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International Journal of Nursing Education Scholarship

Volume 5, Issue 1 2008 Article 17

Debriefing 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.

clinical reasoning. 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. situated cognition . the Outcome Present State-Test Model of clinical reasoning following high fidelity patient simulation. April Matthias. Meki J. Considerations for the future include incorporating patient simulation activities as part of student evaluation and curriculum development. The arguments for using high fidelity patient simulation in the current educational environment has obvious short term benefits. is described in this paper. 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. the long term benefit of developing clinical expertise remains to be discovered. Carol Heinrich. KEYWORDS: patient simulation. however. debriefing.Debriefing with the OPT Model of Clinical Reasoning during High Fidelity Patient Simulation RuthAnne Kuiper. A project that uses a structured debriefing activity.

to determine the clinical reasoning activities surrounding patient simulation and how they compare with authentic clinical experiences. 2008 1 . Cataldi.Kuiper et al. The practice with a simulator is also a scaffolding activity involving successes and failures which is prerequisite to the development of expertise (Feltovick. In fact. Curren. It is hypothesized that debriefing with a clinical reasoning model can structure cognition. 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). 2004). encourage reflection. Little is known about the impact of simulation-mediated practice on learning for real-life practice environments. Grahm & Mathias. Kallen. Brown. Corey. Calauce. a project is described that incorporates a structured debriefing activity. 2007. 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 Outcome Present State-Test Model (OPT) of clinical reasoning (Pesut & Herman. This process has been referred to as ““debriefing”” and extends analytical learning and supports a habit of self-correction (Fanning & Gaba. 2007. & Black. 1999) (see figures 1& 2). to determine if the OPT model could be used as a method of debriefing following patient simulation.: Debriefing with the OPT Model of Clinical Reasoning Proposed in evidenced-based educational practices. 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. 2006). In this paper. Rudolph. 2004. Rudolph. Kovalsky & Swanson. Prietula. Seropian. 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. & Raemer. Simon. first. Petranek. 2006). and problem solving in simulation. 1992. 2004. is comparable to authentic clinical experiences. The major premise is that the constructivist theory of experiential learning implemented through situated cognition. et al. Gavilanes & Diggers. and clinical skill reasoning. Dufresne. 2004. McCausland. 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. 2004a.). following high fidelity patient simulation (Kuiper. and enhance judgments for clinical expertise. The desired goals of this project are twofold. Bell-Kotwall. & Ericsson. Secondly. 2004b). Published by The Berkeley Electronic Press.

internal images of external reality (Rudolph. 1977). Conversation brings faculty judgments out in the open.com/ijnes/vol5/iss1/art17 DOI: 10.bepress.). personal and a result of their own cognitions (Schunk. et al. understand.International Journal of Nursing Education Scholarship. 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. As well. behaviors and environments interact in a reciprocal fashion to influence learning (Bandura. but a non-judgmental frame is important to keep motivation active and provide psychological safety..2202/1548-923X. 2004). et al. 17 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. Significance of Debriefing Debriefing following simulation is an important period of self-reflecting about what just took place. persons. The assumption is that with social cognitive theory. et al. i. Vol. Iss. 5 [2008]. 2004).). If the debriefing is unstructured. The debriefing technique can be facilitated using a variety of methods. writing can extend analytical learning by forcing students to organize information and debrief on an individual basis (Petranek. teachers structure situations and pedagogy so learners are actively involved through manipulation of materials and social interactions to influence cognition. et al. et al. et al. This analytic work promotes exploration of learning and encourages self-reflection (Jeffries. 1992). Faculty can gain insight into student problem-solving during debriefing or when thinking aloud about experiences (McCausland. However. particularly when debriefing is structured (Petranek. and debriefing is a venue where significant concerns can be discussed. the connections between the experience and cognition remain poorly understood (Petranek. 1. 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.). and knowledge is subjective. http://www. Art.. Therefore. Situated cognition reinforces appropriate patterns of behavior from specific actions during simulation practice that lead to desired outcomes. Constructivism is a philosophy that states individuals form or construct what they learn. the responses may be at various cognitive levels and incorrectly applied to authentic experiences (Petranek. Faculty need to know which frames drive failures and successes. Highly affective and behavioral learning occurs during simulations. 2005).).e. et al. 2006).1466 2 .. This monetary framing can lead to intentional rational actions that result in mistakes or correct decisions..

Discussion of the OPT model components after simulation experiences makes visible the sense-making process. and then to choose a leverage point in the sets of relationships that emerge. Kuiper & Pesut. Student selfefficacy for problem solving also improves if they see that their actions bring about desired outcomes (Bandura. comparison.Kuiper et al. Raths. Instructions linked with the webbing exercise encourage students to create and evaluate the complex interactions associated with a constellation of nursing care diagnoses. This keystone issue serves as the basis for defining a present state. classification. This leverage point becomes a priority focus of care and is defined as a keystone issue. 1987). content and procedures. Creation of a clinical reasoning web enables students to reason about relationships between and among competing nursing diagnoses within a given particular client scenario. Reflective use of thinking strategies are embedded in the model which guide reasoning processes along the way. 1977). OPT Model of Clinical Reasoning The OPT model of clinical reasoning uses creative thinking.: Debriefing with the OPT Model of Clinical Reasoning By using the OPT model to structure debriefing. Once a priority or keystone focus has been determined. and analysis (Petranek.. 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. et al. 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 Published by The Berkeley Electronic Press. 1999) (Figure 1). the client's present state is described and compared with a desired outcome state. It frames the situation and gives meaning to the clinical reasoning that takes place. The client story for simulation and authentic clinical experiences is determined by assessment. cognitive frames. Clinical judgments and conclusions are revisited due to continuous evaluation of evidence about outcome achievements. 1992. summarization. Cognitive knowledge is gained by using critical thinking strategies to understand nursing diagnoses. evaluation. students use the cognitive critical thinking strategies of organization. and focuses on outcomes (Pesut & Herman. emphasizes the importance of framing client situations. 2008 3 . emotions. 1992. 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. 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). while metacognitive knowledge is gained by reflecting and self-regulating to monitor those cognitive processes (Pesut & Herman. 2004). and assumptions.

tertiary care hospital (867 beds) which has a level II trauma designation. surgical/trauma intensive care and cardiovascular post-recovery. Authentic clinical experiences are scheduled during 14 weeks of an adult health medical/surgical nursing course on a variety of acute care units. 1. Kautz & Pesut. Students in these studies quickly identified priority nursing diagnoses. They served as a basis for clinical reasoning and reflective processes which occurred during authentic clinical experiences. Kuiper. senior and junior level baccalaureate nursing students demonstrated cognitive and metacognitive skills co-existing during clinical reasoning activities (Kuiper.2202/1548-923X. 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. Kuiper and Pesut. 2005). Vol. interventions. 17 medical/surgical nursing courses.bepress. 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. The experience is typically structured by (a) http://www. METHODOLOGY Setting and Sample The setting of this current project was a mid-sized city in the southeastern United States. Iss. Simulations have been used in this program for three years.com/ijnes/vol5/iss1/art17 DOI: 10.International Journal of Nursing Education Scholarship. and completing another OPT model worksheet related to the scenario. These students had no previous exposure to patient simulation scenario practice apart from task trainer exercises during their fundamental junior level nursing course. and outcomes for analysis and interpretation after client assessment. 2002. debriefing with an instructor. 2004. primarily in medical/surgical nursing courses. these students rotated out of the clinical setting at various points in time to spend four hours completing a patient simulation scenario. Of the 44 undergraduate senior baccalaureate nursing students who participated in this project.1466 4 . 5 [2008]. such as coronary care. After two weeks of OPT practice. the majority were female (89%). medical intensive care. Kautz. Throughout the length of the semester. Art. Caucasian (98%). 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. with a mean age of 22 years. The clinical setting was a nonprofit.

2007). they provide basic care. et al. with a consistent pattern over time (Kautz. 2007). 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.703.Kuiper et al. During the shift. completed independently at an off clinical site. Published by The Berkeley Electronic Press. Bartlett. revealed an inter-rater reliability of 87% between two clinical instructors for a random selection of 16 OPT work sheets. Buck. since early in a semester. (b) arriving for morning report.573. The third version of the rating tool. administer medications and treatments. Kuiper & Pesut 2005. individual scores tend to be lower. The OPT model worksheets from the authentic clinical experiences with the highest scores are chosen to remove the influence of maturation. & Williams. The validity of subsection scores on the tool continues to be tested and shows significant differences between students (p = . patient. Students collect pertinent data from the patient record. and given to the clinical faculty within one week of the experience.000) (Kautz.001) but no significant differences between semesters. The inter-rater reliability of this version tested significant (Kendall’’s coefficient: W = . Kuiper 2004). p = . family and health care team. The OPT Model rating tool has been used by researchers working with the OPT model since 2003 and it continues to be refined (Kautz. 2008 5 . used in this project. They are collected and rated by the faculty with the OPT model rating tool (see Figure 3). X2 (24) = . and (c) caring for the assigned patient for the next 10 hours.. The OPT worksheets (see Figures 1 & 2) are started during the clinical experience.: Debriefing with the OPT Model of Clinical Reasoning preparing the day before the clinical experience. The second version of the rating tool was used with undergraduate nursing students from a variety of settings. and develop a plan of care using the OPT model of clinical reasoning (see Figure 1). Kuiper. 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.

bepress. laboratory values 3. ABG. chronic atrial fibrillation.International Journal of Nursing Education Scholarship.2202/1548-923X. something just popped! I can’’t get any air. electrolytes. atrovent Judgments 1. cardiac enzymes.Chest x-ray: 80% pneumothorax . 1999 Figure 1 OPT Model of Clinical Reasoning http://www. CBC.Hypertension and tachypnea . Monitor .Left anterior chest tube Client -in-Context Story Cue Logic .Current medications: coumadin.com/ijnes/vol5/iss1/art17 DOI: 10.Risk for impaired tissue perfusion .Vital signs: BP 170/110.Pain and anxiety . After collapsing in the hallway.Ineffective breathing pattern .ABG’’s within normal limits . Patient stated.Anxiety . ““Oh. Respirations 30-38.vital signs.Risk for decreased cardiac output . After chest tube.ABG’’s: Arterial blood gas pH 7. Breath sounds were symmetrical and unlabored 3. Vol.Risk for aspiration . Wound care OPT Model . Assist with activities of daily living 6. pO2 82 mm Hg. Hbg/HCT.Sa02 < 85% . breathing.52-year-old male admitted to the ED c/o dyspnea.Risk for infection . 1. 17 Reflection Frame 52 year old anxious male with spontaneous pneumothorax.Breath sounds symmetrical .Activity intolerance . Encourage incentive spirometry and deep breathing 2.Sa02 > 90% .Risk for altered urinary elimination . Sa02 < 85% . Sa02 NANDA Keystone Issue Impaired Gas Exchange Decisions .NIC 1. heart failure . Incentive spiromentry and breathing excursion were adequate depth 4. Assist with position changes to aid breathing 5.1466 6 . Art. EKG. chest x-ray. Outcome State NOC . Positioned for ease of breathing 7.”” .33.Pain and anxiety relieved .Pesut & Herman.Vital signs within normal limits .History of smoking for 34 pack/yrs.Altered comfort (acute pain) .Respiratory acidosis/hypoxia . Pain and anxiety were relieved with position and pain medication 5.Chest tube maintained Present State .EKG monitor shows atrial fibrillation rate 180 bpm . No signs of wound infection Testing Assessment. pCO2 48 mm Hg . Chest x-ray –– expanded L lung 6. Sa02 > 90%.Decreased breath sounds on L . Iss. Administer pain medications and monitor pain 4. 5 [2008]. ABG’’s and vital signs within normal limits 2. emphysema.

pain medication .hypoxia Anxiety .Respiratory acidosis /hypoxia . 1999 Figure 2. Identify medical diagnosis and NANDA diagnoses that apply 2. Include supporting data to define each NANDA diagnosis 3. OPT Clinical Reasoning Web Published by The Berkeley Electronic Press.< Sa02 .aspiration Steps for Web creation 1.hypoxia Risk for aspiration .decreased breath sounds L chest .pain on inspiration Ineffective breathing pattern .Kuiper et al.creating a ““web”” leading to the priority or keystone problem -diagnosis with most arrows Clinical Reasoning Web .acute pain Risk for infection . Connect related diagnoses with arrows .pneumothorax .hypertension .Decreased breath sounds left chest Risk for altered urinary elimination .chest tube Risk for impaired tissue perfusion .Pesut & Herman.asymmetrical breathing Impaired Gas Exchange . 2008 7 .chest tube wound .hypertension Activity intolerance .pain medications .pain & anxiety .respiratory acidosis .: 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 .““something popped in my chest”” .Dyspnea .chest trauma Spontaneous Pneumothorax Emphysema Altered comfort (acute pain) .

OPT Model Rating Tool http://www. Iss. 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. 9=5) 1-5 10––18 connections between diagnoses (10 = 1. 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 1 2 3 4 5 6 Figure 3. Vol.1466 8 .International Journal of Nursing Education Scholarship.com/ijnes/vol5/iss1/art17 DOI: 10. 9=5) 1-5 5 –– 9 NANDA diagnoses have supporting data (5=1.2202/1548-923X. 5 [2008]. 17 Items Weeks Reasoning Web 5 –– 9 NANDA diagnoses (5=1. Art.bepress. 1.

pO2 82 mm Hg. The simulator had abnormal heart. as shown in Table 1. followed by a list of laboratory values and a potential list of medications. Most students became involved in the scenarios when the simulator spoke and responded to their questions. A typical scenario might be as follows: A 52-year-old white male is a visitor in the hospital walking by the Emergency Department. ““I can’’t get any air.100/65 Respiratory rate < 6 Pulse oximetry < (82%) Atrial fibrillation –– 180 bpm BP 172/110 then 120/75 Respiratory rate 25 Pulse oximetry 90’’s Published by The Berkeley Electronic Press. 2008 Slow heart rate by vagal maneuvers Medicate with Cardizem Continue to monitor 9 . ““Oh something just popped!”” He then whispers to you. You are a nurse returning from lunch and passing him in the hallway. and intentional wounds.”” 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. observe him suddenly grabbing the left side of his chest and gasps. lung and bowel sounds.: Debriefing with the OPT Model of Clinical Reasoning The simulation scenario consisted of a case study. Chest x-ray ( 80% pneumothorax on the left) Arterial blood gas pH 7. 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 .Kuiper et al.33.

interventions and outcomes. These reflections included the following comments: 1. and connecting present-outcome states and NANDA diagnoses. Art. http://www. Overall. nursing diagnoses.2202/1548-923X. p=. 3. the scores were higher for simulation OPT worksheets on listing interventions. Iss. students completed the OPT model worksheets. Vol. The experience made us actually think for ourselves without relying on an instructor or preceptor to step in. It was the first time I had to think fast to assess an unstable patient and prevent them from declining. 1.1466 10 . 5. making judgments regarding tests. 5 [2008]. Once the primary medical diagnoses was determined and the priority nursing care issues identified. 4. p = . 2. students used textbooks and PDA resources to search information on medications. 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=-. A comparison of the two groups revealed no significant differences between the mean scores (t = -1.com/ijnes/vol5/iss1/art17 DOI: 10. These scores were then compared with the clinical reasoning scores of the same 44 students during authentic clinical experiences with critically ill medicalsurgical patients.194).680. ANALYSIS Simulation debriefing discussions deal with issues of how clinical problems were solved and the efficacy of the interventions attempted. diagnostic and laboratory studies. recording laboratory data. The 44 OPT model scores for the simulation experiences averaged 48 points from a possible 76 points. To complete the assignment. The faculty then collected the worksheets and rated them using the OPT model rating tool (see Figure 3). I think this was a fairly decent learning experience. The students were also asked to evaluate their simulation experience in narrative format.321. The 44 OPT model rating scale scores averaged 47 points from a possible 76 points. we could get some of this practice in clinical. The experience challenged my clinical decision-making skills but it was difficult to write an OPT model about a mannequin. The OPT model worksheets were completed within 2-3 hours following the simulation experience. however. 17 The students worked together as a group to complete the OPT worksheets but submitted independent assignments for review and scoring.504).International Journal of Nursing Education Scholarship. The experience makes you think on the spot which I need practice with because it enhances critical thinking skills.bepress. and medical diagnoses.

and chose appropriate nursing interventions. 2004). 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. The clinical reasoning activities allowed for controlled. practiced data collection. McCausland. strategies. The situated and interactive simulated experience built on previously learned knowledge and related it to authentic clinical situations. students relied on their own knowledge base. 2004). which included debriefing with the OPT model worksheets. consistent. simulated experiences offered students a variety of clinical problems and practice with the clinical reasoning skills they will eventually use. relationships. 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. situated cognitive and metacognitive activities. et al. 2004. leadership and group dynamics (Jeffries. and feelings during the simulation as they experimented with interventions and interacted with fellow students. and problem solving with models of clinical reasoning.). We were able to practice doing all the things we would have to do in real situations without practicing on a living patient. McCausland. focused. outcomes. This type of experiential learning also involved team work. Therefore.. 2006). As the students noted in their responses. exploration of alternatives. 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. Students had to process facts. confidence. The projected outcomes were skill competency. and self-efficacy in clinical practice (Kovalsky & Swanson. they had to think on the spot and solve problems independently. During simulation experiences.. et al.).. one can Published by The Berkeley Electronic Press. 2004). While authentic clinical experience with patients cannot be replaced (Feingold.Kuiper et al. et al. 2008 11 . The second goal was to determine if the OPT model could be used as a method of debriefing following patient simulation. The OPT model worksheets used with these simulations provided the scaffolding for reflection and review of the clinical reasoning activities during simulation. 2005. Since the OPT model worksheet scores for patient simulation were comparable to the authentic clinical experiences. knowledge and strategies in order to monitor and control cognitive processes to perform tasks efficiently and effectively (Feltovich.: Debriefing with the OPT Model of Clinical Reasoning 6. 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. expertise is developed by amassing skills. analyzed situations. et al. et al.

in order to direct student learning for the best reinforcement of clinical reasoning outcomes. Controlling for variables such as maturation. Other considerations for the future include incorporating patient simulation activities as part of student evaluation and curriculum evaluation. and for enhancement of didactic content. and type of authentic clinical assignments will further the exploration of simulation evaluation. 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.International Journal of Nursing Education Scholarship. 5 [2008]. Simulation allows for errors in decisions and judgments without jeopardizing patient safety.1466 12 .com/ijnes/vol5/iss1/art17 DOI: 10. Future testing of models and theories as described here is needed in the area of simulation-based learning. and taking into consideration student learning styles. Art. There is still a great deal of knowledge to be gained in understanding the role of debriefing for learning from simulation (Fanning & Gaba.2202/1548-923X. 2007). the findings showed comparable results between the two measurements. the arguments for using high fidelity patient simulation in the current educational environment have obvious short term benefits. Measuring the maturation of clinical reasoning with students at various points in time. 1. 17 speculate that the inherent clinical reasoning supported by these activities is occurring during the debriefing following simulation. Admittedly. Vol. Iss. practice with simulation. 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. http://www. student characteristics. While this project was limited by a small sample and a descriptive design. Evidence in this study supports the use of patient simulation as a source of remediation for students with clinical challenges. However. long term benefits of developing clinical expertise remain to be discovered. will add to the evidence needed to know when and how to best use simulation to support clinical learning.bepress. yet enhances clinical reasoning competence. 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.

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