debriefing with the opt model of clinical reasoning

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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, [email protected] of North Carolina Wilmington, [email protected]

Southeastern Community College, [email protected] of North Carolina at Pembroke, [email protected] Hanover Regional Medical Center, [email protected]

Copyright c2008 The Berkeley Electronic Press. All rights reserved.


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Debriefing 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 learn-

ing strategy to promote situated cognition and clinical reasoning to teach nursing students how to

solve problems. A project that uses a structured debriefing activity, the Outcome Present State-Test

Model of clinical reasoning following high fidelity 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 argu-

ments for using high fidelity patient simulation in the current educational environment has obvious

short term benefits, however, the long term benefit of developing clinical expertise remains to be

discovered.

KEYWORDS: patient simulation, debriefing, clinical reasoning, situated cognition


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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 occursthrough 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 ofexpertise (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 andsupports 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 clinicalreasoning (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 clinicalexperiences 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 skillreasoning, 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 longterm 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 onlearning for real-life practice environments.

The desired goals of this project are twofold, first, to determine the clinicalreasoning 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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Kuiper et al.: Debriefing with the OPT Model of Clinical Reasoning

Published by The Berkeley Electronic Press, 2008


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Theoretical Framework

Situated cognition during patient simulation is an instructional approach

that exemplifies the constructivist theory of learning through experience andbrings about clinical reasoning skill practice. Constructivism is a philosophy that

states individuals form or construct what they learn, understand, and knowledge issubjective, 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 areactively 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 stimulithrough 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 thisprocess 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 isa 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 responsesmay be at various cognitive levels and incorrectly applied to authentic

experiences (Petranek, et al.). As well, writing can extend analytical learning byforcing students to organize information and debrief on an individual basis

(Petranek, et al.). This analytic work promotes exploration of learning andencourages self-reflection (Jeffries, 2005). However, the connections between the

experience and cognition remain poorly understood (Petranek, et al.).

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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 self-

efficacy for problem solving also improves if they see that their actions bringabout 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 criticalthinking strategies to understand nursing diagnoses, content and procedures, while

metacognitive knowledge is gained by reflecting and self-regulating to monitorthose cognitive processes (Pesut & Herman, 1992; Kuiper & Pesut, 2004). Theclient 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 analysisand 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 givenparticular 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 thesets 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 fordefining 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 gapthat 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 continuousevaluation of evidence about outcome achievements. Reflective use of thinking

strategies are embedded in the model which guide reasoning processes along theway.

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 thesestudies quickly identified priority nursing diagnoses, interventions, and outcomes

for analysis and interpretation after client assessment. The OPT model andclinical 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 southeasternUnited States. Simulations have been used in this program for three years,

primarily in medical/surgical nursing courses. The clinical setting was a non-

profit, tertiary care hospital (867 beds) which has a level II trauma designation. Of

the 44 undergraduate senior baccalaureate nursing students who participated inthis 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 juniorlevel nursing course.

Design

This descriptive design included a purposive sample of students in anadult health medical/surgical course whose clinical assignment was to complete 5-

6 OPT worksheets after authentic clinical experiences. Throughout the length of

the semester, these students rotated out of the clinical setting at various points intime 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 OPTmodel worksheets completed for authentic clinical experiences.

Authentic clinical experiences are scheduled during 14 weeks of an adulthealth 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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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 clinicalexperience, 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 cognitiveactivities 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 thencompared to their OPT model worksheets completed for high-fidelity patient

simulation. The OPT model worksheets from the authentic clinical experienceswith the highest scores are chosen to remove the influence of maturation, sinceearly in a semester; individual scores tend to be lower.

The OPT Model rating tool has been used by researchers working with theOPT 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-raterreliability 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 16OPT 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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Outcome State

NOC- Sa02 > 90%- ABGs within

normal limits- Vital signs within

normal limits- Breath soundssymmetrical

- Pain and anxietyrelieved

- Chest tubemaintained

Present State

- Sa02 < 85%- Respiratoryacidosis/hypoxia

- Hypertension andtachypnea

- Decreased breathsounds on L

- Pain and anxiety- Left anterior chest

tube

Decisions - NIC1. Encourage incentive spirometry and deep breathing2. Monitor - vital signs, breathing, laboratory values3. Administer pain medications and monitor pain4. Assist with position changes to aid breathing5. Assist with activities of daily living6. Wound care

Judgments

1. After chest tube,Sa02 > 90%, ABGs

and vital signswithin normal limits

2. Breath sounds weresymmetrical andunlabored

3. Incentivespiromentry and

breathing excursionwere adequate depth

4. Pain and anxietywere relieved with

position and painmedication

5. Chest x-ray expanded L lung

6. Positioned for easeof breathing

7. No signs of woundinfection

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

Frame 52 year old anxious male with spontaneous

pneumothorax.

Reflection

Cue Logic

- Risk for alteredurinary elimination

- Risk for impairedtissue perfusion

- Risk for infection- Risk for decreased

cardiac output- Risk for aspiration- Altered comfort(acute pain)

- Ineffectivebreathing pattern- Activity intolerance- Anxiety

NANDA

Keystone IssueImpaired Gas

Exchange

OPT Model - Pesut & Herman, 1999

Client -in-Context

Story- 52-year-old maleadmitted to the ED c/odyspnea. Aftercollapsing in the

hallway. Patient stated,Oh, something justpopped! I cant get anyair.

- EKG monitor showsatrial fibrillation rate180 bpm

- Vital signs: BP170/110, Respirations30-38, Sa02 < 85%

- ABGs: Arterialblood gas pH 7.33,pO2 82 mm Hg, pCO248 mm Hg

- Chest x-ray: 80%pneumothorax

- History of smoking for34 pack/yrs,emphysema, chronicatrial fibrillation, heartfailure

- Current medications:coumadin, atrovent

Testing

Figure 1 OPT Model of Clinical Reasoning

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Impaired Gas

Exchange

- < Sa02- Respiratory acidosis/hypoxia

- Dyspnea- Decreased breath

sounds left chest

Clinical Reasoning Web - Pesut & Herman, 1999

Ineffectivebreathing pattern- decreased breath soundsL chest

- chest tu e

Risk for impairedtissue perfusion- respiratory acidosis- hypoxia

Anxiety

- something popped inmy chest

- acute pain

Spontaneous

Pneumothorax

Emphysema

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

Risk for aspiration- pain medication- asymmetricalbreathing

Activity intolerance- pain & anxiety- hypertension- hypoxia

Risk for decreasedcardiac output- pneumothorax- hypertension

Risk for alteredurinary elimination- pain medications

- chest trauma

Risk for infection- chest tube wound

- aspiration

Alteredcomfort(acute pain)- pain onins iration

Keystone

issue:

focusing on

this

diagnosis

will assist

in

resolving

other

diagnoses

Figure 2. OPT Clinical Reasoning Web

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Figure 3. OPT Model Rating Tool

Items Weeks 1 2 3 4 5 6

Reasoning Web

5 9 NANDA diagnoses (5=1, 9=5) 1 - 5

5 9 NANDA diagnoses have supporting data (5=1, 9=5) 1 - 51018 connections between diagnoses (10 = 1, 18 = 5) 1 - 5

NANDA related to Medical Diagnosis 1

Connections lead to keystone 1

NANDA represent domains: 6

PhysiologicBehavior/psychosocialSafetyFamily

CommunityHealth system

Patient Story

Medical Diagnosis 1

Assessment History 1

Signs & Symptoms 1Laboratory Data 1

Social/Family History1

Outcome Present State

Keystone is NANDA Diagnosis 1

5 Present state statements related to 5 keystone / NANDA hassupporting data 5

5 Outcome state statements related to 5 keystone / NOC app. for

NANDA 5

5 Outcome state statements improvement5 from Present state / Maintenance 5

5 Interventions rt keystone / 5 NIC Activities related to 5 outcomes5

5 Tests rt to keystone/ 5 NOC Clinical Indicators related to outcomes5

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: 2PhysiologicBehavior/psychosocial

SafetyFamily

CommunityHealth system

Kuiper & Kautz Total Score 76

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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 bowelsounds, and intentional wounds. A typical scenario might be as follows:

A 52-year-old white male is a visitor in the hospital walking by theEmergency 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: Which prompts the student to:

Respiratory rate 30Pulse oximetry < (85%)

Shortness of breath

Absent of breath sounds on L

Diminished breath sounds R

Coughing and c/o pain

Vital signs: BP 170/110

Respiratory rate 38

Change in vital signs:

BP - 100/65

Respiratory rate < 6Pulse oximetry < (82%)

Atrial fibrillation 180 bpm

BP 172/110 then 120/75

Respiratory rate 25Pulse oximetry 90s

Elevate head of bedApply oxygen via facemask

Auscultate breath sounds;

Chest x-ray ( 80% pneumothorax onthe 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

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 tosearch information on medications, diagnostic and laboratory studies, nursingdiagnoses, 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 modelscores 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 medical-surgical patients. The 44 OPT model rating scale scores averaged 47 points from a

possible 76 points. A comparison of the two groups revealed no significantdifferences 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 fidelitypatient 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 andNANDA diagnoses.

The students were also asked to evaluate their simulation experience innarrative 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 wasdifficult 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 preventthem from declining.

5. I think this was a fairly decent learning experience; however, we could getsome of this practice in clinical.

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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 authenticclinical experiences. Students had to process facts, strategies, outcomes,

relationships, and feelings during the simulation as they experimented withinterventions 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 modelworksheets. 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 datacollection, 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 interactivesimulated 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). Asthe 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 willeventually use.

The second goal was to determine if the OPT model could be used as amethod 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 andstrategies 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 providesopportunities for reflection, exploration of alternatives, and problem solving with

models of clinical reasoning. The OPT model worksheets used with thesesimulations 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 descriptivedesign, the findings showed comparable results between the two measurements.

Controlling for variables such as maturation, student characteristics, practice withsimulation, 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 usesimulation 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 groupcollaboration impacted choices made during simulation. There is still a great deal

of knowledge to be gained in understanding the role of debriefing for learningfrom simulation (Fanning & Gaba, 2007). Future testing of models and theories asdescribed 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 bestreinforcement 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 forcomprehension. Evidence in this study supports the use of patient simulation as a

source of remediation for students with clinical challenges, and for enhancementof 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 simulationactivities 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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