International Journal of Nursing Education Scholarship

Volume 5, Issue 1 2008 Article 17

Debrieng with the OPT Model of Clinical Reasoning during High Fidelity Patient Simulation
RuthAnne Kuiper Carol Heinrich April Matthias Meki J. Graham Lorna Bell-Kotwall

University of North Carolina Wilmington, kuiperr@uncw.edu University of North Carolina Wilmington, heinrichc@uncw.edu Southeastern Community College, abmatthias@embarqmail.com University of North Carolina at Pembroke, meki.graham@uncp.edu New Hanover Regional Medical Center, bellkotwalll@uncw.edu

c Copyright 2008 The Berkeley Electronic Press. All rights reserved.

Debrieng with the OPT Model of Clinical Reasoning during High Fidelity Patient Simulation
RuthAnne Kuiper, Carol Heinrich, April Matthias, Meki J. Graham, and Lorna Bell-Kotwall

Abstract
Evidenced-based educational practices propose simulation as a valuable teaching and learning strategy to promote situated cognition and clinical reasoning to teach nursing students how to solve problems. A project that uses a structured debrieng activity, the Outcome Present State-Test Model of clinical reasoning following high delity patient simulation, is described in this paper. The results of this project challenge faculty to create and manage patient simulation scenarios that coordinate with didactic content and clinical experiences to direct student learning for the best reinforcement of clinical reasoning outcomes. Considerations for the future include incorporating patient simulation activities as part of student evaluation and curriculum development. The arguments for using high delity patient simulation in the current educational environment has obvious short term benets, however, the long term benet of developing clinical expertise remains to be discovered. KEYWORDS: patient simulation, debrieng, clinical reasoning, situated cognition

Kuiper et al.: Debriefing with the OPT Model of Clinical Reasoning

Proposed in evidenced-based educational practices, is that simulation as a valuable teaching and learning strategy promotes situated cognition and clinical reasoning to teach nursing students how to solve problems (Nehring & Lashley, 2004; McCausland, Curren, Cataldi, 2004; Seropian, Brown, Gavilanes & Diggers, 2004a; 2004b). In fact, some authors speculate that simulation fosters adaptation to the clinical setting because the experiential learning that occurs through practice with a simulator refines patient assessment and practice skills necessary for safe and effective care (Feingold, Calauce, Kallen, 2004; Kovalsky & Swanson, 2004). The practice with a simulator is also a scaffolding activity involving successes and failures which is prerequisite to the development of expertise (Feltovick, Prietula, & Ericsson, 2006). One of the most important issues surrounding simulated practice is the reflection that transpires afterward so students recognize and come to terms with clinical issues raised by the simulation (Fanning & Gaba, 2007; Rudolph, Simon, Dufresne, & Raemer, 2006). This process has been referred to as debriefing and extends analytical learning and supports a habit of self-correction (Fanning & Gaba, 2007; Petranek, Corey, & Black, 1992; Rudolph, et al.). In this paper, a project is described that incorporates a structured debriefing activity, the Outcome Present State-Test Model (OPT) of clinical reasoning (Pesut & Herman, 1999) (see figures 1& 2), following high fidelity patient simulation (Kuiper, Bell-Kotwall, Grahm & Mathias, 2004). Debriefing activities following simulation are compared to those after authentic clinical experiences in terms of differences or similarities for possible curriculum development and refinement. The major premise is that the constructivist theory of experiential learning implemented through situated cognition, and clinical skill reasoning, and problem solving in simulation, is comparable to authentic clinical experiences. The purpose of this project is to explore the impact of patient simulation technology on situated cognition of undergraduate nursing students with the long term goal of preparing a workforce of practitioners who effectively manage clinical issues. It is hypothesized that debriefing with a clinical reasoning model can structure cognition, encourage reflection, and enhance judgments for clinical expertise. Little is known about the impact of simulation-mediated practice on learning for real-life practice environments. The desired goals of this project are twofold, first, to determine the clinical reasoning activities surrounding patient simulation and how they compare with authentic clinical experiences. Secondly, to determine if the OPT model could be used as a method of debriefing following patient simulation.

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Theoretical Framework Situated cognition during patient simulation is an instructional approach that exemplifies the constructivist theory of learning through experience and brings about clinical reasoning skill practice. Constructivism is a philosophy that states individuals form or construct what they learn, understand, and knowledge is subjective, personal and a result of their own cognitions (Schunk, 2004). The assumption is that with social cognitive theory, persons, behaviors and environments interact in a reciprocal fashion to influence learning (Bandura, 1977). Therefore, teachers structure situations and pedagogy so learners are actively involved through manipulation of materials and social interactions to influence cognition. Situated cognition reinforces appropriate patterns of behavior from specific actions during simulation practice that lead to desired outcomes. Significance of Debriefing Debriefing following simulation is an important period of self-reflecting about what just took place. The overall purpose is to uncover the cognitive frame that was operating during the experience and make sense of external stimuli through internal cognitive frames, i.e., internal images of external reality (Rudolph, et al., 2006). This monetary framing can lead to intentional rational actions that result in mistakes or correct decisions. De-briefing uncovers this process and leads to the development of self-correcting practice habits when faculty help students recognize and resolve clinical and behavioral dilemmas occurring during simulation (Rudolph, et al.). Faculty can gain insight into student problem-solving during debriefing or when thinking aloud about experiences (McCausland, et al., 2004). The debriefing technique can be facilitated using a variety of methods. Conversation brings faculty judgments out in the open, but a non-judgmental frame is important to keep motivation active and provide psychological safety. Faculty need to know which frames drive failures and successes, and debriefing is a venue where significant concerns can be discussed. Highly affective and behavioral learning occurs during simulations, particularly when debriefing is structured (Petranek, et al., 1992). If the debriefing is unstructured, the responses may be at various cognitive levels and incorrectly applied to authentic experiences (Petranek, et al.). As well, writing can extend analytical learning by forcing students to organize information and debrief on an individual basis (Petranek, et al.). This analytic work promotes exploration of learning and encourages self-reflection (Jeffries, 2005). However, the connections between the experience and cognition remain poorly understood (Petranek, et al.).

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Kuiper et al.: Debriefing with the OPT Model of Clinical Reasoning

By using the OPT model to structure debriefing, students use the cognitive critical thinking strategies of organization, comparison, classification, evaluation, summarization, and analysis (Petranek, et al., 1992; Raths, 1987). Student selfefficacy for problem solving also improves if they see that their actions bring about desired outcomes (Bandura, 1977). Discussion of the OPT model components after simulation experiences makes visible the sense-making process, cognitive frames, emotions, and assumptions. OPT Model of Clinical Reasoning The OPT model of clinical reasoning uses creative thinking, emphasizes the importance of framing client situations, and focuses on outcomes (Pesut & Herman, 1999) (Figure 1). Cognitive knowledge is gained by using critical thinking strategies to understand nursing diagnoses, content and procedures, while metacognitive knowledge is gained by reflecting and self-regulating to monitor those cognitive processes (Pesut & Herman, 1992; Kuiper & Pesut, 2004). The client story for simulation and authentic clinical experiences is determined by assessment. It frames the situation and gives meaning to the clinical reasoning that takes place. Use of the model starts with creating a clinical reasoning web that enables the practitioner to choose a priority focus of care based on an analysis and synthesis of functional relationships among competing nursing diagnoses (see figure 2). Creation of a clinical reasoning web enables students to reason about relationships between and among competing nursing diagnoses within a given particular client scenario. Instructions linked with the webbing exercise encourage students to create and evaluate the complex interactions associated with a constellation of nursing care diagnoses, and then to choose a leverage point in the sets of relationships that emerge. This leverage point becomes a priority focus of care and is defined as a keystone issue. This keystone issue serves as the basis for defining a present state. Once a priority or keystone focus has been determined, the client's present state is described and compared with a desired outcome state. The gap between the present and desired state constitutes a test or an evidence gap that must be filled in order to make judgments about outcome achievement. Research-based nursing interventions are guided by deciding which treatment might be most useful to help the client transition to achieve the desired outcome state. Clinical judgments and conclusions are revisited due to continuous evaluation of evidence about outcome achievements. Reflective use of thinking strategies are embedded in the model which guide reasoning processes along the way. There are a few published studies related to the use of the OPT model with undergraduate nursing students in settings of 7 week-long advanced

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medical/surgical nursing courses. After two weeks of OPT practice, senior and junior level baccalaureate nursing students demonstrated cognitive and metacognitive skills co-existing during clinical reasoning activities (Kuiper, 2002; Kuiper, Kautz & Pesut, 2004; Kautz, Kuiper and Pesut, 2005). Students in these studies quickly identified priority nursing diagnoses, interventions, and outcomes for analysis and interpretation after client assessment. The OPT model and clinical reasoning web worksheets were used for debriefing in these projects as a guide to discover applied cognitive knowledge and organization of care. They served as a basis for clinical reasoning and reflective processes which occurred during authentic clinical experiences. METHODOLOGY Setting and Sample The setting of this current project was a mid-sized city in the southeastern United States. Simulations have been used in this program for three years, primarily in medical/surgical nursing courses. The clinical setting was a nonprofit, tertiary care hospital (867 beds) which has a level II trauma designation. Of the 44 undergraduate senior baccalaureate nursing students who participated in this project, the majority were female (89%), Caucasian (98%), with a mean age of 22 years. These students had no previous exposure to patient simulation scenario practice apart from task trainer exercises during their fundamental junior level nursing course. Design This descriptive design included a purposive sample of students in an adult health medical/surgical course whose clinical assignment was to complete 56 OPT worksheets after authentic clinical experiences. Throughout the length of the semester, these students rotated out of the clinical setting at various points in time to spend four hours completing a patient simulation scenario, debriefing with an instructor, and completing another OPT model worksheet related to the scenario. The simulation rotation and related OPT model worksheets could be completed at any time during the semester regardless of the number of OPT model worksheets completed for authentic clinical experiences. Authentic clinical experiences are scheduled during 14 weeks of an adult health medical/surgical nursing course on a variety of acute care units, such as coronary care, medical intensive care, surgical/trauma intensive care and cardiovascular post-recovery. The experience is typically structured by (a)

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Kuiper et al.: Debriefing with the OPT Model of Clinical Reasoning

preparing the day before the clinical experience, (b) arriving for morning report, and (c) caring for the assigned patient for the next 10 hours. Students collect pertinent data from the patient record, patient, family and health care team. During the shift, they provide basic care, administer medications and treatments, and develop a plan of care using the OPT model of clinical reasoning (see Figure 1). The OPT worksheets (see Figures 1 & 2) are started during the clinical experience, completed independently at an off clinical site, and given to the clinical faculty within one week of the experience. They are collected and rated by the faculty with the OPT model rating tool (see Figure 3). Clinical faculty provide feedback on the components of OPT model worksheets to direct cognitive activities so as to maintain or improve the thinking responses on subsequent clinical assignments. The OPT model worksheets from the authentic clinical experiences with the highest scores for all 44 students are collected and then compared to their OPT model worksheets completed for high-fidelity patient simulation. The OPT model worksheets from the authentic clinical experiences with the highest scores are chosen to remove the influence of maturation, since early in a semester; individual scores tend to be lower. The OPT Model rating tool has been used by researchers working with the OPT model since 2003 and it continues to be refined (Kautz, Kuiper & Pesut 2005; Kuiper 2004). The second version of the rating tool was used with undergraduate nursing students from a variety of settings. The inter-rater reliability of this version tested significant (Kendalls coefficient: W = .703, X2 (24) = .573, p = .000) (Kautz, Kuiper, Bartlett, Buck, & Williams, 2007). The third version of the rating tool, used in this project, revealed an inter-rater reliability of 87% between two clinical instructors for a random selection of 16 OPT work sheets. The validity of subsection scores on the tool continues to be tested and shows significant differences between students (p = .001) but no significant differences between semesters, with a consistent pattern over time (Kautz, et al., 2007).

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Reflection Frame 52 year old anxious male with spontaneous pneumothorax. Outcome State NOC - Sa02 > 90% - ABGs within normal limits - Vital signs within normal limits - Breath sounds symmetrical - Pain and anxiety relieved - Chest tube maintained Present State - Sa02 < 85% - Respiratory acidosis/hypoxia - Hypertension and tachypnea - Decreased breath sounds on L - Pain and anxiety - Left anterior chest tube

Client -in-Context Story Cue Logic

- Risk for altered urinary elimination - Risk for impaired tissue perfusion - Risk for infection - Risk for decreased cardiac output - Risk for aspiration - Altered comfort (acute pain) - Ineffective breathing pattern - Activity intolerance - Anxiety - 52-year-old male admitted to the ED c/o dyspnea. After collapsing in the hallway. Patient stated, Oh, something just popped! I cant get any air. - EKG monitor shows atrial fibrillation rate 180 bpm - Vital signs: BP 170/110, Respirations 30-38, Sa02 < 85% - ABGs: Arterial blood gas pH 7.33, pO2 82 mm Hg, pCO2 48 mm Hg - Chest x-ray: 80% pneumothorax - History of smoking for 34 pack/yrs, emphysema, chronic atrial fibrillation, heart failure - Current medications: coumadin, atrovent

Judgments 1. After chest tube, Sa02 > 90%, ABGs and vital signs within normal limits 2. Breath sounds were symmetrical and unlabored 3. Incentive spiromentry and breathing excursion were adequate depth 4. Pain and anxiety were relieved with position and pain medication 5. Chest x-ray expanded L lung 6. Positioned for ease of breathing 7. No signs of wound infection

Testing
Assessment, chest x-ray, ABG, EKG, Hbg/HCT, CBC, cardiac enzymes, electrolytes, Sa02

NANDA Keystone Issue

Impaired Gas Exchange

Decisions - NIC
1. Encourage incentive spirometry and deep breathing 2. Monitor - vital signs, breathing, laboratory values 3. Administer pain medications and monitor pain 4. Assist with position changes to aid breathing 5. Assist with activities of daily living 6. Wound care

OPT Model - Pesut & Herman, 1999

Figure 1 OPT Model of Clinical Reasoning

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Kuiper et al.: Debriefing with the OPT Model of Clinical Reasoning

Keystone issue: focusing on this diagnosis will assist in resolving other diagnoses

Risk for decreased cardiac output - pneumothorax - hypertension

Activity intolerance - pain & anxiety - hypertension - hypoxia

Risk for aspiration - pain medication - asymmetrical breathing

Impaired Gas Exchange - < Sa02 - Respiratory acidosis /hypoxia - Dyspnea - Decreased breath sounds left chest

Risk for altered urinary elimination - pain medications - chest trauma

Spontaneous Pneumothorax Emphysema

Altered comfort (acute pain) - pain on inspiration

Ineffective breathing pattern - decreased breath sounds L chest - chest tube Risk for impaired tissue perfusion - respiratory acidosis - hypoxia Anxiety - something popped in my chest - acute pain

Risk for infection - chest tube wound - aspiration

Steps for Web creation 1. Identify medical diagnosis and NANDA diagnoses that apply 2. Include supporting data to define each NANDA diagnosis 3. Connect related diagnoses with arrows - creating a web leading to the priority or keystone problem -diagnosis with most arrows Clinical Reasoning Web - Pesut & Herman, 1999

Figure 2. OPT Clinical Reasoning Web

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Items Weeks Reasoning Web 5 9 NANDA diagnoses (5=1, 9=5) 1-5 5 9 NANDA diagnoses have supporting data (5=1, 9=5) 1-5 1018 connections between diagnoses (10 = 1, 18 = 5) 1-5 NANDA related to Medical Diagnosis 1 Connections lead to keystone 1 NANDA represent domains: 6 Physiologic Behavior/psychosocial Safety Family Community Health system Patient Story Medical Diagnosis 1 Assessment History 1 Signs & Symptoms 1 Laboratory Data 1 Social/Family History 1 Outcome Present State Keystone is NANDA Diagnosis 1 5 Present state statements related to 5 keystone / NANDA has supporting data 5 5 Outcome state statements related to 5 keystone / NOC app. for NANDA 5 5 Outcome state statements improvement 5 from Present state / Maintenance 5 5 Interventions rt keystone / 5 NIC Activities related to 5 outcomes 5 5 Tests rt to keystone/ 5 NOC Clinical Indicators related to outcomes 5 Judgments 5 Statements (1 point each) 5 5 Statements reflect tests/clinical indicators 5 5 Statements reflect interventions/activities 5 5 Statements reflect outcomes 5 Frame Frame reflects 2 of 6 domains: 2 Physiologic Behavior/psychosocial Safety Family Community Health system Kuiper & Kautz Total Score 76

Figure 3. OPT Model Rating Tool

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Kuiper et al.: Debriefing with the OPT Model of Clinical Reasoning

The simulation scenario consisted of a case study, followed by a list of laboratory values and a potential list of medications, as shown in Table 1. Most students became involved in the scenarios when the simulator spoke and responded to their questions. The simulator had abnormal heart, lung and bowel sounds, and intentional wounds. A typical scenario might be as follows: A 52-year-old white male is a visitor in the hospital walking by the Emergency Department. You are a nurse returning from lunch and passing him in the hallway, observe him suddenly grabbing the left side of his chest and gasps, Oh something just popped! He then whispers to you, I cant get any air. What do you do now? Table 1 Simulation scenario The simulator presents with: Respiratory rate 30 Pulse oximetry < (85%) Shortness of breath Absent of breath sounds on L Diminished breath sounds R

Which prompts the student to: Elevate head of bed Apply oxygen via facemask Auscultate breath sounds; Chest x-ray ( 80% pneumothorax on the left) Arterial blood gas pH 7.33, pO2 82 mm Hg, pCO2 48 mm Hg Insert peripheral IV Medicate: Morphine & Versed Prepare for Chest tube insertion Bag and mask ventilation Medicate with Narcan to counteract Morphine

Coughing and c/o pain Vital signs: BP 170/110 Respiratory rate 38 Change in vital signs: BP - 100/65 Respiratory rate < 6 Pulse oximetry < (82%) Atrial fibrillation 180 bpm BP 172/110 then 120/75 Respiratory rate 25 Pulse oximetry 90s
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Slow heart rate by vagal maneuvers Medicate with Cardizem Continue to monitor

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The students worked together as a group to complete the OPT worksheets but submitted independent assignments for review and scoring. The OPT model worksheets were completed within 2-3 hours following the simulation experience. To complete the assignment, students used textbooks and PDA resources to search information on medications, diagnostic and laboratory studies, nursing diagnoses, interventions and outcomes, and medical diagnoses. The faculty then collected the worksheets and rated them using the OPT model rating tool (see Figure 3). ANALYSIS Simulation debriefing discussions deal with issues of how clinical problems were solved and the efficacy of the interventions attempted. Once the primary medical diagnoses was determined and the priority nursing care issues identified, students completed the OPT model worksheets. The 44 OPT model scores for the simulation experiences averaged 48 points from a possible 76 points. These scores were then compared with the clinical reasoning scores of the same 44 students during authentic clinical experiences with critically ill medicalsurgical patients. The 44 OPT model rating scale scores averaged 47 points from a possible 76 points. A comparison of the two groups revealed no significant differences between the mean scores (t = -1.321, p = .194). A paired sample t-test comparing the scores for each section of the model by student revealed no significant difference between authentic clinical experiences and high fidelity patient simulation (t=-.680, p=.504). Overall, the scores were higher for simulation OPT worksheets on listing interventions, recording laboratory data, making judgments regarding tests, and connecting present-outcome states and NANDA diagnoses. The students were also asked to evaluate their simulation experience in narrative format. These reflections included the following comments: 1. The experience made us actually think for ourselves without relying on an instructor or preceptor to step in. 2. The experience challenged my clinical decision-making skills but it was difficult to write an OPT model about a mannequin. 3. The experience makes you think on the spot which I need practice with because it enhances critical thinking skills. 4. It was the first time I had to think fast to assess an unstable patient and prevent them from declining. 5. I think this was a fairly decent learning experience; however, we could get some of this practice in clinical.

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Kuiper et al.: Debriefing with the OPT Model of Clinical Reasoning

6. We were able to practice doing all the things we would have to do in real situations without practicing on a living patient. FINDINGS AND DISCUSSION The first goal of this study was to determine the clinical reasoning activities surrounding patient simulation and how these compare with authentic clinical experiences. Students had to process facts, strategies, outcomes, relationships, and feelings during the simulation as they experimented with interventions and interacted with fellow students. This type of experiential learning also involved team work, leadership and group dynamics (Jeffries, 2005; McCausland, et al., 2004), which included debriefing with the OPT model worksheets. The clinical reasoning activities allowed for controlled, consistent, focused, situated cognitive and metacognitive activities. During simulation experiences, students relied on their own knowledge base, practiced data collection, analyzed situations, and chose appropriate nursing interventions. This degree of realism promoted similar thinking in authentic clinical experiences where students must work through the nursing process and use these very same strategies (Feingold, et al., 2004; McCausland, et al.). The situated and interactive simulated experience built on previously learned knowledge and related it to authentic clinical situations. The projected outcomes were skill competency, confidence, and self-efficacy in clinical practice (Kovalsky & Swanson, 2004). As the students noted in their responses, they had to think on the spot and solve problems independently. While authentic clinical experience with patients cannot be replaced (Feingold, et al.), simulated experiences offered students a variety of clinical problems and practice with the clinical reasoning skills they will eventually use. The second goal was to determine if the OPT model could be used as a method of debriefing following patient simulation. It has been shown that practice with feedback and monitoring promotes higher-order cognitive skills along with reflective metacognition which are learnable in special contexts (Kuiper & Pesut, 2004). Therefore, expertise is developed by amassing skills, knowledge and strategies in order to monitor and control cognitive processes to perform tasks efficiently and effectively (Feltovich, et al., 2006). This focused practice on every aspect of the human body becomes less demanding over time as faculty scaffold the learning in a protected environment with simulation and provides opportunities for reflection, exploration of alternatives, and problem solving with models of clinical reasoning. The OPT model worksheets used with these simulations provided the scaffolding for reflection and review of the clinical reasoning activities during simulation. Since the OPT model worksheet scores for patient simulation were comparable to the authentic clinical experiences, one can
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speculate that the inherent clinical reasoning supported by these activities is occurring during the debriefing following simulation. While this project was limited by a small sample and a descriptive design, the findings showed comparable results between the two measurements. Controlling for variables such as maturation, student characteristics, practice with simulation, and type of authentic clinical assignments will further the exploration of simulation evaluation. Measuring the maturation of clinical reasoning with students at various points in time, and taking into consideration student learning styles, will add to the evidence needed to know when and how to best use simulation to support clinical learning. Another consideration for further research is to determine if the absence of OPT worksheet score variability between students was related to the similarity of clinical experiences or if group collaboration impacted choices made during simulation. There is still a great deal of knowledge to be gained in understanding the role of debriefing for learning from simulation (Fanning & Gaba, 2007). Future testing of models and theories as described here is needed in the area of simulation-based learning. CONCLUSION The results of this project indicate that faculty should be challenged to create and manage patient simulation scenarios that coordinate with didactic content and clinical experiences, in order to direct student learning for the best reinforcement of clinical reasoning outcomes. Simulation activities are aligned with constructivist learning theory and situated cognition that are experientially determined according to individual learning styles and at a pace for comprehension. Evidence in this study supports the use of patient simulation as a source of remediation for students with clinical challenges, and for enhancement of didactic content. Simulation allows for errors in decisions and judgments without jeopardizing patient safety, yet enhances clinical reasoning competence. Other considerations for the future include incorporating patient simulation activities as part of student evaluation and curriculum evaluation. Admittedly, the arguments for using high fidelity patient simulation in the current educational environment have obvious short term benefits. However, long term benefits of developing clinical expertise remain to be discovered.

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REFERENCES Bandura, A. (1977). Self-efficacy: toward a unifying theory of behavior change. Psychology Review, 84, 191-215. Fanning, R. M., & Gaba, D. M. (2007). The role of debriefing in simulation-based learning. Simulation in Healthcare, 2(2), 115-125. Feingold, C. E., Calauce, M., & Kallen, M. A. (2004). Computerized patient model and simulated clinical experiences: Evaluation with baccalaureate nursing students. Journal of Nursing Education, 43(4), 156-163. Feltovich, P. J., Prietula, M. J., & Ericsson, K. A. (2006). Studies of expertise from psychological perspectives (In Cambridge Handbook of Expertise and Expert Performance, K. A. Ericsson, N. Charness, P. J. Peltovich & R. R. Hoffman (Eds.). Cambridge University Press, New York: NY. Jeffries, P. R. (2005). Designing, implementing and evaluating simulations used as teaching strategies in nursing. Nursing Education Perspectives 26(2), 96-103 Kautz, D. D., Kuiper, R. A., & Pesut, D. J. (2005) Promoting clinical reasoning in undergraduate nursing students: Application and evaluation of the Outcome Present State Test (OPT) Model of clinical reasoning. International Journal of Nursing Education Scholarship, 12(1), http://www.bepress.com/ijnes/vol12/iss1/art1 Kautz, D. D., Kuiper R. A., Bartlett, R., Buck, R., & Williams, R. (2007). Quantitatively Evaluating Students Clinical Reasoning with the Outcome-Present State-Test (OPT) Model. Vienna, Austria: Paper presentation at the 18th International Research Congress: Sigma Theta Tau International. Kuiper, R.A. (2002). Nursing students use and experience with the OPT model of reflective clinical reasoning. Unpublished pilot study. Winston-Salem State University, Winston-Salem, North Carolina. Kuiper, R., Bell-Kotwall, L., Matthias, A., & Graham, M. J. (2004). A Comparison of Clinical Reasoning Abilities in Senior Baccalaureate Nursing Students: Authentic Clinical Experiences Versus Human Simulations. IUPUI, Indianapolis, IN: Paper presentation at the 9th National Nurse Educator Conference: Assessing Program Outcomes, Kuiper, R., Kautz, D. & Pesut, D. (2004). Self-regulated Learning and the Outcome Present-State Test Model of Clinical Reasoning: Accelerating Critical Thinking Skill Acquisition of Nursing Students. Toronto, Ontario, Canada: 37th Biennial Convention of Sigma Theta Tau International Kuiper, R. A. & Pesut, D. J. (2004) Promoting cognitive and metacognitive reflective clinical reasoning skills in nursing practice: self-regulated learning theory. Journal of Advanced Nursing, 45(4), 381-391.

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Kovalsky, A. A., & Swanson, R. (2004). Integration of Patient Care Simulators into the Nursing Curriculum can Enhance a Students Ability to Perform in the Clinical Setting. Deans Notes, 25(5), 1-3. McCausland, L. L., Curran, C. C., & Cataldi P. (2004). 1(1). Use of a human simulator for undergraduate nurse education. International Journal of Nursing Education Scholarship, 1(1), 1-17, http://www.bepress.com/injes/vol1/iss1/art23. Nehring, W. M., & Lashley, F. R. (2004). Human patient simulators in nursing education: An international survey. Nursing Education Perspectives, 25(5), 244-248. Pesut, D.J., & Herman, J. (1992). Metacognitive skills in diagnostic reasoning: making the implicit, Nursing Diagnosis, 3(4), 148-154. Pesut, D.J., & Herman, J. (1999). Clinical Reasoning: The Art & Science of Critical & Creative Thinking, Albany, NY: Delmar Publishers. Petranek, C. F., Corey, S. & Black R. (1992). Three levels of learning in simulations: Participating, debriefing and journal writing. Simulation & Gaming, 23(2), 174-185. Raths, J. (1987). Enhancing understanding through debriefing. Educational Leadership, 45(2), 24-27. Rudolph, J. W., Simon, R. Dufresne, R. L. & Raemer, D. B. (2006). Theres no such thing as nonjudgmental debriefing: A Theory and method for debriefing with good judgment. Simulation in Healthcare, 1(1), 49-55. Schunk, D. H. 2004. Learning theories an educational perspective (4th ed.) Upper Saddle River, NJ: Pearson Education Inc. Seropian, M. A., Brown, K., Gavilanes, J. S., & Driggers, B. (2004a). An approach to simulation program development. Journal of Nursing Education, 43(4), 170-174. Seropian, M. A., Brown, K., Gavilanes, J. S., & Driggers, B. (2004b) Simulation: not just a manikin. Journal of Nursing Education, 43(4), 164-169.

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