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Year : 2017  |  Volume : 10  |  Issue : 3  |  Page : 657-663
Application of an outcome present test-peer learning model to improve clinical reasoning of nursing students in the intensive care unit

1 Faculty of Nursing and Health, Universitas Muhammadiyah, Semarang, Indonesia
2 Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
3 University of Boston, USA

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Date of Web Publication21-Aug-2017


Aim: High clinical reasoning skills are required by nurses in the intensive care unit (ICU). Nurses should perform clinical reasoning and make important clinical assessments and decisions for the provision of nursing care in the ICU. However, they often have difficulty in making decisions because of a lack of skills and proficiency in clinical reasoning methods. The outcome present test model through peer learning (OPT-peer learning) constitutes one of the important strategies to improve clinical reasoning skills. This research is aimed to explore the experience of nursing students and clinical instructors, following the application of the OPT-peer learning model. This phenomenology study was conducted with eight students of the nursing profession and four clinical instructors after applying the model of OPT-peer learning for 6 weeks. Materials and Methods: Data were collected through focus group discussions and in-depth interviews. Thematic analysis techniques were applied using Atlas.ti software version 6.1. There are six themes identified from participants pertaining to their experience in using the OPT-peer learning model: The model facilitates the guidance process; improves clinical reasoning skills; strengthens self-directed learning; triggers a successful group process; strengthens use of interrelated terminology of the North American Nursing Diagnosis Association (NANDA), Nursing Intervention Classification (NIC), and Nursing Outcome Classification (NOC); and facilitates the preparation of report documentation. Results: The OPT-peer learning model can be applied as an effective learning strategy for developing clinical reasoning skills in the students of the nursing profession who take specialization in the ICU. Training on the OPT-peer learning model, especially the mastery of its modules and terminologies of NANDA, NIC, and NOC, is needed before the model is applied.

Keywords: Clinical reasoning, North American Nursing Diagnosis Association, Nursing Intervention Classification, Nursing Outcome Classification, outcome present test model, peer learning

How to cite this article:
Wuryanto E, Rahayu GR, Emilia O, Harsono, Octavia AP. Application of an outcome present test-peer learning model to improve clinical reasoning of nursing students in the intensive care unit. Ann Trop Med Public Health 2017;10:657-63

How to cite this URL:
Wuryanto E, Rahayu GR, Emilia O, Harsono, Octavia AP. Application of an outcome present test-peer learning model to improve clinical reasoning of nursing students in the intensive care unit. Ann Trop Med Public Health [serial online] 2017 [cited 2021 Mar 9];10:657-63. Available from:

   Introduction Top

Clinical reasoning skills are highly needed by nurses in the intensive care unit (ICU). ICU nurses perform at least 50 important clinical reasons during their 8 h shifts [1] and make clinical assessments and decisions every 30 s. However, nurses often have difficulty to make clinical decisions.[2] Half of the clinical signs noted within 24 h are left without further action.[3] Changes in the condition of critically ill patients such as pulse rate, respiration, and oxygenation are often not followed up because nurses are not well versed in clinical reasoning skills.[4]

The learning methods used for clinical education are essential to improve the clinical skills of the students. Learners need learning experiences to effectively improve their clinical reasoning skills to be capable to collect accurate data, solve problems, make decisions, and provide quality services.[5] However, the available clinical reasoning learning methods for nursing education are limited terbatas.[6] The outcome present test (OPT) model that was developed by Pesut and Herman [7] is one of the learning models that can be used to improve clinical reasoning skills.


The OPT model is a nursing process model designed to develop the clinical reasoning skills of learners. The focus of this model is the result (outcome) of nursing, with the reversal way of thinking to change the client from the current health status (present state) to the desired state (outcome), as shown in [Figure 1]. The clinical reasoning web constitutes other components in the OPT model as shown in [Figure 2].[8]
Figure 1: Outcome present state test model[8]

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Figure 2: Clinical reasoning web[8]

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The OPT model is the third generation of the nursing process model designed to help improve learners' clinical reasoning skills to better plan and evaluate care. Pesut and Herman [8] developed the OPT model based on Bandura's learning theory of self-efficacy, which envisions that the participants' ability to solve problems increases when they see nursing interventions bringing the desired results to the patients they care for.[9]

Research shows that students among other skills make progress in self-observation and self-judgment that improve clinical reasoning skills acquisition;[5] they become able to organize and evaluate the data collected to identify critical problems or needs of the patient [6] and master the use of terminology of North American Nursing Diagnosis Association (NANDA), Nursing Intervention Classification (NIC), and Nursing Outcome Classification (NOC) and their interrelation. According to Bartlett et al.,[10] the model also encourages cognitive knowledge of learners that can be obtained using critical thinking strategies to better understand nursing diagnoses, contents, and procedures, while developing metacognitive knowledge obtained by self-reflection and self-regulation.

The OPT model constitutes a complex process that requires mastery of high cognitive and metacognitive skills. Meanwhile, the limited time spent by students in clinical practice and the tight schedule of clinical instructors due to a high workload have caused the time for student guidance to be very limited. As a result, students need to learn with friends or through peer learning. Peer learning strategies are highly needed to improve the effectiveness of the teaching and learning process.[11]

Evidence suggests that learners gain their satisfaction because their thoughts are appreciated, they are able to work in teams, and they can solve problems together.[12],[13],[14] OPT also encourages students taking of responsibility for their own learning,[15],[16],[17] thereby reducing their anxiety and reinforcing the feeling that other people who can help are available.[13],[18] In the process, OPT can improve communication skills and reinforce previous learning [15],[16] while encouraging independent learning, improving self-confidence, and developing essential problem-solving, decision-making, and critical thinking skills.[12],[17],[19]


This study aims to explore the perceptions of students and clinical instructors after applying the model of OPT-peer learning during clinical learning in the ICU.

   Research Methods Top

This study rigorously employed the qualitative method by emphasizing the phenomenology approach. The study was conducted with eight nursing profession students of Nursing and Health Sciences (FIKKES) Faculty taking clinical practice concentration in ICU for 6 weeks between July and September 2014. During the study, students were accompanied by four clinical supervisors. The application of purposive sampling was employed as the sampling technique in this study. In accomplishing the study, students were divided into four groups of two. Every group was given a sample case to be solved collaboratively every week, and they were asked to write a report and present it in accordance with the OPT portfolio and clinical reasoning web. Every participant was interviewed and asked to join the focus group discussion (FGD) related to their weekly learning experience. The clinical supervisors were also interviewed at the end of the study. Data were analyzed by using  Atlas More Details. Ti 6.1 software ( which included the process of coding, categorizing, and theme arranging based on the verbatim transcript.

Ethical agreement

This study was approved by the Faculty of Medical Research Ethical Committee at Universitas Gadjah Mada, The Institute of Research and Community Service (LPPM) of University of Muhammadiyah Semarang, The Director of RSUD Tugurejo Semarang, and The National Unity and Society Advocacy, City Government of Pekalongan.


The study indicated that the average age of most respondents was 24 years, with mean GPA of 3.06 and majority were female (62.5%), as shown in [Table 1].
Table 1: The distribution of respondent frequency based on age, grade point average, and sex

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Qualitative analysis of students' and clinical supervisor's experience

It was clearly observed that students' and clinical supervisor's experience in applying OPT-peer learning showed that generally this model was found more effective in increasing clinical logic compared with the conventional one.

There were at least six themes identified in this study, including: this method would facilitate the supervision process, improve students clinical logic ability, foster self-directed learning, encourage collaborative learning, enrich the terminology of NANDA, NIC, and NOC, and help the documentation process of report writing.

  • Facilitate the supervision process

All clinical supervisors were asked to explain the application of the OPT-peer learning model to facilitate the supervision process, encourage and supervise the discussion, improve students' preparation before the discussion, and encourage the target competency. Although many clinical supervisors assumed that this model was somewhat time-consuming, they agreed about the positive merits of the model.

“…this model applied the easier way than the conventional one. Students are mentally ready to have discussion with their peers.” (PK.1).

“…it will be much easier to teach students using this model and they tend to get what the subject is about…” (PK.2)

  • Improve students' clinical logic ability

Compared to the nursing process method, the OPT-peer learning model encourages students to be more critical and logical. Applying the model, they are able to design a simpler and more understandable framework that is interesting and challenging. It helps students better understand about pathophysiology and disease concepts, and students found it easier to respond and give comment in FGDs.

During the review process, the model would refer and focus to problem-solving data. When there were unsynchronized data and solutions, it would be depicted on the framework model. This study showed that by only minimal input from the students, it would provide answers to the interrelated problems that appeared.

“….it is easier….when we…analyze…by using several data, we would make many diagnoses…. It will make us learn easier …and it also helps CI to correct the mistakes.” (M.8)

This framework model also helps students analyze data, determine nursing diagnosis, and identify keystone issue in decision-making process. The model allows for several comprehensive nursing diagnoses.

“In this model, we should master the pathway before performing clinical reasoning data. The data taken should be appropriate.” (M.2)

However, this model demanded standard terminology that prevents students from copy/pasting from the internet.

“…there are pages of review…(but)… only 3 diagnoses, …sometimes 1 diagnosis only…. In OPT model, we can take more diagnoses for its clinical reasoning…. (M.5)

We (once) fake the diagnose and (copy paste from internet)… and it's not patient real condition….” (M.5)

This model also focused on the outcome and nursing interventions based on the problems found.

“It is simple and we don't need to write a lot, and we can conduct nursing application according to the guidance book. (M.7)

  • Foster self-directed learning

This model was found to improve students' interest and motivation for learning, to increase the ability of patient management, as well as to foster self-confidence and responsibility.

“…we thought that our willingness to read is getting stronger…. It is simply to avoid lack of information or embarrassment. (M.4)

“….I just feel relaxed and more confident….” (M.8)

The higher learning motivation was due to this model being more understandable, simple, interesting, and challenging. It also demanded the conceptual and theoretical mastery about pathophysiology and critical reflection from clinical supervisors.

“when my OPT was checked by the supervisor, we only do little revision so it will improve my motivation.” (M.1)

“But in this (OPT), we feel that our motivation is increasing, I don't know why, Sir…. Here…we have to be more careful and understand the concepts well. The most important part is we have to learn to know how (something) is going on? (M.2)

  • Encourage collaborative learning

This model essentially encourages the discussion within groups by helping to develop better understanding of each other, creating a comfortable atmosphere to learn, and distributing well-organized job descriptions in a way that is simple, easy, and interesting. Through the process, they learn how to eliminate selfishness, increase responsibility, and deliver their opinions confidently.

“…now we understand patient's case more easily because by performing something in collaboration, we would discuss more and complete each other. We know better since information owned by two different people will increase our mastery level….” (M.7)

“… here we can learn more and understand more. We also find it is easy to do the supervision.” (M.4)

  • Foster NANDA, NIC, and NOC terminology

Students were motivated to learn and understand NANDA, NIC, and NOC terminology so that they would not just copy/paste from the internet.

“…before applying OPT, we would just do copy/paste from any source (internet), but after applying OPT, we were automatically forced to learn NANDA,….” (M.8)

Students should learn how to correlate terminology in NANDA, NIC, and NOC.

“There are several criteria of supporting the diagnosis in NANDA, so we can observe a patient's condition and match it with the existing data.…. It is simply said that NANDA, NIC, and NOC are related to each other.” (M.6)

  • Help record the documentation easily

This simpler, shorter yet comprehensive model requires less writing. This model can be comprehended quickly, is supported by deep review, and is simple to be evaluated.

“…report documentation could be carried out easily…and a well-organized supervision schedule.” (PK.1)

“…the conventional method would spend more paper….less focus. However this model demanded students to think critically.” (PA.1)

Obstacles of the learning process

There were some obstacles in the learning process, such as lack of patients, lack of the clinical advisors' availability, and less than optimal guidance process. The nonattendance of patients most frequently occurred in the 4th week, and this caused uninteresting management that resulted in feeling bored.

“…little bit bored because the patients are all the same. So, we are not really interested in the case.” (M.6)

“…since there are only a very few patients… the clinical advisor gets difficult to meet because being busy.” (M.3)

The other obstacles during the implementation of the model were the difficulty in determining the keystone issues, developing the clinical reasoning web, and challenges in understanding and finding the relation between the terminologies of NANDA, NIC, and NOC.

“In the web (clinical reasoning web), we didn't really master the available concepts and theories. We found it rather difficult to determine the keystone issue.” (M.5)

“… we have some difficulty in understanding NNN. The language (English), the intervention… and how to understand them.” (M.1)

   Discussion Top

The findings of the research showed that the OPT-peer learningmodel could effectively improve the clinical reasoning skills of the students. This finding was supported previous researches by Pesut and Herman,[7] Kautz et al.,[5] Kautz et al.,[20] Kuiper et al.,[21] and Bland et al.,[6] who demonstrated the positive impacts of the OPT model on the improvement of clinical reasoning. The use of peer learning strategies in applying the OPT model also supported the improvement of the clinical reasoning skills, as found by Ladyshewsky et al.,[22] Goker,[23] Parker et al.,[24] Bennett et al.,[25] Christiansen and Bell,[15] Bell,[26] Himes and Ravert,[27] Harmon and Thompson,[28] and Currey et al.[29]

Various reasons related to the finding were proposed, but according to Pesut and Herman,[8] the advantage of the OPT model is that it emphasizes the framing process, including present state, outcome stateand testing, significantly influencing the planning and intervention. The framing process in this study formed a framework, which was called by the students as OPT-peer learning. It was considered simpler, easier to understand, interesting, challenging, and more helpful for them to understand pathophysiology and disease concepts so that their critical thinking and decision-making abilities were improved.

The research findings above strengthened the understanding about terminologies involved in NANDA, NIC, and NOC. It is in line with the statement of Johnson and Chen [30] that the OPT model used NANDA, NIC, and NOC as well as the relation between them as the basis of teaching clinical reasoning. The OPT model is an effective way to make use of the connections between NANDA, NIC, and NOC in the practices of nursing care as it creates a conceptual structure with standardization of the terminology. The use of the Clinical Reasoning Weband the OPT model improved the uses of the terms from NANDA NIC and NOC during the students' learning. Kautz et al.,[31] who analyzed nursing terminology using an OPT worksheet, found that the percentage of correct NANDAs was as much as 92%, of correct NOCs was 72%, and of correct NICs was as much as 61%. The learning process required students' innovation and creativity to understand the problem of a patient, arrange the right plan for him/her, and determine the outcome that matched with the patient' condition.

This study's findings showed that the OPT model facilitated guidance, triggered group process, and strengthened self-directed learning. This result was due to the impact of the use of peer learning strategies, in addition to the application of the OPT framework. In reflection the clinical advisor expressed that the model facilitated guidance, triggered and directed discussion, and improved mental readiness helping students to reach the competence target. The model also triggered a better group process, for example, holding discussion between group members, helping, complementing, and understanding each other, making group members feel comfortable, making it easier to share tasks between the members, creating a fun atmosphere, learning to give in, repressing egoism, being more responsible, daring to express opinion, and having more confidence.

The above findings were in line with what Bennett et al.[25] found where 75% of students went through a positive peer learning process, 78% of students improved their togetherness, 61% of students got group support, and 71% of students felt that there was no threatening situation. In line with those results, Parker et al.[24] found that approximately three-quarter of the students were satisfied with the peer learning process, 60% of teachers felt having given contributions to their personal growth, and 60% felt that they had been useful to the team.

In a broader sense, Currey et al.[29] found four peer learning impact themes including (1) strengthening personal growth and learning to be autonomous, valuable group process, socialization, and establishing relationships; (2) improving learning effectiveness, facilitating learning cooperation, improving understanding, encouraging acquisition and knowledge retention, and connecting with experiences; (3) improving motivation and participation, such as self-caring, team loyalty, safe learning environment, and determination of direction and references; and (4) stimulating critical thinking, including openness to alternative ideas, evidence-based decision-making, encouragement to apply theory to practice, and clinical practice improvement.

Similarly, Christiansen and Bell [15] based on their findings stated that active supports from students with each other could reduce students' socially isolated feelings during clinical practices, help them take care of various challenges more effectively, decrease friction-causing factors, and improve readiness to enter professional practices. Meanwhile, Sevenhuysen et al.[32] stated that peer learning could relieve anxiety, decrease educators' burdens, optimize the use of time, and build professional skills including collaboration and feedback.

This study's findings showed that peer learning strengthened self-directed learning, improving learning interest and motivation, patient management, confidence, trust, and responsibility. These results are in line with Asghar,[33] who stated that peer learning as a learning strategy could help in establishing a self-regulation process. Self-regulation includes motivation, self-efficacy, time management, aim formulation, meta-cognition, and self-emotion. According to their research findings, Himes and Ravert [27] stated that peer learning improved the ability to give feedback, show strong motivation, and conduct self-regulated learning. Similar to those results, Parker et al.[24] stated that there were a number of positive impacts of peer learning, such as students succeeded in dealing with changes, there were supports to reach both personal and professional goals, confidence was improved, accuracy on self-image was improved, soft skills were developed, and transmission of feedback was empowered and improved.

Essentially, students' clinical reasoning skills were significantly improved through collaborative learning activities. According to the recent related research, the performance score of nursing students who applied the peer learning model was better than those who did not apply the peer learning model. There were many advantages of applying peer learning model for both teachers and students.[34]


Limitations of the study included the following concerns: Guidance from clinical advisors was not optimal, student-patient ratio in ICU was not balanced, and there was a lack of students' mastery of NANDA, NIC, and NOC terminologies.

   Conclusion and Recommendation Top

The OPT-peer learning model not only can be applied as an effective clinical reasoning learning strategy for students of the Nursing Professional Program in ICU but also can improve the mastery of NANDA, NIC, and NOC terminologies as well as become a positive learning strategy for the clinical students and advisors. It is recommended to clinical educators or teachers to use the OPT-peer learning modules in the clinical education for nursing students. Training on model development with related modules and NANDA, NIC, and NOC terminologies is required before the application of the OPT model. Further studies focusing on learning strategies, techniques, teaching tools, and methods of evaluation of clinical reasoning are also needed, primarily for final-year students.

Financial support and sponsorship


Conflicts of interest

All authors declare no conflicts of interest.

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Correspondence Address:
Edy Wuryanto
Faculty of Nursing and Health, Universitas Muhammadiyah, Semarang
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ATMPH.ATMPH_201_17

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