Contributor: Daniel J. Pesut

Authors: Daniel J. Pesut, PhD RN FAAN and RuthAnne Kuiper, PhD, RN, CNE, ANEF

First published – 1998

Major Concepts

Clinical Reasoning
Reflection
Metacognition
Nursing Knowledge Work
Standardized Nursing Nomenclature
Clinical Decision Making
Clinical Judgment
Self Regulated Learning

Typology –

The OPT model provides a structure for a more sophisticated, systems-based reasoning process. The model uses the facts associated with a client’s story to frame the context and content for clinical reasoning that enhances metacognition and self-regulated learning.

Brief Description

Clinical reasoning is the reflective, con current, creative, and critical thinking embedded in nursing practice. Contemporary nursing practice with its focus on outcomes and complex analysis of multiple client conditions requires clinical reason ing. The OPT model provides the structure for the iterative reasoning necessary for purposeful self-reflective judgements. The OPT model provides a structure for a more sophisticated, systems-based reasoning process. The model uses the facts associated with a client’s story to frame the context and content for clinical reasoning. Contemporary nursing practice with its focus on outcomes and complex analysis of multiple client conditions requires clinical reasoning. Clinical decision making in this model is defined as choosing nursing actions. Clinical judgments are the conclusions drawn from tests that compare present-state data to specified outcome-state criteria. Concurrent judgments related to the match or mismatch of present-state data and outcome-state data result in reframing the situation, the creation of new tests, additional clinical decisions, or the conclusion that a reasoning task is complete. The OPT model is a transformation of the traditional nursing process and builds on critical and metacognitive (reflective) thinking skills. The specific thinking strategies of knowledge work, self-talk, prototype identification, schema search, hypothesizing, if-then think ing, juxtaposing, comparative analysis, reflexive comparison, and metacognitive check are the core techniques of reflection. A client-in-context story provides facts and cues linked in logical ways to frame situations. From cue logic and framing, the present state and outcome states are identified. The side-by-side comparison or juxtaposition of the present state and outcome state creates a match or mismatch test condition. Decisions or nursing actions help clients make the transition from the initial resent state to the desired outcome state. Iterative judgments determine the meaning of test results. Reflection and specific thinking techniques support this concurrent reasoning process. The OPT clinical reasoning model differs from the earlier generations of the nursing process. Its strengths include: the model builds on a foundation of reflective judgment and is derived from empirical data; the model honors the holistic nature of nursing; the model approaches patient situations in terms of outcomes; the model identifies the thinking skills and strategies involved in making clinical decisions and judgments; and the model can be used with interprofessional taxonomies that provide the content for clinical reasoning. Given contemporary developments in nursing informatics and health analytics, as well as the increased use of artificial intelligence, future generations of the nursing process are likely to emerge Pesut forecasts future transformations of the nursing process and suggests a fourth generation (2010-2030) will be about knowledge modeling, The Fifth generation (2030-2050) will be about prescriptive nursing, and the sixth generation (2050-2070) will be about predictive nursing care. Given the changes and transformations of developing nursing process models the essential structure and components of reflective clinical reasoning are grounded in the Outcome Present State Test (OPT) Model of Reflective Clinical Reasoning.

Primary Source(s)

Primary web source – https://connect.springerpub.com/content/book/978-0-8261-3184-3/part/part01/chapter/ch01

Application Sources

Pesut, D.J. & Herman, J. (1992). Metacognitive skills in diagnostic reasoning: Making the implicit explicit. Nursing Diagnosis, 3(4), 148-154.

Herman, J., Pesut, D. J., & Conard, L. P. (1994). Using metacognitive skills: the quality audit tool. International Journal of Nursing Terminologies and Classifications, 5(2), 56-64.

Pesut, D & Herman, J. (1998). OPT Transformation of the Nursing Process for Contemporary Nursing Practice, Nursing Outlook, 46(1), 29-36.

Pesut, D. & Herman, J. (1999). Clinical Reasoning: The Art and Science of Critical and Creative Thinking. New York: Delmar Publishing. https://archive.org/details/clinicalreasonin0000pesu

Kuiper, R. & Pesut, D. (2004). Promoting cognitive and metacognitive reflective learning skills in nursing practice: Self-regulated learning theory. Journal of Advanced Nursing, 45 (4), 381-391.

Pesut, D. (2004). Reflective clinical reasoning is the development of practical intelligence as a source of power. Chapter 7, pages 146-162, in Linda Haynes, Howard Butcher and Teresa Boese Nursing in Contemporary Society: Issues, Trends, and Transitions to Practice. Prentice Hall, NJ.

Pesut, D. (2004). Epilogue: Toward the Future. In Linda Haynes, Howard Butcher, and Teresa Boese Nursing in Contemporary Society: Issues, Trends, and transitions to practice. Prentice Hall, NJ.

Kautz, D., Kuiper, R., Pesut, D., Knight-Brown, P., Daneker, D. (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 Scholarship.2:1, 1-21.

Kautz, D., Kuiper, R., Pesut, D., Williams, R. (2006). Using NANDA, NIC and NOC language for clinical reasoning with the Outcome –Present State- Test Model, International Journal of Nursing Terminologies and Classification, Vol. 17, No. 3-4, July – December, 129-138.

Pesut, DJ. (2006). 21st Century Nursing Knowledge Work: Reasoning into the Future (pages 13-23) In Charlotte Weaver, Connie White Delaney, Patrick Weber, Robyn Carr (Eds) Nursing and Informatics for the 21st Century: An International Look at Practice, Trends, and the Future. Chicago, IL: Health Care Information and Management Systems Society (HIMSS).

Kuiper, Ruth Anne, Pesut, Daniel, Kautz, Donald (2009). Promoting the self-regulation of clinical reasoning skills in nursing students. The Open Nursing Journal, 2009, 3, 76-85.

Kuiper, Ruthanne, O’Donnell, Sandy, Pesut, Daniel, Turnise, Stephanie (2017). Essentials of Clinical Reasoning for Nurses: Using the Outcome – Present State – Test Model for Reflective Practice, Honor Society of Nursing, Sigma Theta Tau International Press, Indianapolis, IN.

Kuiper, Ruthanne, Pesut, Daniel J, Arms, Tamara (2016). Clinical Reasoning and Care Coordination for Advanced Practice Nursing, New York: Springer Publishing.

Kuiper, R. A. (2002). Enhancing metacognition through the reflective use of self-regulated learning strategies. The Journal of Continuing Education in Nursing, 33(2), 78-87.

Kuiper, R. (2008). Promoting Cognitive and Metacognitive Thinking Skills by Reflecting with Self-Regulated Learning Prompts. In. N. C. Facione & P. A. Facione (Eds.), Critical Thinking and Clinical Reasoning in the Health Sciences: An International Multidisciplinary Teaching Anthology (pp. 145-155). Millbrae, CA: The California Academic Press. www.InsightAssessment.com

About the Authors

Authors’ Note: The original OPT model was developed by Daniel J Pesut and JoAnne Herman. Dr. Ruth Anne Kuiper built on the original model with self-regulated learning theory. Dr. Kuiper also led a team of colleagues that tested the model and developed additional teaching learning tools as well as instruments and research studies to evaluate use of the model. Colleagues of Dr. Kuiper were invited to submit case studies based on the application of the model to subsequent textbooks: For example, Sandra O’Donnell, & Stephanie Turrise, contributed to The Essentials of Clinical Reasoning for Nurses: Using the Outcome-Present State Test Model for Reflective Practice published by Sigma Theta Tau in 2017. Daniel Pesut and Ruth Anne Kuiper further evolved and developed the model to incorporate concepts, principles, and practices of Care Coordination Clinical Reasoning. Dr. Tamatha E. Arms contributed case studies and was a co-author of Clinical Reasoning and Care Coordination in Advanced Practice Nursing, published by Springer in 2016.

Dr. RuthAnne Kuiper received a Diploma in Nursing from Mountainside Hospital School of Nursing in Montclair, New Jersey in 1976. She practiced as a coronary care nurse for 8 years while attending Excelsior College, Albany, New York, and received a BSN in 1987. She moved to Los Angeles, California, and continued to work as a critical care nurse while attending the University of California at Los Angeles and received a Master’s of Nursing as a clinical specialist in cardio-pulmonary nursing in 1989. After moving to Philadelphia, Pennsylvania, she worked as an educator at Methodist Hospital School of Nursing for 1 year. Then, she moved to Charlotte, North Carolina, to teach at Presbyterian Hospital School of Nursing for 10 years. While living in Charlotte, she attended the University of South Carolina at Columbia and received a Doctorate of Philosophy in Nursing in 1999. She is currently a tenured professor and Professor at the University of North Carolina School of Nursing, Wilmington. She is also the lead instructor for the graduate nurse educator track. Her research interests include clinical reasoning, metacognition, self-regulated learning, and technological innovation in nursing education. Dr. Kuiper has been the primary investigator for eleven studies related to nursing education, totaling over 300,000.00. She has authored over 25 articles and two book chapters in this area. Instructional and clinical expertise is in the area of adult health, specifically critical care nursing. She is a grant reviewer for the National League for Nursing, Sigma Theta Tau International, and the Department of Health and Human Services. She is on the editorial board for Clinical Simulation in Nursing and reviews nursing research articles for 5 other peer-reviewed journals. She has been a member of Sigma Theta Tau International since 1989, holds alum status from AACN for CCRN certification since 1990, and has been a certified nurse educator since 2007. In 2011, Dr. Kuiper was inducted into the Academy of Nursing Education Fellows. She continues to teach nurse educator classes, supervises nurse educator practicums, and mentors graduate students both at UNCW and around the country on master’s and dissertation research projects. She has been a faculty mentor in the Nurse Faculty Leadership Academy, co-sponsored by Sigma Theta Tau International and Elsevier Foundation, for the 2012 – 2013 and 2014-2015 classes. Dr. Kuiper is a full professor faculty emeritus from the University of North Carolina Wilmington School of Nursing. She is currently teaching part-time in graduate programs, teaching informatics and health promotion, and serving on dissertation committees.

Daniel J. Pesut, PhD RN FAAN is an Emeritus Professor of Nursing in the Nursing Population Health and Systems Cooperative Unit of the School of Nursing at the University of Minnesota and Emeritus Katherine R. and C. Walton Lillehei Chair in Nursing Leadership. He has held academic and administrative positions at the University of Michigan, University of South Carolina, and is an Emeritus Professor of Nursing at Indiana University School of Nursing. Dr. Pesut is an American nurse educator, academic, researcher and coach. He is a popular speaker, and consultant, and is known for his ability to inspire and encourage people as they develop creative ideas and design innovative practices with a desired future in mind. Pesut is internationally known for his work in reflective clinical reasoning, nursing education, psychiatric mental health nursing, and leadership development. Dr. Pesut is a master teacher and has held academic and administrative positions in both the education and public service sector. His research interests include volitional psychosomatic self-regulation, clinical reasoning, creative thinking, innovation, future studies, and leadership development. He speaks on the topics of creative, complexity, and integral thinking, clinical reasoning in nursing, and foresight leadership. Throughout his professional career he has been interested in how the creative process supports personal and professional development, enhances reasoning and scientific thinking, and promotes innovations in health care. Through time his educational and research interests focused on the development and evaluation of cognitive and metacognitive aspects of thinking, and development and dissemination of the Outcome-Present-State-Test (OPT) model of reflective clinical reasoning. Dr. Pesut earned a PhD in Nursing from the University of Michigan, a master’s degree in Psychiatric Mental Health Nursing from the University of Texas Health Science Center in San Antonio, TX and BS degree in Nursing from Northern Illinois University, DeKalb, IL while being supported by the US Army Student Nurse Program. He has completed Certificates in Management Development from Harvard Institute for Higher Education, Core Mediation Skills Training from the International Association of Dispute Resolution (IARD) and Integral Studies from Fielding Graduate University. He is a certified Hudson Institute of Santa Barbara coach and is a member of the International Coaching Federation (ICF). He served on the Board of Directors of the Honor Society of Nursing, Sigma Theta Tau International for eight years. He was President Elect from 2001-2003 and President of the Society from 2003-2005. Sigma established the Daniel J Pesut Spirit of Renewal Award to honor his legacy and contributions to the nursing profession. This international award is given every two years to a nursing professional who meets the following criteria: Service to others through civic, professional, and/or community engagement. Scholarly habits that stimulate reflective practice in self and others. Commitments to the development of knowledge, learning, and service. Organizational contributions that foster professional growth, development, and renewal in others. Mentoring and coaching that foster renewal. The ability to raise the spirit of colleagues, self, and other associates.