Sigma book helps nurses improve clinical reasoning

By RuthAnne Kuiper and Daniel Pesut | 12/21/2017

Use of OPT Model develops competence and confidence in reflective practice.

Sigma book helps nurses improve clinical reasoning
RuthAnne Kuiper and Daniel Pesut, two of the four authors of The Essentials of Clinical Reasoning for Nurses, respond to questions posed by the editor of Reflections on Nursing Leadership. 

In your book, The Essentials of Clinical Reasoning for Nurses, the Outcome-Present State-Test (OPT) Model of Clinical Reasoning is presented and explained. In the introduction, the reader is informed that the model builds on but is different from the traditional nursing process. What will nurses learn from this book, and what will they gain in their practice by adopting the model?

RuthAnne Kuiper RuthAnne Kuiper and Daniel Pesut:
The nursing process has evolved since the 1950s, with the focus changing from problem identification to diagnostic reasoning to outcome specification. As the process evolved, the use and value of standardized terminologies also evolved. The Outcome-Present State-Test (OPT) Model of Clinical Reasoning is designed to help novice nurses gain problem-solving competency in complex healthcare systems by supporting relevant teaching and learning activities (Kuiper, O’Donnell, Pesut, & Turrise, 2017). 

Daniel PesutDrawing upon patient stories in clinical settings, the OPT Model, together with associated thinking strategies, tactics, and worksheets, helps students develop habitual thinking patterns that support development of clinical reasoning. In The Essentials of Clinical Reasoning for Nurses, we show how to evaluate competing patient needs and nursing diagnoses to determine priorities for care, specify desired outcomes, and activate required nursing interventions to achieve patient goals and outcomes.

In the book, we define the five types of thinking—critical thinking, creative thinking, systems thinking, complexity thinking, and reflective self-regulation (metacognitive thinking)—that support clinical reasoning. The OPT Model illustrates how they work together for mastery of clinical reasoning skills.

In an earlier book, Clinical Reasoning: The Art and Science of Critical and Creative Thinking (Pesut & Herman, 1999), clinical reasoning was defined as critical, reflective, concurrent, and creative thinking embedded in nursing practice to recognize juxtaposition of problems and identify outcomes amenable to nursing interventions and clinical judgment. As people worked with that model, it became clear that other types of implicit thinking needed to be made explicit. The evolved OPT Model incorporates use of critical thinking skills such as analysis, synthesis, evaluation, creativity, and judgment (Anderson et al., 2001) while emphasizing the value, importance, and need for also mastering metacognition and self-regulation learning principles and theory.

Essentials of Clinical Reasoning for NursesUsing worksheets developed for use with the model and nursing diagnoses chosen from patient assessment data, students create visual graphic representations that illustrate relationships and linkages between and among these diagnoses. The visual representation of these linkages, which looks like a spider web, illustrates the complexity of these relationships. Using cue and web logic that poses if-then propositions and how-so relationships among nursing diagnoses, the nurse thinks and explains how competing patient-care issues may or may not be related. Concurrent iteration, thinking, and explaining often reveal a priority diagnosis called the “keystone.” This is a central supporting element of the diagnostic-reasoning challenge associated with the patient’s story. Juxtaposing problems with outcomes reveals the contrast between a present and a desired state. 

As nurses contemplate interventions that move the patient from present to desired states, they create mental “tests” to determine if desired outcomes are achieved. They make reflective judgments to determine if priority issues are resolved, outcomes are achieved, or further actions are needed. Reflecting on these processes and the iterative nature of the thinking and reasoning associated with progress over time adds to an experiential learning base and develops pattern recognition and habits of mind that are the foundations of clinical reasoning. Experience and pattern recognition support development of knowledge representations or schemas that prove useful in the future when caring for patients with similar stories, clinical issues, and care coordination needs. 

We believe that, by using the OPT Model of Clinical Reasoning, nurses and other healthcare providers develop clinical reasoning skills that activate confidence and competence in day-to-day practice situations. While the seasoned practitioner develops thinking and practice skills over time, the novice can advance these skills in a shorter period by using the OPT Model.

Recognizing that there isn’t sufficient space to explain in detail the clinical reasoning you describe in the book, provide two or three examples of how using the model has made or can make a difference in health outcomes.

Kuiper and Pesut:
For orienting new graduates to their first jobs. New graduates came together weekly to share OPT Model worksheets that were used to solve a clinical problem. During a debriefing session, they shared their reflections and thinking about clinical problems and how they or their mentors solved them using thinking strategies embedded in the clinical reasoning process (Kuiper, 1999).

For incorporation in undergraduate curricula. Integrating the OPT Model throughout an undergraduate curriculum fosters development of clinical reasoning and thinking abilities. The results are improved pass rates on the NCLEX examination, more confidence in practice abilities, and easier transition to first-job orientations.

As a tool for clinical supervisors. In this new book, we advocate use of the OPT Model as a tool that clinical supervisors on a clinical unit or in a community setting can use effectively to help healthcare workers think through new methods and means of care. Reflective clinical practice fosters various types of thinking. Using the OPT Model as a point of reference, staff members can talk with each other about situations encountered, discuss case studies, and participate in patient care conferences. Dialogue can be structured with prompts and questions based on the OPT Model to determine issues, outcomes, interventions, and judgments surrounding new and novel situations.

I like the subtitle of Chapter 3: “Thinking About Thinking,” also known as metacognition or being aware of being aware. In the book, you identify five kinds of thinking that contribute to clinical reasoning, one of which is critical thinking. As one develops and gains facility with these higher-level thinking skills, do they become intuitive so that one becomes less conscious of using them?

Kuiper and Pesut:
Yes, as a nurse gains experience, many conscious and intentional thinking strategies and tactics become subconscious, and, almost without realizing it, nurses develop competence as experts. The OPT Model is designed to encourage and facilitate cognitive and metacognitive—or higher order—thinking skills. Our research with the OPT Model of Clinical Reasoning provides evidence that students raise their thinking abilities to higher levels and improve their focus on patient problems. In analyzing reflection journals, we have seen that, after using the model for about five weeks, students shift focus from themselves and their own anxieties and issues to patients and their needs. New nurses who use the model become less conscious of personal apprehensions related to new practice situations and more focused on patient problems.

The worksheets help nurses focus on the patient. Over time, they become less conscious of the thinking strategy they are using and more focused on achieving improved patient outcomes—while simultaneously building metacognitive strategies and schemas that represent the complexity of clinical reasoning.

RuthAnne Kuiper, PhD, RN, CNE, ANEF, is professor in the School of Nursing at the University of North Carolina Wilmington.

Daniel J. Pesut, PhD, RN, FAAN, past president of Sigma, is professor of nursing in the Nursing Population Health and Systems Cooperative Unit of the University of Minnesota School of Nursing and director of the Katharine J. Densford International Center for Nursing Leadership.

About the book:
The Essentials of Clinical Reasoning for Nurses, by RuthAnne Kuiper, Sandra M. O’Donnell, Daniel J. Pesut, and Stephanie L. Turrise, was published by Sigma in 2017. ISBN-13: 9781945157097 Soft cover, 464 pages. Also available digitally. Price: $59.95.

Anderson, L. W., Karthwohl, D. R., Airasian, P. W., Cruikshank, K. A., Mayer, R. E., Pintrich, P. R., Raths, J., & Wittrock, M. C. (2001). A taxonomy for learning, teaching, and assessing: a revision of Bloom’s taxonomy of educational objectives. New York, NY: Longman.

Kuiper, R. A. (1999). The effect of prompted self-regulated learning strategies in clinical nursing preceptorship (Unpublished doctoral dissertation). University of South Carolina, Columbia, SC.

Kuiper, R. A., O’Donnell, S., Pesut, D., & Turrise, S. (2017). The essentials of clinical reasoning for nurses. Indianapolis, IN: Sigma Theta Tau International.

Pesut, D., & Herman, J. (1999). Clinical reasoning: The art and science of critical and creative thinking. New York, NY: Delmar Publishers.

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