, second, and third year CRLT students ( N = 84). A one-way analysis of variance in participants' scores was conducted. No significant differences were revealed in any of the five dimensions of the SLPI among the first, second, and third year students at p < .05. However, two dimensions (model and encourage) approached significance and may hint at a possible influence the program is having on its students as they progress into the third year. The second research question asked whether perceptions of leadership vary by gender. Comparing the mean scores between the males and females on the five dimensions of the SLPI, no significant differences were found. The third research question asked whether prior leadership experience results in better academic performance for CRLT students in their 1st term. A one-way analysis of variance was conducted to evaluate the relationship between prior leadership experience and mean scores on academic performance. No significant correlations were found between grades and low, medium, or high levels of prior leadership experience F(2,79) = 2.67, p = .08. A correlation coefficient was also computed to determine whether there was a relationship between the Recreation Leadership I course grade and prior leadership experience. The correlation coefficient (.02) was statistically significant, r(80) = .24, p < .05. However, further studies with a larger sample size would be necessary to help determine this. The fourth question asked whether there was a correlation between students' first semester grades and their scores on the Student Leadership Practice Inventory (SLPI). Bivariate correlations (Pearson) were computed for the five SLPI dimensions with academic performance. None of the correlations using the five SLPI indicators was significant. Qualitative data was examined to discover what factors and experiences help students to assert a more effective leadership role. The study relied on content analysis of personal statements, and focus groups. Student perceptions of an effective leader, students' perceptions of their own abilities, and the strengths of the program were explored. A content analysis of the 'Personal Statements' was carried out to determine how students defined leadership prior to their having had any formal teaching in a college program. The result of the analysis of personal statements provided eight leadership categories used as an initial baseline for the study. Six focus groups (totaling N = 30) were conducted. Students responded to four key questions: how they define leadership. What is the single most effective quality of a leader? What leadership skills did they feel they had gained? How had the program helped them obtain their skills? Students credited the CRLT program with helping them develop a variety of leadership skills. Students revealed that they had gained skills such as confidence, knowledge and understanding of people's needs, and becoming more self-directed. They attributed their skill development to such things as good course design, intensive outdoor education and fieldwork courses, "hands on" learning approaches, group work, skill practice, the support they received from teachers, and encouragement they were given by their peers. A common finding among genders was defining an effective leader as someone who is "confident". However, the definition of the most important quality of a leader varied by gender. While males showed a tendency to prefer a leader being "confident," females preferred a leader being a "teacher".