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Do Problem-Solving Skills Affect Success in Nursing Process Applications? An Application Among Turkish Nursing Students Ayfer Bayindir Çevik, MSN, PhD, and Nermin Olgun, MSN, PhD Ayfer Bayindir Çevik, MSN, PhD, is an Assistant Professor, at the Department of Nursing, School of Health, Recep Tayyip Erdog ˘an University, Rize, Turkey, and Nermin Olgun, MSN, PhD, is a Professor, at the Department of Nursing, Science Health School, Acibadem University, Istanbul, Turkey.
Search terms: Nursing care plan, nursing process, problem-solving skill. Author contact: [email protected], with a copy to the Editor: [email protected] Funding: The author(s) received no financial support for the research and/or authorship of this article. Conflicts of interest: No conflict of interest has been declared by the authors. This study was presented as a poster presentation at the 17th International Nursing Research Conference, November 12–15, 2013, Lleida, Spain.
PURPOSE: This study aimed to determine the relationship between problemsolving and nursing process application skills of nursing. METHODS: This is a longitudinal and correlational study. The sample included 71 students. An information form, Problem-Solving Inventory, and nursing processes the students presented at the end of clinical courses were used for data collection. FINDINGS: Although there was no significant relationship between problemsolving skills and nursing process grades, improving problem-solving skills increased successful grades. CONCLUSIONS: Problem-solving skills and nursing process skills can be concomitantly increased. CLINICAL REVELANCE: Students were suggested to use critical thinking, practical approaches, and care plans, as well as revising nursing processes in order to improve their problem-solving skills and nursing process application skills.
The need for autonomous and professional nurses with high problem-solving skills, who can think independently and make right decisions, is ever increasing. In order to be professional, a nurse needs to possess critical thinking, problem-solving, decision-making, and clinical judgment skills (Gabrand Mohamed, 2011; Günis¸en, Serçekus¸, & Edeer, 2014). Clinical experience is also important for problem solving in clinical settings and making good clinical decisions. The factor that separates a novice nurse from an expert nurse is their problem-solving skills (Günis¸en et al., 2014). In order to provide high-quality care for complex patients, nurses should be able to identify and solve the patient’s problems. The problem-solving approach should be adopted for making a good clinical decision. In professions that involve providing direct services for people, such as nursing, it is expected to have good problem-solving skills. For this reason, the nurse, who provides care for individuals with various problems and who has to solve the 90
conflicts that occur in the clinical environment, is expected to have good problem-solving skills (Haeran & Dongsook, 2011; Hewitt-Taylor, 2012). Professional nursing training education prepares students to gain critical thinking, problem-solving, and decision-making skills (Marchigiano, Eduljee, & Harvey, 2011). The basis of professional nursing training education is formed of cultural and professional information as well as clinical applications, which are strong in bestowing decision-making and problem-solving skills, and professional nursing applications, which are more theoretical in nature (Can & Erol, 2012; Potter, 2009). It is important to graduate from a nursing school possessing these skills (Burns, O’Donnell, & Artman, 2010). The nursing process is identified as a structure that realizes the systematical use of problem-solving methods, which encompasses the processes of a nurse independently performing critical thinking and taking action (Choi, © 2014 NANDA International, Inc. International Journal of Nursing Knowledge Volume 26, No. 2, April 2015
A. Bayindir Çevik and N. Olgun Lindquist, & Song, 2014). In clinical training education, the preparation of nursing processes and the realization of theoretical knowledge through application present an opportunity for nurses to improve their problem-solving skills (Marchigiano et al., 2011). The nursing process includes data gathering, identification, planning, application, and evaluation (Craven & Hirnle, 2010). The skills and information that nurses need to use for nursing processes are learned in nursing training education (Yuan, Williams, & Fan, 2008). Nurses with higher levels of problem-solving skills can utilize nursing processes better and increase the care provided for healthy or ill individuals. For this reason, the problem-solving and nursing process application skills of students should be improved during training education. In bachelor’s degree nursing training education in Turkey, the nursing process is presented in all of the clinical courses according to the theoretical and applied context of the course (Acıbadem University Faculty of Health Sciences, 2014; Hacettepe University School of Nursing, 2014; Istanbul University Faculty of Nursing, 2014; Marmara University Faculty of Health Sciences, 2014; Recep Tayyip Erdog ˘ an University School of Health, 2014). In Turkish nursing schools, the North American Nursing Diagnosis Association (NANDA-I) classification system and the Living Activities (LA) Model are used for teaching nursing processes (Babadag ˘ , Kaya, & Esen, 2004). Roper, Logan, and Tierney (2001) described 12 living activities: maintaining a safe environment, communication, breathing, eating and drinking, elimination, washing and dressing, controlling temperature, mobilization, working and playing, expressing sexuality, sleeping, and death and dying. The Living Activities Model is important for planning and evaluating patient care in an effective way and for reaching target aims (Olgun, Karabacak, & Eti Aslan, 2012). The NANDA-I diagnosis and classification system provide national and international standardization of patient problems, nursing interventions, and care outputs for nurses and other caregivers in means of defining and determining care (Herdman, 2012). Although there are studies evaluating the problemsolving skills of nursing students in Turkey, there are not any studies evaluating the relationship between problemsolving skills and nursing processes. For these reasons, this study aimed to examine the relationship between the problem-solving skills of nursing students and their success in implementing nursing processes, and to improve both problem solving and application of the nursing process skills in nursing education. Methods Sampling and Participants The universe of the study included all first-year nursing students (n = 71) in a state university in Rize, Turkey. There were no methods used for sample selection. The sample encompasses the whole universe. Students who took the
An Application Among Turkish Nursing Students Fundamentals of Nursing course and who practiced clinical application for the first time (6 hr of theoretical and 16 hr of practical course) during their first year of education were included in the sample. The same student group was evaluated at the end of the second year when they took the Internal Medicine Nursing course and practiced clinical application (6 hr of theoretical and 16 hr of practical course). The same sample was evaluated during the second year of the students. Data obtained from four students who were transferred to the second year were excluded from the study because there were no data pertaining to their first year. Instruments The information form. The information form included 12 questions about personal characteristics and six literaturebased questions about the students’ thoughts on the nursing process. The Problem-Solving Inventory. The Problem-Solving Inventory was developed by Heppner and Peterson (1982). The Turkish adaptation study of the Problem-Solving Inventory was conducted by Sahin, Sahin, and Heppner (1993). The inventory measures adults’ and adolescents’ perceptions about their problem-solving skills and contains 35 items that can be scored between 1 and 6. Negative items (1, 2, 3, 4, 11, 13, 14, 15, 17, 21, 25, 26, 30, 34) are reverse scored, and certain items (9, 22, 29) are excluded from scoring. Total scores range between 32 and 192. Lower scores indicate behaviors and attitudes about effective and successful problem solving, whereas higher scores indicate not being able to find efficient solutions for problems. The Problem-Solving Inventory includes three dimensions. These dimensions are problem-solving confidence (PSC), which measures the person’s beliefs about his/her ability to solve new problems (items 5, 10, 11, 12, 19, 23, 24, 27, 33, 34, 35); approach–avoidance (AA), which measures the ability to review initial problem-solving efforts for use in the future and to conduct an active search for different alternative solutions (items 1, 2, 4, 6, 7, 8, 13, 15, 16, 17, 18, 20, 21, 28, 30, 31); and personal control (PK), which expresses the ability to maintain control during problematic situations (items 3, 13, 14, 25, 26, 32) (Heppner & Peterson, 1982; Sahin et al., 1993). The average score is 80 points. Higher total scores indicate that the person perceives his/her problem-solving skills as insufficient, whereas lower total scores indicate that the person perceives his/her problem-solving skills as sufficient (Altay, Cabar, Bal Ozkaptan, & Gumus, 2012; Heppner & Peterson, 1982; Olgun, Kan Onturk, Karabacak, Eti Aslan, & Serbest, 2010; Sahin et al., 1993). In this study, the Cronbach’s alpha coefficient for the Problem-Solving Inventory was found to be 0.80. Altay et al. (2012) found the Cronbach’s alpha coefficient for the Problem-Solving Inventory to be 0.81, whereas Olgun et al. (2010) found the coefficient to be 0.83. 91
An Application Among Turkish Nursing Students Evaluation of the Nursing Process A care plan for each of the students who took both the first-year Fundamentals of Nursing and the second-year Internal Medicine Nursing courses were evaluated at the end of these courses. Both courses include 6 hr of theoretical and 16 hr of applied lessons per week. The care plans, which were prepared by the students, were discussed during seminar lessons within the semester. In the evaluation of the phases of the nursing process, “data collection” received 35 points, “diagnosing” 10 points, “planning” 10 points, “application” 35 points, and “evaluation” 10 points, adding up to a total of 100 points. The students were requested to use the nursing classification systems of NANDA-I and the LA model for preparing a care plan. The evaluation of the nursing process was conducted by the same instructor who taught both courses. Knowledge about the scope of data collection, use of various data collection methods, data grouping, correct use of data collection models, taking anamnesis, collecting demographical information, and physical assessment methods were taken into consideration in the process of rating data collection. Being able to visually diagnose the relationship between data, report the diagnosis according to the NANDA-I and LA models, make a diagnosis that matches etiological factors, patient-specific data/symptoms and findings, and the PES [(P = Problem statement), (E = Etiology), (S = signs/ symptoms)] format, group problems as real, possible, potential, and common, and identify priorities were taken into consideration in the process of rating diagnosing. The viability of the determined objectives, reporting specific, measurable, prioritized objectives that are appropriate for the patient’s needs, and being able to define the criteria for the expected results were taken into consideration in the process of rating goals/objectives. Determining realistic interventions that are suitable for the diagnosis, using the appropriate intervention tools and supplies, providing patient-centered applications, sharing the reasons for performing a specific intervention with the patient, and regular recording were taken into consideration in the process of rating application. In the evaluation process, factors such as being or not being able to achieve the targets, reasons for not being able to achieve the targets, and making or not making a new care plan (Lee & Brysiewicz, 2009) were taken into consideration.
Data Collection Data were collected from first-year students during the 2012–2013 academic year at the end of the Fundamentals of Nursing course (n = 71), and from the same students who were second-year students during the 2013–2014 academic year at the end of the Internal Medicine Nursing course (n = 71). The data of four students who arrived as sophomores 92
A. Bayindir Çevik and N. Olgun via transfer were excluded since there were not any data pertaining to their freshman year. The study consisted of two parts. In the first part, the information form (18 questions) and the Problem-Solving Inventory (35 questions) were administered and the nursing care plans for the Fundamentals of Nursing course were evaluated. In the second part of the study, the same questionnaire was applied and the nursing care plans for the Internal Medicine Nursing course were evaluated. Data Analysis Data were analyzed using the SPSS 16.0 program. The confidence interval was accepted as 95%. Statistical methods, including number and percentage distributions, arithmetic means, t-tests, Wilcoxon tests, McNemar tests, and correlation analysis were used. Ethical Considerations The students were informed about the study process and told that the nursing care plans they prepared at the end of the two professional courses will be evaluated in addition to the questionnaire administration. Furthermore, the students were told that they would be informed about the study results and that the study findings would not affect them, and that the study findings would be beneficial for future students. Prior to the study, institutional permissions and written consent from the students were obtained. Results General Characteristics A total of 71 nursing students (29.6% male and 70.4% female) were included in the study. The mean age of the students was 19.38 ± 0.79 years. Among the students, 85.9% had a nuclear family and 77.5% graduated from high school. It was found that 63.4% of the students’ mothers and 54.9% of their fathers graduated from elementary school. Problem-Solving Ability and the Nursing Process When we compared problem-solving skills according to the year of study, we found a statistically significant difference between the PSC subscale scores and the problemsolving total scores (Table 1). It was determined that the students found the NANDA-I method they used for preparing the nursing process more difficult and the LA model easier during the second year. The difference was found to be statistically significant (Table 2). When we compared the students’ grades, which comprised the phases of the nursing process points and the general total scores according to their year of study, it was determined that there were significant differences between
A. Bayindir Çevik and N. Olgun
An Application Among Turkish Nursing Students
Table 1. Comparison of the Problem-Solving Skills During the First and Second Years
Problem-solving confidence I Problem-solving confidence II Approach–avoidance I Approach–avoidance II Personal control I Personal control II Problem-solving success I Problem-solving success II a
x ± SD
t
p
30.12 ± 7.66 26.54 ± 8.01 45.02 ± 9.10 43.39 ± 8.45 22.33 ± 4.85 20.87 ± 3.53 97.49 ± 14.19 90.81 ± 14.88
2.95
.004a
1.18
.242
1.93
.057
2.92
.005a
p < .005.
the objective/goal setting and the application of the nursing process phases and the grades (Table 3). There was no significant difference between the students’ problem-solving skills mean scores (PSS) and the average grades in the semester of applying the nursing process (Table 4). Discussion In professional nursing education, the students’ problem solving and the application of the nursing process skills should be improved. Nurses who have better problemsolving skills apply the nursing process more successfully and therefore they may increase the level of care provided for the healthy person/patient (Hewitt-Taylor, 2012; Olgun et al., 2010). In our study, it was determined that the nursing students had moderate levels of problem solving and application of the nursing process skills during the first year of nursing education. Similarly, previous studies which investigate problem solving showed that nursing students had moderate levels of problem solving and application of the nursing process skills (Altay et al., 2012; Olgun et al., 2010). In the previously mentioned studies, the reasons for having moderate levels of problem solving and application of the nursing process skills include not following special strategies which develop problem-solving skills, the students’ failure in comprehending the problem-solving process, not discussing the care plans in the clinical setting with the students, not sparing sufficient time, the students’ tendency toward a work-centered approach instead of a patient/care-centered approach during clinical applications, not having sufficient theoretical and practical knowledge in the field of applying the nursing process, and the instructors’ tendency toward not recognizing the importance of developing problem-solving skills. Nonetheless, compared to the first year of nursing education, the students’ PSC, PSS, and application of the nursing process skills improved in the second year. In a study by Günis¸en, Serçekus¸, and Edeer (2014), which evaluated the relationship between nursing students’ problemsolving skills and locus of control, it was determined that
the level of problem-solving skills increased as the students’ class level year of study increased. A large number of studies revealed that students and nurses found it difficult to prepare the nursing process and to use the nursing diagnosis systems during their clinical experiences (Kaya, Babadag ˘ , Yesiltepe, Kacar, & Uygur, 2010; Ozer & Kuzu, 2006). In our study, the students reported that they found it easy to use the LA model for preparing the nursing process, whereas they found it difficult to use the NANDA-I classification model. Moreover, NANDA-I use was found difficult by more second-year students. In a study by Hakverdiog ˘ lu Yönt, Korhan, Erdemir, and Müller-Staub (2014), which recruited first-semester students with no clinical experience, it was determined that the students were successful in describing nursing diagnoses which were theoretically presented with a case on paper. On the other hand, in this study, the students were required to diagnose patients in the clinic by taking an anamnesis to determine aims/goals, to conduct interventions, and to evaluate what they did. During the first year of applying care plans, students usually focus on taking the vitals of the patient, participating in routine applications for the patient, communicating with the patient or family and the healthcare team, and self-care activities. They report their own opinions about those tasks. In the second year, they were required to integrate care and disease knowledge. In the care plans that were evaluated during the second year, it was observed that the students had difficulties in integrating care and disease knowledge into care plans. Most students learn the nursing process on a theoretical basis but fail to plan and provide clinical care for the patients in an effective way. The use of the NANDA-I model may have been difficult for more second-year students when they were requested to prepare a more comprehensive care plan that examines the systems in means of disease knowledge during the Internal Medicine Nursing course. Students’ insufficiency in any of the nursing process phases may cause the problem-solving process to fail during the preparation of the care plan (Can & Erol, 2012; Kaya et al., 2010). In the present study, the students showed the best improvements in the objective/goal setting and the application of nursing interventions phases of the nursing process. In a study by Babadag ˘ et al. (2004), which evaluated the nursing processes performed by Turkish students, it was found that the nursing interventions were implemented according to the expected results and were successful. This finding seems to be parallel to our results. The students could not significantly increase their phase of diagnosing comprehensive processes points, which was prepared in the second year. On the other hand, nevertheless, it was determined that the level of awareness increased as the class level year of study increased and thereby the nursing process grades increased. According to the results of a study conducted with Turkish nursing students, it was found that only 14.7% of the students determined a nursing diagnosis which is suitable to etiological factors (Ozer & Kuzu, 2006). Furthermore, in a study by 93
An Application Among Turkish Nursing Students
A. Bayindir Çevik and N. Olgun
Table 2. Model Ease of Use Second class Easy
Difficult
Total
Model ease of use first class
n
%
n
%
n
%
p
NANDA ease of use
7 18 25 37 20 57
50.0 31.6 35.2 88.1 69.0 80.3
7 39 46 5 9 14
50.0 68.4 64.8 11.9 31.0 19.7
14 57 71 42 29 71
19.7 80.3 100.0 59.2 40.8 100.0
.04a
Easy Difficult Total Easy Difficult Total
LA ease of use
.004b
a p < .05, bp < .001. LA, Living Activities; NANDA, North American Nursing Diagnosis Association.
Table 3. Comparison of Phases of the Nursing Process and the Nursing Process Success Grades during the First and Second Years The phases of the nursing process points Data collection points I Data collection points II Diagnostics points I Diagnostics points II Objective/goal setting points I Objective/goal setting points II Initiatives in nursing practice points I Initiatives in nursing practice points II Evaluation points I Evaluation points II Nursing process success grade I Nursing process success grade II a
x ± SD
Range
p
25.01 ± 6.73 28.27 ± 5.76 6.79 ± 2.22 7.31 ± 2.15 6.80 ± 2.17 7.42 ± 2.182 22.92 ± 8.08
8–35 10–35 3–10 0–10 5–10 0–10 5–35
.12
27.39 ± 5.45
15–35
5.85 ± 2.18 6.41 ± 3.04 67.31 ± 17.34 76.66 ± 16.10
0–10 0–10 33–98 40–100
.089 .05a .001b
.16 .000b
p < .05, bp < .001.
Table 4. The Relationship Between the Problem-Solving Skills Mean Scores and the Average Grades in the Semester of Application
PSS I total score PSS II total score
First class average grade
Second class average grade
r
p
r
p
−0.59
.62
−0.83
.49
p > .05. PSS, problem-solving skill.
a
Babadag ˘ et al. (2004), it was determined that students did not implement interventions which are suitable to the nursing diagnosis. In a study by Can and Erol (2012), which evaluated the care plans of nursing students receiving oncology training education, no significant differences were found between the level of sufficiency of the care plans before and after the clinical practice training education. 94
In this study, there was no significant relationship between the students’ problem-solving skills and nursing process grades. However, it was determined that the nursing process grades increased as problem-solving skills increased. Students’ insufficiency in any of the nursing process phases may cause the problem-solving process to fail during the preparation of care plans (Can & Erol, 2012; Kaya et al., 2010). In a study by Babadag ˘ et al. (2004) which evaluates the nursing processes performed by Turkish students, it was found that the nursing interventions were implemented according to the expected results and were successful. This finding seems to be parallel to our results. How nurses evaluate their problem-solving skills is important for improving these skills (Lee & Brysiewicz, 2009). Therefore, our study focused on improving both problem solving and application of the nursing process skills. In a study by Lee and Brysiewicz (2009), which recruited third-year nursing students, it was reported that the students improved their problem solving and application of the nursing process skills. In our study, there was no significant relationship between problem-solving skills and nursing process grades. Similarly, nonetheless, in our study it was found that the students’ problem solving and application of the nursing process skills increased. Limitations We included only one class of first-year students in the study sample since the department we conducted the study in was newly opened. Therefore, our sample enclosed the whole universe of the study. Conclusion and Implications Our results support the hypothesis that problem solving and the application of the nursing process skills can be improved during nursing education and that students who improve their problem-solving skills would be more successful in performing the nursing process. In light of these results, we can make the following recommendations: Beginning from the first year of nursing
A. Bayindir Çevik and N. Olgun education, personal and scientific problem-solving methods should be improved every year according to the class level year of study and should be integrated into the theoretical and practical courses of nursing education curriculums. More time should be spared for discussing the nursing process in clinical settings and these discussions should be supported by case studies. Students’ creative ideas about problem solving in patient care should be supported. During the nursing process, patient-centered, individual-specific, realistic, and practical methods should be used. Acknowledgment. We sincerely thank the students who consented to participate in the study. References Acıbadem University Faculty of Health Sciences. (2014). Retrieved from http://www.acibadem.edu.tr Altay, B., Cabar, H. D., Bal Ozkaptan, B., & Gumus, K. (2012). Examining the relation between sociotropic and autonomic and problem solving abilities of nursing students. Health and Medicine: Journal of the Health and Medicine Policy Research Group, 6(10), 3286–3297. Babadag ˘, K., Kaya, N., & Esen, F. (2004). Og ˘rencilerin NANDA hemsirelik tanilarini belirleme durumlarinin saptanmasi. [Status of the determination of NANDA nursing diagnoses by students]. Hemsirelik Forumu, 7(3), 37–41. Burns, H. K., O’Donnell, J., & Artman, J. (2010). High-fidelity simulation in teaching problem solving to 1st year nursing students. A novel use of the nursing process. Clinical Simulation in Nursing, 6(3), e87–e95. Can, G., & Erol, O. (2012). Nursing students’ perceptions about nursing care plans: A Turkish perspective. International Journal of Nursing Practice, 18(1), 12–19. Choi, E., Lindquist, R., & Song, Y. (2014). Effects of problem-based learning vs. traditional lecture on Korean nursing students’ critical thinking, problem solving, and self-directed learning. Nurse Education Today, 34(1), 52–56. Craven, R. F., & Hirnle, C. J. (2010). Fundamentals of nursing. Human health and function (4th ed.). Philadelphia: Lippincott Williams & Wilkins. Gabrand Mohamed, H. N. (2011). Effect of problem-based learning on undergraduate nursing students enrolled in nursing administration course. International Journal of Academic Research, 3(1), 154–162. Günis¸en, N. P., Serçekus¸, P., & Edeer, A. D. (2014). A comparison of problembased and traditional education on nursing students’ locus of control and problem solving skills. International Journal of Nursing Knowledge, 25(2), 110–115. doi:10.1111/2047-3095.12024 Hacettepe University School of Nursing. (2014). Retrieved May 1, 2014, from http://www.hemsirelik.hacettepe.edu.tr/amac Haeran, C., & Dongsook, C. (2011). Influence of nurses’ performance with critical thinking and problem solving process. Korean Journal of Women Health Nursing, 17(3), 265–274. Hakverdiog ˘lu Yönt, G., Korhan, E. A., Erdemir, F., & Müller-Staub, M. (2014). Nursing diagnoses determined by first year student: A vignette study. International Journal of Nursing Knowledge, 25(1), 39–42.
An Application Among Turkish Nursing Students Heppner, P. P., & Peterson, C. H. (1982). The development and implications of a personal problem solving inventory. Journal of Counseling Psychology, 29(1), 66–75. Herdman, T. H. (Ed.). (2012). NANDA International: Nursing diagnoses: definitions and classification, 2012–2014 (9th ed.). Oxford: Wiley-Blackwell, American Psychological Association. Hewitt-Taylor, J. (2012). Identifying, analyzing and solving problems in practice. Nursing Standard, 26(40), 35–41. Istanbul University Faculty of Nursing. (2014). Retrieved May 1, 2014, from http://egitimdeyapilanma.istanbul.edu.tr/akademik Kaya, N., Babadag ˘, K., Yesiltepe, Kacar, G., & Uygur, E. (2010). Hemsirelerin hemsirelik model/ kuramlarini, hemsirelik surecini ve siniflama sistemlerini bilme ve uygulama durumlari. [Nurses’ status of knowing and applying nursing models/theories, nursing process, and classification systems]. Maltepe Universitesi Hemsirelik Bilim ve Sanati Dergisi, 3(1), 24–33. Lee, M. B., & Brysiewicz, P. (2009). Enhancing problem solving and nursing diagnosis in year III Bachelor of Nursing students. Nurse Education Today, 29(4), 389–397. Marchigiano, G., Eduljee, N., & Harvey, K. (2011). Developing critical thinking skills from clinical assignments: A pilot study on nursing students’ selfreported perceptions. Journal of Nursing Management, 19(1), 143–152. Marmara University Faculty of Health Sciences. (2014). Retrieved May 1, 2014, from http://llp.marmara.edu.tr/Organizasyon Olgun, N., Kan Onturk, Z., Karabacak, U., Eti Aslan, F., & Serbest, S. (2010). Hemsirelik og ˘rencilerinin problem cozme becerileri: bir yillik izlem sonuclari. [Problem-solving skills of nursing students: results of a oneyear follow-up]. Acibadem Universitesi Sag ˘lik Bilimleri Dergisi, 1(4), 188– 194. Olgun, N., Karabacak, U., & Eti Aslan, F. (2012). In P. Veliog ˘lu & S. Oktay (Eds.), Yasam modeline dayali hemsirelik modeli. Hemsirelikte Kavram ve Kuramlar. [The Nursing model based on the life model. concepts and theories in nursing, 2nd ed.] (pp. 184–233). Istanbul: Akademi Basin ve Yayincilik. Ozer, F. G., & Kuzu, N. (2006). Ög ˘rencilerin bakim planlarinda hemsirelik sureci ve NANDA tanilarini kullanma durumlari. [Students’ status of using nursing process and NANDA diagnoses in care plans]. Ege Universitesi Hemsirelik Yuksekokulu Dergisi, 22(1), 69–80. Potter, P. A. (2009). Critical thinking in nursing practice. In P. A. Potter & A. G. Perry (Eds.), Fundamentals of nursing (7th ed., pp. 215–230). St. Louis, MO: Mosby Elsevier. Recep Tayyip Erdog ˘an University School of Health. (2014). Retrieved May 1, 2014, from http://syo.erdogan.edu.tr/tr Roper, N., Logan, W., & Tierney, A. (2001). The Roper–Logan–Tierney model of nursing: Based on activities of living (pp. 10–11). Edinburgh: Churchill Livingstone Publications. Sahin, N., Sahin, N. H., & Heppner, P. P. (1993). Psychometric properties of the problem solving inventory in a group of Turkish university students. Cognitive Therapy Research, 17(4), 379–439. Yacin, B. M., Karahan, T. F., Karadenizli, D., & S ¸ ahin, E. M. (2006). Short-term effect of problem learning curriculum on students’ self-directed skills development. Croatian Medical Journal, 47(3), 491–498. Yuan, H., Williams, B. A., & Fan, L. (2008). A systematic review of selected evidence on developing nursing students’ critical thinking through problem-based learning. Nurse Education Today, 28(6), 657–663.
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Do Problem-Solving Skills Affect Success in Nursing Process Applications? An Application Among Turkish Nursing Students Ayfer Bayindir Çevik, MSN, PhD, and Nermin Olgun, MSN, PhD Ayfer Bayindir Çevik, MSN, PhD, is an Assistant Professor, at the Department of Nursing, School of Health, Recep Tayyip Erdog ˘an University, Rize, Turkey, and Nermin Olgun, MSN, PhD, is a Professor, at the Department of Nursing, Science Health School, Acibadem University, Istanbul, Turkey.
Search terms: Nursing care plan, nursing process, problem-solving skill. Author contact: [email protected], with a copy to the Editor: [email protected] Funding: The author(s) received no financial support for the research and/or authorship of this article. Conflicts of interest: No conflict of interest has been declared by the authors. This study was presented as a poster presentation at the 17th International Nursing Research Conference, November 12–15, 2013, Lleida, Spain.
PURPOSE: This study aimed to determine the relationship between problemsolving and nursing process application skills of nursing. METHODS: This is a longitudinal and correlational study. The sample included 71 students. An information form, Problem-Solving Inventory, and nursing processes the students presented at the end of clinical courses were used for data collection. FINDINGS: Although there was no significant relationship between problemsolving skills and nursing process grades, improving problem-solving skills increased successful grades. CONCLUSIONS: Problem-solving skills and nursing process skills can be concomitantly increased. CLINICAL REVELANCE: Students were suggested to use critical thinking, practical approaches, and care plans, as well as revising nursing processes in order to improve their problem-solving skills and nursing process application skills.
The need for autonomous and professional nurses with high problem-solving skills, who can think independently and make right decisions, is ever increasing. In order to be professional, a nurse needs to possess critical thinking, problem-solving, decision-making, and clinical judgment skills (Gabrand Mohamed, 2011; Günis¸en, Serçekus¸, & Edeer, 2014). Clinical experience is also important for problem solving in clinical settings and making good clinical decisions. The factor that separates a novice nurse from an expert nurse is their problem-solving skills (Günis¸en et al., 2014). In order to provide high-quality care for complex patients, nurses should be able to identify and solve the patient’s problems. The problem-solving approach should be adopted for making a good clinical decision. In professions that involve providing direct services for people, such as nursing, it is expected to have good problem-solving skills. For this reason, the nurse, who provides care for individuals with various problems and who has to solve the 90
conflicts that occur in the clinical environment, is expected to have good problem-solving skills (Haeran & Dongsook, 2011; Hewitt-Taylor, 2012). Professional nursing training education prepares students to gain critical thinking, problem-solving, and decision-making skills (Marchigiano, Eduljee, & Harvey, 2011). The basis of professional nursing training education is formed of cultural and professional information as well as clinical applications, which are strong in bestowing decision-making and problem-solving skills, and professional nursing applications, which are more theoretical in nature (Can & Erol, 2012; Potter, 2009). It is important to graduate from a nursing school possessing these skills (Burns, O’Donnell, & Artman, 2010). The nursing process is identified as a structure that realizes the systematical use of problem-solving methods, which encompasses the processes of a nurse independently performing critical thinking and taking action (Choi, © 2014 NANDA International, Inc. International Journal of Nursing Knowledge Volume 26, No. 2, April 2015
A. Bayindir Çevik and N. Olgun Lindquist, & Song, 2014). In clinical training education, the preparation of nursing processes and the realization of theoretical knowledge through application present an opportunity for nurses to improve their problem-solving skills (Marchigiano et al., 2011). The nursing process includes data gathering, identification, planning, application, and evaluation (Craven & Hirnle, 2010). The skills and information that nurses need to use for nursing processes are learned in nursing training education (Yuan, Williams, & Fan, 2008). Nurses with higher levels of problem-solving skills can utilize nursing processes better and increase the care provided for healthy or ill individuals. For this reason, the problem-solving and nursing process application skills of students should be improved during training education. In bachelor’s degree nursing training education in Turkey, the nursing process is presented in all of the clinical courses according to the theoretical and applied context of the course (Acıbadem University Faculty of Health Sciences, 2014; Hacettepe University School of Nursing, 2014; Istanbul University Faculty of Nursing, 2014; Marmara University Faculty of Health Sciences, 2014; Recep Tayyip Erdog ˘ an University School of Health, 2014). In Turkish nursing schools, the North American Nursing Diagnosis Association (NANDA-I) classification system and the Living Activities (LA) Model are used for teaching nursing processes (Babadag ˘ , Kaya, & Esen, 2004). Roper, Logan, and Tierney (2001) described 12 living activities: maintaining a safe environment, communication, breathing, eating and drinking, elimination, washing and dressing, controlling temperature, mobilization, working and playing, expressing sexuality, sleeping, and death and dying. The Living Activities Model is important for planning and evaluating patient care in an effective way and for reaching target aims (Olgun, Karabacak, & Eti Aslan, 2012). The NANDA-I diagnosis and classification system provide national and international standardization of patient problems, nursing interventions, and care outputs for nurses and other caregivers in means of defining and determining care (Herdman, 2012). Although there are studies evaluating the problemsolving skills of nursing students in Turkey, there are not any studies evaluating the relationship between problemsolving skills and nursing processes. For these reasons, this study aimed to examine the relationship between the problem-solving skills of nursing students and their success in implementing nursing processes, and to improve both problem solving and application of the nursing process skills in nursing education. Methods Sampling and Participants The universe of the study included all first-year nursing students (n = 71) in a state university in Rize, Turkey. There were no methods used for sample selection. The sample encompasses the whole universe. Students who took the
An Application Among Turkish Nursing Students Fundamentals of Nursing course and who practiced clinical application for the first time (6 hr of theoretical and 16 hr of practical course) during their first year of education were included in the sample. The same student group was evaluated at the end of the second year when they took the Internal Medicine Nursing course and practiced clinical application (6 hr of theoretical and 16 hr of practical course). The same sample was evaluated during the second year of the students. Data obtained from four students who were transferred to the second year were excluded from the study because there were no data pertaining to their first year. Instruments The information form. The information form included 12 questions about personal characteristics and six literaturebased questions about the students’ thoughts on the nursing process. The Problem-Solving Inventory. The Problem-Solving Inventory was developed by Heppner and Peterson (1982). The Turkish adaptation study of the Problem-Solving Inventory was conducted by Sahin, Sahin, and Heppner (1993). The inventory measures adults’ and adolescents’ perceptions about their problem-solving skills and contains 35 items that can be scored between 1 and 6. Negative items (1, 2, 3, 4, 11, 13, 14, 15, 17, 21, 25, 26, 30, 34) are reverse scored, and certain items (9, 22, 29) are excluded from scoring. Total scores range between 32 and 192. Lower scores indicate behaviors and attitudes about effective and successful problem solving, whereas higher scores indicate not being able to find efficient solutions for problems. The Problem-Solving Inventory includes three dimensions. These dimensions are problem-solving confidence (PSC), which measures the person’s beliefs about his/her ability to solve new problems (items 5, 10, 11, 12, 19, 23, 24, 27, 33, 34, 35); approach–avoidance (AA), which measures the ability to review initial problem-solving efforts for use in the future and to conduct an active search for different alternative solutions (items 1, 2, 4, 6, 7, 8, 13, 15, 16, 17, 18, 20, 21, 28, 30, 31); and personal control (PK), which expresses the ability to maintain control during problematic situations (items 3, 13, 14, 25, 26, 32) (Heppner & Peterson, 1982; Sahin et al., 1993). The average score is 80 points. Higher total scores indicate that the person perceives his/her problem-solving skills as insufficient, whereas lower total scores indicate that the person perceives his/her problem-solving skills as sufficient (Altay, Cabar, Bal Ozkaptan, & Gumus, 2012; Heppner & Peterson, 1982; Olgun, Kan Onturk, Karabacak, Eti Aslan, & Serbest, 2010; Sahin et al., 1993). In this study, the Cronbach’s alpha coefficient for the Problem-Solving Inventory was found to be 0.80. Altay et al. (2012) found the Cronbach’s alpha coefficient for the Problem-Solving Inventory to be 0.81, whereas Olgun et al. (2010) found the coefficient to be 0.83. 91
An Application Among Turkish Nursing Students Evaluation of the Nursing Process A care plan for each of the students who took both the first-year Fundamentals of Nursing and the second-year Internal Medicine Nursing courses were evaluated at the end of these courses. Both courses include 6 hr of theoretical and 16 hr of applied lessons per week. The care plans, which were prepared by the students, were discussed during seminar lessons within the semester. In the evaluation of the phases of the nursing process, “data collection” received 35 points, “diagnosing” 10 points, “planning” 10 points, “application” 35 points, and “evaluation” 10 points, adding up to a total of 100 points. The students were requested to use the nursing classification systems of NANDA-I and the LA model for preparing a care plan. The evaluation of the nursing process was conducted by the same instructor who taught both courses. Knowledge about the scope of data collection, use of various data collection methods, data grouping, correct use of data collection models, taking anamnesis, collecting demographical information, and physical assessment methods were taken into consideration in the process of rating data collection. Being able to visually diagnose the relationship between data, report the diagnosis according to the NANDA-I and LA models, make a diagnosis that matches etiological factors, patient-specific data/symptoms and findings, and the PES [(P = Problem statement), (E = Etiology), (S = signs/ symptoms)] format, group problems as real, possible, potential, and common, and identify priorities were taken into consideration in the process of rating diagnosing. The viability of the determined objectives, reporting specific, measurable, prioritized objectives that are appropriate for the patient’s needs, and being able to define the criteria for the expected results were taken into consideration in the process of rating goals/objectives. Determining realistic interventions that are suitable for the diagnosis, using the appropriate intervention tools and supplies, providing patient-centered applications, sharing the reasons for performing a specific intervention with the patient, and regular recording were taken into consideration in the process of rating application. In the evaluation process, factors such as being or not being able to achieve the targets, reasons for not being able to achieve the targets, and making or not making a new care plan (Lee & Brysiewicz, 2009) were taken into consideration.
Data Collection Data were collected from first-year students during the 2012–2013 academic year at the end of the Fundamentals of Nursing course (n = 71), and from the same students who were second-year students during the 2013–2014 academic year at the end of the Internal Medicine Nursing course (n = 71). The data of four students who arrived as sophomores 92
A. Bayindir Çevik and N. Olgun via transfer were excluded since there were not any data pertaining to their freshman year. The study consisted of two parts. In the first part, the information form (18 questions) and the Problem-Solving Inventory (35 questions) were administered and the nursing care plans for the Fundamentals of Nursing course were evaluated. In the second part of the study, the same questionnaire was applied and the nursing care plans for the Internal Medicine Nursing course were evaluated. Data Analysis Data were analyzed using the SPSS 16.0 program. The confidence interval was accepted as 95%. Statistical methods, including number and percentage distributions, arithmetic means, t-tests, Wilcoxon tests, McNemar tests, and correlation analysis were used. Ethical Considerations The students were informed about the study process and told that the nursing care plans they prepared at the end of the two professional courses will be evaluated in addition to the questionnaire administration. Furthermore, the students were told that they would be informed about the study results and that the study findings would not affect them, and that the study findings would be beneficial for future students. Prior to the study, institutional permissions and written consent from the students were obtained. Results General Characteristics A total of 71 nursing students (29.6% male and 70.4% female) were included in the study. The mean age of the students was 19.38 ± 0.79 years. Among the students, 85.9% had a nuclear family and 77.5% graduated from high school. It was found that 63.4% of the students’ mothers and 54.9% of their fathers graduated from elementary school. Problem-Solving Ability and the Nursing Process When we compared problem-solving skills according to the year of study, we found a statistically significant difference between the PSC subscale scores and the problemsolving total scores (Table 1). It was determined that the students found the NANDA-I method they used for preparing the nursing process more difficult and the LA model easier during the second year. The difference was found to be statistically significant (Table 2). When we compared the students’ grades, which comprised the phases of the nursing process points and the general total scores according to their year of study, it was determined that there were significant differences between
A. Bayindir Çevik and N. Olgun
An Application Among Turkish Nursing Students
Table 1. Comparison of the Problem-Solving Skills During the First and Second Years
Problem-solving confidence I Problem-solving confidence II Approach–avoidance I Approach–avoidance II Personal control I Personal control II Problem-solving success I Problem-solving success II a
x ± SD
t
p
30.12 ± 7.66 26.54 ± 8.01 45.02 ± 9.10 43.39 ± 8.45 22.33 ± 4.85 20.87 ± 3.53 97.49 ± 14.19 90.81 ± 14.88
2.95
.004a
1.18
.242
1.93
.057
2.92
.005a
p < .005.
the objective/goal setting and the application of the nursing process phases and the grades (Table 3). There was no significant difference between the students’ problem-solving skills mean scores (PSS) and the average grades in the semester of applying the nursing process (Table 4). Discussion In professional nursing education, the students’ problem solving and the application of the nursing process skills should be improved. Nurses who have better problemsolving skills apply the nursing process more successfully and therefore they may increase the level of care provided for the healthy person/patient (Hewitt-Taylor, 2012; Olgun et al., 2010). In our study, it was determined that the nursing students had moderate levels of problem solving and application of the nursing process skills during the first year of nursing education. Similarly, previous studies which investigate problem solving showed that nursing students had moderate levels of problem solving and application of the nursing process skills (Altay et al., 2012; Olgun et al., 2010). In the previously mentioned studies, the reasons for having moderate levels of problem solving and application of the nursing process skills include not following special strategies which develop problem-solving skills, the students’ failure in comprehending the problem-solving process, not discussing the care plans in the clinical setting with the students, not sparing sufficient time, the students’ tendency toward a work-centered approach instead of a patient/care-centered approach during clinical applications, not having sufficient theoretical and practical knowledge in the field of applying the nursing process, and the instructors’ tendency toward not recognizing the importance of developing problem-solving skills. Nonetheless, compared to the first year of nursing education, the students’ PSC, PSS, and application of the nursing process skills improved in the second year. In a study by Günis¸en, Serçekus¸, and Edeer (2014), which evaluated the relationship between nursing students’ problemsolving skills and locus of control, it was determined that
the level of problem-solving skills increased as the students’ class level year of study increased. A large number of studies revealed that students and nurses found it difficult to prepare the nursing process and to use the nursing diagnosis systems during their clinical experiences (Kaya, Babadag ˘ , Yesiltepe, Kacar, & Uygur, 2010; Ozer & Kuzu, 2006). In our study, the students reported that they found it easy to use the LA model for preparing the nursing process, whereas they found it difficult to use the NANDA-I classification model. Moreover, NANDA-I use was found difficult by more second-year students. In a study by Hakverdiog ˘ lu Yönt, Korhan, Erdemir, and Müller-Staub (2014), which recruited first-semester students with no clinical experience, it was determined that the students were successful in describing nursing diagnoses which were theoretically presented with a case on paper. On the other hand, in this study, the students were required to diagnose patients in the clinic by taking an anamnesis to determine aims/goals, to conduct interventions, and to evaluate what they did. During the first year of applying care plans, students usually focus on taking the vitals of the patient, participating in routine applications for the patient, communicating with the patient or family and the healthcare team, and self-care activities. They report their own opinions about those tasks. In the second year, they were required to integrate care and disease knowledge. In the care plans that were evaluated during the second year, it was observed that the students had difficulties in integrating care and disease knowledge into care plans. Most students learn the nursing process on a theoretical basis but fail to plan and provide clinical care for the patients in an effective way. The use of the NANDA-I model may have been difficult for more second-year students when they were requested to prepare a more comprehensive care plan that examines the systems in means of disease knowledge during the Internal Medicine Nursing course. Students’ insufficiency in any of the nursing process phases may cause the problem-solving process to fail during the preparation of the care plan (Can & Erol, 2012; Kaya et al., 2010). In the present study, the students showed the best improvements in the objective/goal setting and the application of nursing interventions phases of the nursing process. In a study by Babadag ˘ et al. (2004), which evaluated the nursing processes performed by Turkish students, it was found that the nursing interventions were implemented according to the expected results and were successful. This finding seems to be parallel to our results. The students could not significantly increase their phase of diagnosing comprehensive processes points, which was prepared in the second year. On the other hand, nevertheless, it was determined that the level of awareness increased as the class level year of study increased and thereby the nursing process grades increased. According to the results of a study conducted with Turkish nursing students, it was found that only 14.7% of the students determined a nursing diagnosis which is suitable to etiological factors (Ozer & Kuzu, 2006). Furthermore, in a study by 93
An Application Among Turkish Nursing Students
A. Bayindir Çevik and N. Olgun
Table 2. Model Ease of Use Second class Easy
Difficult
Total
Model ease of use first class
n
%
n
%
n
%
p
NANDA ease of use
7 18 25 37 20 57
50.0 31.6 35.2 88.1 69.0 80.3
7 39 46 5 9 14
50.0 68.4 64.8 11.9 31.0 19.7
14 57 71 42 29 71
19.7 80.3 100.0 59.2 40.8 100.0
.04a
Easy Difficult Total Easy Difficult Total
LA ease of use
.004b
a p < .05, bp < .001. LA, Living Activities; NANDA, North American Nursing Diagnosis Association.
Table 3. Comparison of Phases of the Nursing Process and the Nursing Process Success Grades during the First and Second Years The phases of the nursing process points Data collection points I Data collection points II Diagnostics points I Diagnostics points II Objective/goal setting points I Objective/goal setting points II Initiatives in nursing practice points I Initiatives in nursing practice points II Evaluation points I Evaluation points II Nursing process success grade I Nursing process success grade II a
x ± SD
Range
p
25.01 ± 6.73 28.27 ± 5.76 6.79 ± 2.22 7.31 ± 2.15 6.80 ± 2.17 7.42 ± 2.182 22.92 ± 8.08
8–35 10–35 3–10 0–10 5–10 0–10 5–35
.12
27.39 ± 5.45
15–35
5.85 ± 2.18 6.41 ± 3.04 67.31 ± 17.34 76.66 ± 16.10
0–10 0–10 33–98 40–100
.089 .05a .001b
.16 .000b
p < .05, bp < .001.
Table 4. The Relationship Between the Problem-Solving Skills Mean Scores and the Average Grades in the Semester of Application
PSS I total score PSS II total score
First class average grade
Second class average grade
r
p
r
p
−0.59
.62
−0.83
.49
p > .05. PSS, problem-solving skill.
a
Babadag ˘ et al. (2004), it was determined that students did not implement interventions which are suitable to the nursing diagnosis. In a study by Can and Erol (2012), which evaluated the care plans of nursing students receiving oncology training education, no significant differences were found between the level of sufficiency of the care plans before and after the clinical practice training education. 94
In this study, there was no significant relationship between the students’ problem-solving skills and nursing process grades. However, it was determined that the nursing process grades increased as problem-solving skills increased. Students’ insufficiency in any of the nursing process phases may cause the problem-solving process to fail during the preparation of care plans (Can & Erol, 2012; Kaya et al., 2010). In a study by Babadag ˘ et al. (2004) which evaluates the nursing processes performed by Turkish students, it was found that the nursing interventions were implemented according to the expected results and were successful. This finding seems to be parallel to our results. How nurses evaluate their problem-solving skills is important for improving these skills (Lee & Brysiewicz, 2009). Therefore, our study focused on improving both problem solving and application of the nursing process skills. In a study by Lee and Brysiewicz (2009), which recruited third-year nursing students, it was reported that the students improved their problem solving and application of the nursing process skills. In our study, there was no significant relationship between problem-solving skills and nursing process grades. Similarly, nonetheless, in our study it was found that the students’ problem solving and application of the nursing process skills increased. Limitations We included only one class of first-year students in the study sample since the department we conducted the study in was newly opened. Therefore, our sample enclosed the whole universe of the study. Conclusion and Implications Our results support the hypothesis that problem solving and the application of the nursing process skills can be improved during nursing education and that students who improve their problem-solving skills would be more successful in performing the nursing process. In light of these results, we can make the following recommendations: Beginning from the first year of nursing
A. Bayindir Çevik and N. Olgun education, personal and scientific problem-solving methods should be improved every year according to the class level year of study and should be integrated into the theoretical and practical courses of nursing education curriculums. More time should be spared for discussing the nursing process in clinical settings and these discussions should be supported by case studies. Students’ creative ideas about problem solving in patient care should be supported. During the nursing process, patient-centered, individual-specific, realistic, and practical methods should be used. Acknowledgment. We sincerely thank the students who consented to participate in the study. References Acıbadem University Faculty of Health Sciences. (2014). Retrieved from http://www.acibadem.edu.tr Altay, B., Cabar, H. D., Bal Ozkaptan, B., & Gumus, K. (2012). Examining the relation between sociotropic and autonomic and problem solving abilities of nursing students. Health and Medicine: Journal of the Health and Medicine Policy Research Group, 6(10), 3286–3297. Babadag ˘, K., Kaya, N., & Esen, F. (2004). Og ˘rencilerin NANDA hemsirelik tanilarini belirleme durumlarinin saptanmasi. [Status of the determination of NANDA nursing diagnoses by students]. Hemsirelik Forumu, 7(3), 37–41. Burns, H. K., O’Donnell, J., & Artman, J. (2010). High-fidelity simulation in teaching problem solving to 1st year nursing students. A novel use of the nursing process. Clinical Simulation in Nursing, 6(3), e87–e95. Can, G., & Erol, O. (2012). Nursing students’ perceptions about nursing care plans: A Turkish perspective. International Journal of Nursing Practice, 18(1), 12–19. Choi, E., Lindquist, R., & Song, Y. (2014). Effects of problem-based learning vs. traditional lecture on Korean nursing students’ critical thinking, problem solving, and self-directed learning. Nurse Education Today, 34(1), 52–56. Craven, R. F., & Hirnle, C. J. (2010). Fundamentals of nursing. Human health and function (4th ed.). Philadelphia: Lippincott Williams & Wilkins. Gabrand Mohamed, H. N. (2011). Effect of problem-based learning on undergraduate nursing students enrolled in nursing administration course. International Journal of Academic Research, 3(1), 154–162. Günis¸en, N. P., Serçekus¸, P., & Edeer, A. D. (2014). A comparison of problembased and traditional education on nursing students’ locus of control and problem solving skills. International Journal of Nursing Knowledge, 25(2), 110–115. doi:10.1111/2047-3095.12024 Hacettepe University School of Nursing. (2014). Retrieved May 1, 2014, from http://www.hemsirelik.hacettepe.edu.tr/amac Haeran, C., & Dongsook, C. (2011). Influence of nurses’ performance with critical thinking and problem solving process. Korean Journal of Women Health Nursing, 17(3), 265–274. Hakverdiog ˘lu Yönt, G., Korhan, E. A., Erdemir, F., & Müller-Staub, M. (2014). Nursing diagnoses determined by first year student: A vignette study. International Journal of Nursing Knowledge, 25(1), 39–42.
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