problem solving skills for nursing

The Value of Critical Thinking in Nursing

• How Nurses Use Critical Thinking
• How to Improve Critical Thinking
• Common Mistakes

Some experts describe a person’s ability to question belief systems, test previously held assumptions, and recognize ambiguity as evidence of critical thinking. Others identify specific skills that demonstrate critical thinking, such as the ability to identify problems and biases, infer and draw conclusions, and determine the relevance of information to a situation.

Nicholas McGowan, BSN, RN, CCRN, has been a critical care nurse for 10 years in neurological trauma nursing and cardiovascular and surgical intensive care. He defines critical thinking as “necessary for problem-solving and decision-making by healthcare providers. It is a process where people use a logical process to gather information and take purposeful action based on their evaluation.”

“This cognitive process is vital for excellent patient outcomes because it requires that nurses make clinical decisions utilizing a variety of different lenses, such as fairness, ethics, and evidence-based practice,” he says.

How Do Nurses Use Critical Thinking?

Successful nurses think beyond their assigned tasks to deliver excellent care for their patients. For example, a nurse might be tasked with changing a wound dressing, delivering medications, and monitoring vital signs during a shift. However, it requires critical thinking skills to understand how a difference in the wound may affect blood pressure and temperature and when those changes may require immediate medical intervention.

Nurses care for many patients during their shifts. Strong critical thinking skills are crucial when juggling various tasks so patient safety and care are not compromised.

Jenna Liphart Rhoads, Ph.D., RN, is a nurse educator with a clinical background in surgical-trauma adult critical care, where critical thinking and action were essential to the safety of her patients. She talks about examples of critical thinking in a healthcare environment, saying:

“Nurses must also critically think to determine which patient to see first, which medications to pass first, and the order in which to organize their day caring for patients. Patient conditions and environments are continually in flux, therefore nurses must constantly be evaluating and re-evaluating information they gather (assess) to keep their patients safe.”

The COVID-19 pandemic created hospital care situations where critical thinking was essential. It was expected of the nurses on the general floor and in intensive care units. Crystal Slaughter is an advanced practice nurse in the intensive care unit (ICU) and a nurse educator. She observed critical thinking throughout the pandemic as she watched intensive care nurses test the boundaries of previously held beliefs and master providing excellent care while preserving resources.

“Nurses are at the patient’s bedside and are often the first ones to detect issues. Then, the nurse needs to gather the appropriate subjective and objective data from the patient in order to frame a concise problem statement or question for the physician or advanced practice provider,” she explains.

Top 5 Ways Nurses Can Improve Critical Thinking Skills

We asked our experts for the top five strategies nurses can use to purposefully improve their critical thinking skills.

Case-Based Approach

Slaughter is a fan of the case-based approach to learning critical thinking skills.

In much the same way a detective would approach a mystery, she mentors her students to ask questions about the situation that help determine the information they have and the information they need. “What is going on? What information am I missing? Can I get that information? What does that information mean for the patient? How quickly do I need to act?”

Consider forming a group and working with a mentor who can guide you through case studies. This provides you with a learner-centered environment in which you can analyze data to reach conclusions and develop communication, analytical, and collaborative skills with your colleagues.

Practice Self-Reflection

Rhoads is an advocate for self-reflection. “Nurses should reflect upon what went well or did not go well in their workday and identify areas of improvement or situations in which they should have reached out for help.” Self-reflection is a form of personal analysis to observe and evaluate situations and how you responded.

This gives you the opportunity to discover mistakes you may have made and to establish new behavior patterns that may help you make better decisions. You likely already do this. For example, after a disagreement or contentious meeting, you may go over the conversation in your head and think about ways you could have responded.

It’s important to go through the decisions you made during your day and determine if you should have gotten more information before acting or if you could have asked better questions.

During self-reflection, you may try thinking about the problem in reverse. This may not give you an immediate answer, but can help you see the situation with fresh eyes and a new perspective. How would the outcome of the day be different if you planned the dressing change in reverse with the assumption you would find a wound infection? How does this information change your plan for the next dressing change?

Develop a Questioning Mind

McGowan has learned that “critical thinking is a self-driven process. It isn’t something that can simply be taught. Rather, it is something that you practice and cultivate with experience. To develop critical thinking skills, you have to be curious and inquisitive.”

To gain critical thinking skills, you must undergo a purposeful process of learning strategies and using them consistently so they become a habit. One of those strategies is developing a questioning mind. Meaningful questions lead to useful answers and are at the core of critical thinking .

However, learning to ask insightful questions is a skill you must develop. Faced with staff and nursing shortages , declining patient conditions, and a rising number of tasks to be completed, it may be difficult to do more than finish the task in front of you. Yet, questions drive active learning and train your brain to see the world differently and take nothing for granted.

It is easier to practice questioning in a non-stressful, quiet environment until it becomes a habit. Then, in the moment when your patient’s care depends on your ability to ask the right questions, you can be ready to rise to the occasion.

Practice Self-Awareness in the Moment

Critical thinking in nursing requires self-awareness and being present in the moment. During a hectic shift, it is easy to lose focus as you struggle to finish every task needed for your patients. Passing medication, changing dressings, and hanging intravenous lines all while trying to assess your patient’s mental and emotional status can affect your focus and how you manage stress as a nurse .

Staying present helps you to be proactive in your thinking and anticipate what might happen, such as bringing extra lubricant for a catheterization or extra gloves for a dressing change.

By staying present, you are also better able to practice active listening. This raises your assessment skills and gives you more information as a basis for your interventions and decisions.

Use a Process

As you are developing critical thinking skills, it can be helpful to use a process. For example:

• Ask questions.
• Gather information.
• Implement a strategy.
• Evaluate the results.
• Consider another point of view.

These are the fundamental steps of the nursing process (assess, diagnose, plan, implement, evaluate). The last step will help you overcome one of the common problems of critical thinking in nursing — personal bias.

Common Critical Thinking Pitfalls in Nursing

Your brain uses a set of processes to make inferences about what’s happening around you. In some cases, your unreliable biases can lead you down the wrong path. McGowan places personal biases at the top of his list of common pitfalls to critical thinking in nursing.

“We all form biases based on our own experiences. However, nurses have to learn to separate their own biases from each patient encounter to avoid making false assumptions that may interfere with their care,” he says. Successful critical thinkers accept they have personal biases and learn to look out for them. Awareness of your biases is the first step to understanding if your personal bias is contributing to the wrong decision.

New nurses may be overwhelmed by the transition from academics to clinical practice, leading to a task-oriented mindset and a common new nurse mistake ; this conflicts with critical thinking skills.

“Consider a patient whose blood pressure is low but who also needs to take a blood pressure medication at a scheduled time. A task-oriented nurse may provide the medication without regard for the patient’s blood pressure because medication administration is a task that must be completed,” Slaughter says. “A nurse employing critical thinking skills would address the low blood pressure, review the patient’s blood pressure history and trends, and potentially call the physician to discuss whether medication should be withheld.”

Fear and pride may also stand in the way of developing critical thinking skills. Your belief system and worldview provide comfort and guidance, but this can impede your judgment when you are faced with an individual whose belief system or cultural practices are not the same as yours. Fear or pride may prevent you from pursuing a line of questioning that would benefit the patient. Nurses with strong critical thinking skills exhibit:

• Learn from their mistakes and the mistakes of other nurses
• Look forward to integrating changes that improve patient care
• Treat each patient interaction as a part of a whole
• Evaluate new events based on past knowledge and adjust decision-making as needed
• Solve problems with their colleagues
• Are self-confident
• Acknowledge biases and seek to ensure these do not impact patient care

An Essential Skill for All Nurses

Critical thinking in nursing protects patient health and contributes to professional development and career advancement. Administrative and clinical nursing leaders are required to have strong critical thinking skills to be successful in their positions.

By using the strategies in this guide during your daily life and in your nursing role, you can intentionally improve your critical thinking abilities and be rewarded with better patient outcomes and potential career advancement.

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

Nursing practice utilizes critical thinking skills to provide the best care for patients. Often, the patient’s cause of pain or health issue is not immediately clear. Nursing professionals need to use their knowledge to determine what might be causing distress, collect vital information, and make quick decisions on how best to handle the situation.

How does nursing school develop critical thinking skills?

Nursing school gives students the knowledge professional nurses use to make important healthcare decisions for their patients. Students learn about diseases, anatomy, and physiology, and how to improve the patient’s overall well-being. Learners also participate in supervised clinical experiences, where they practice using their critical thinking skills to make decisions in professional settings.

Do only nurse managers use critical thinking?

Nurse managers certainly use critical thinking skills in their daily duties. But when working in a health setting, anyone giving care to patients uses their critical thinking skills. Everyone — including licensed practical nurses, registered nurses, and advanced nurse practitioners —needs to flex their critical thinking skills to make potentially life-saving decisions.

Meet Our Contributors

Crystal Slaughter, DNP, APRN, ACNS-BC, CNE

Crystal Slaughter is a core faculty member in Walden University’s RN-to-BSN program. She has worked as an advanced practice registered nurse with an intensivist/pulmonary service to provide care to hospitalized ICU patients and in inpatient palliative care. Slaughter’s clinical interests lie in nursing education and evidence-based practice initiatives to promote improving patient care.

Jenna Liphart Rhoads, Ph.D., RN

Jenna Liphart Rhoads is a nurse educator and freelance author and editor. She earned a BSN from Saint Francis Medical Center College of Nursing and an MS in nursing education from Northern Illinois University. Rhoads earned a Ph.D. in education with a concentration in nursing education from Capella University where she researched the moderation effects of emotional intelligence on the relationship of stress and GPA in military veteran nursing students. Her clinical background includes surgical-trauma adult critical care, interventional radiology procedures, and conscious sedation in adult and pediatric populations.

Nicholas McGowan, BSN, RN, CCRN

Nicholas McGowan is a critical care nurse with 10 years of experience in cardiovascular, surgical intensive care, and neurological trauma nursing. McGowan also has a background in education, leadership, and public speaking. He is an online learner who builds on his foundation of critical care nursing, which he uses directly at the bedside where he still practices. In addition, McGowan hosts an online course at Critical Care Academy where he helps nurses achieve critical care (CCRN) certification.

What is Critical Thinking in Nursing? (With Examples, Importance, & How to Improve)

Successful nursing requires learning several skills used to communicate with patients, families, and healthcare teams. One of the most essential skills nurses must develop is the ability to demonstrate critical thinking. If you are a nurse, perhaps you have asked if there is a way to know how to improve critical thinking in nursing? As you read this article, you will learn what critical thinking in nursing is and why it is important. You will also find 18 simple tips to improve critical thinking in nursing and sample scenarios about how to apply critical thinking in your nursing career.

What Is Critical Thinking In Nursing?

4 reasons why critical thinking is so important in nursing, 1. critical thinking skills will help you anticipate and understand changes in your patient’s condition., 2. with strong critical thinking skills, you can make decisions about patient care that is most favorable for the patient and intended outcomes., 3. strong critical thinking skills in nursing can contribute to innovative improvements and professional development., 4. critical thinking skills in nursing contribute to rational decision-making, which improves patient outcomes., what are the 8 important attributes of excellent critical thinking in nursing, 1. the ability to interpret information:, 2. independent thought:, 3. impartiality:, 4. intuition:, 5. problem solving:, 6. flexibility:, 7. perseverance:, 8. integrity:, examples of poor critical thinking vs excellent critical thinking in nursing, 1. scenario: patient/caregiver interactions, poor critical thinking:, excellent critical thinking:, 2. scenario: improving patient care quality, 3. scenario: interdisciplinary collaboration, 4. scenario: precepting nursing students and other nurses, how to improve critical thinking in nursing, 1. demonstrate open-mindedness., 2. practice self-awareness., 3. avoid judgment., 4. eliminate personal biases., 5. do not be afraid to ask questions., 6. find an experienced mentor., 7. join professional nursing organizations., 8. establish a routine of self-reflection., 9. utilize the chain of command., 10. determine the significance of data and decide if it is sufficient for decision-making., 11. volunteer for leadership positions or opportunities., 12. use previous facts and experiences to help develop stronger critical thinking skills in nursing., 13. establish priorities., 14. trust your knowledge and be confident in your abilities., 15. be curious about everything., 16. practice fair-mindedness., 17. learn the value of intellectual humility., 18. never stop learning., 4 consequences of poor critical thinking in nursing, 1. the most significant risk associated with poor critical thinking in nursing is inadequate patient care., 2. failure to recognize changes in patient status:, 3. lack of effective critical thinking in nursing can impact the cost of healthcare., 4. lack of critical thinking skills in nursing can cause a breakdown in communication within the interdisciplinary team., useful resources to improve critical thinking in nursing, youtube videos, my final thoughts, frequently asked questions answered by our expert, 1. will lack of critical thinking impact my nursing career, 2. usually, how long does it take for a nurse to improve their critical thinking skills, 3. do all types of nurses require excellent critical thinking skills, 4. how can i assess my critical thinking skills in nursing.

• Ask relevant questions • Justify opinions • Address and evaluate multiple points of view • Explain assumptions and reasons related to your choice of patient care options

5. Can I Be a Nurse If I Cannot Think Critically?

• Research article
• Open access
• Published: 07 October 2020

Impact of social problem-solving training on critical thinking and decision making of nursing students

• Soleiman Ahmady 1 &
• Sara Shahbazi   ORCID: orcid.org/0000-0001-8397-6233 2 , 3  

BMC Nursing volume  19 , Article number:  94 ( 2020 ) Cite this article

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The complex health system and challenging patient care environment require experienced nurses, especially those with high cognitive skills such as problem-solving, decision- making and critical thinking. Therefore, this study investigated the impact of social problem-solving training on nursing students’ critical thinking and decision-making.

This study was quasi-experimental research and pre-test and post-test design and performed on 40 undergraduate/four-year students of nursing in Borujen Nursing School/Iran that was randomly divided into 2 groups; experimental ( n  = 20) and control (n = 20). Then, a social problem-solving course was held for the experimental group. A demographic questionnaire, social problem-solving inventory-revised, California critical thinking test, and decision-making questionnaire was used to collect the information. The reliability and validity of all of them were confirmed. Data analysis was performed using SPSS software and independent sampled T-test, paired T-test, square chi, and Pearson correlation coefficient.

The finding indicated that the social problem-solving course positively affected the student’ social problem-solving and decision-making and critical thinking skills after the instructional course in the experimental group ( P  < 0.05), but this result was not observed in the control group ( P  > 0.05).

Conclusions

The results showed that structured social problem-solving training could improve cognitive problem-solving, critical thinking, and decision-making skills. Considering this result, nursing education should be presented using new strategies and creative and different ways from traditional education methods. Cognitive skills training should be integrated in the nursing curriculum. Therefore, training cognitive skills such as problem- solving to nursing students is recommended.

Peer Review reports

Continuous monitoring and providing high-quality care to patients is one of the main tasks of nurses. Nurses’ roles are diverse and include care, educational, supportive, and interventional roles when dealing with patients’ clinical problems [ 1 , 2 ].

Providing professional nursing services requires the cognitive skills such as problem-solving, decision-making and critical thinking, and information synthesis [ 3 ].

Problem-solving is an essential skill in nursing. Improving this skill is very important for nurses because it is an intellectual process which requires the reflection and creative thinking [ 4 ].

Problem-solving skill means acquiring knowledge to reach a solution, and a person’s ability to use this knowledge to find a solution requires critical thinking. The promotion of these skills is considered a necessary condition for nurses’ performance in the nursing profession [ 5 , 6 ].

Managing the complexities and challenges of health systems requires competent nurses with high levels of critical thinking skills. A nurse’s critical thinking skills can affect patient safety because it enables nurses to correctly diagnose the patient’s initial problem and take the right action for the right reason [ 4 , 7 , 8 ].

Problem-solving and decision-making are complex and difficult processes for nurses, because they have to care for multiple patients with different problems in complex and unpredictable treatment environments [ 9 , 10 ].

Clinical decision making is an important element of professional nursing care; nurses’ ability to form effective clinical decisions is the most significant issue affecting the care standard. Nurses build 2 kinds of choices associated with the practice: patient care decisions that affect direct patient care and occupational decisions that affect the work context or teams [ 11 , 12 , 13 , 14 , 15 , 16 ].

The utilization of nursing process guarantees the provision of professional and effective care. The nursing process provides nurses with the chance to learn problem-solving skills through teamwork, health management, and patient care. Problem-solving is at the heart of nursing process which is why this skill underlies all nursing practices. Therefore, proper training of this skill in an undergraduate nursing program is essential [ 17 ].

Nursing students face unique problems which are specific to the clinical and therapeutic environment, causing a lot of stresses during clinical education. This stress can affect their problem- solving skills [ 18 , 19 , 20 , 21 ]. They need to promote their problem-solving and critical thinking skills to meet the complex needs of current healthcare settings and should be able to respond to changing circumstances and apply knowledge and skills in different clinical situations [ 22 ]. Institutions should provide this important opportunity for them.

Despite, the results of studies in nursing students show the weakness of their problem-solving skills, while in complex health environments and exposure to emerging diseases, nurses need to diagnose problems and solve them rapidly accurately. The teaching of these skills should begin in college and continue in health care environments [ 5 , 23 , 24 ].

It should not be forgotten that in addition to the problems caused by the patients’ disease, a large proportion of the problems facing nurses are related to the procedures of the natural life of their patients and their families, the majority of nurses with the rest of health team and the various roles defined for nurses [ 25 ].

Therefore, in addition to above- mentioned issues, other ability is required to deal with common problems in the working environment for nurses, the skill is “social problem solving”, because the term social problem-solving includes a method of problem-solving in the “natural context” or the “real world” [ 26 , 27 ]. In reviewing the existing research literature on the competencies and skills required by nursing students, what attracts a lot of attention is the weakness of basic skills and the lack of formal and systematic training of these skills in the nursing curriculum, it indicates a gap in this area [ 5 , 24 , 25 ]. In this regard, the researchers tried to reduce this significant gap by holding a formal problem-solving skills training course, emphasizing the common social issues in the real world of work. Therefore, this study was conducted to investigate the impact of social problem-solving skills training on nursing students’ critical thinking and decision-making.

Setting and sample

This quasi-experimental study with pretest and post-test design was performed on 40 undergraduate/four-year nursing students in Borujen nursing school in Shahrekord University of Medical Sciences. The periods of data collection were 4 months.

According to the fact that senior students of nursing have passed clinical training and internship programs, they have more familiarity with wards and treatment areas, patients and issues in treatment areas and also they have faced the problems which the nurses have with other health team personnel and patients and their families, they have been chosen for this study. Therefore, this study’s sampling method was based on the purpose, and the sample size was equal to the total population. The whole of four-year nursing students participated in this study and the sample size was 40 members. Participants was randomly divided in 2 groups; experimental ( n  = 20) and control (n = 20).

The inclusion criteria to take part in the present research were students’ willingness to take part, studying in the four-year nursing, not having the record of psychological sickness or using the related drugs (all based on their self-utterance).

Intervention

At the beginning of study, all students completed the demographic information’ questionnaire. The study’s intervening variables were controlled between the two groups [such as age, marital status, work experience, training courses, psychological illness, psychiatric medication use and improving cognitive skills courses (critical thinking, problem- solving, and decision making in the last 6 months)]. Both groups were homogeneous in terms of demographic variables ( P  > 0.05). Decision making and critical thinking skills and social problem solving of participants in 2 groups was evaluated before and 1 month after the intervention.

All questionnaires were anonymous and had an identification code which carefully distributed by the researcher.

To control the transfer of information among the students of two groups, the classification list of students for internships, provided by the head of nursing department at the beginning of semester, was used.

Furthermore, the groups with the odd number of experimental group and the groups with the even number formed the control group and thus were less in contact with each other.

The importance of not transferring information among groups was fully described to the experimental group. They were asked not to provide any information about the course to the students of the control group.

Then, training a course of social problem-solving skills for the experimental group, given in a separate course and the period from the nursing curriculum and was held in 8 sessions during 2 months, using small group discussion, brainstorming, case-based discussion, and reaching the solution in small 4 member groups, taking results of the social problem-solving model as mentioned by D-zurilla and gold fried [ 26 ]. The instructor was an assistant professor of university and had a history of teaching problem-solving courses. This model’ stages are explained in Table  1 .

All training sessions were performed due to the model, and one step of the model was implemented in each session. In each session, the teacher stated the educational objectives and asked the students to share their experiences in dealing to various workplace problems, home and community due to the topic of session. Besides, in each session, a case-based scenario was presented and thoroughly analyzed, and students discussed it.

Instruments

In this study, the data were collected using demographic variables questionnaire and social problem- solving inventory – revised (SPSI-R) developed by D’zurilla and Nezu (2002) [ 26 ], California critical thinking skills test- form B (CCTST; 1994) [ 27 , 28 ] and decision-making questionnaire.

SPSI-R is a self - reporting tool with 52 questions ranging from a Likert scale (1: Absolutely not – 5: very much).

The minimum score maybe 25 and at a maximum of 125, therefore:

The score 25 and 50: weak social problem-solving skills.

The score 50–75: moderate social problem-solving skills.

The score higher of 75: strong social problem-solving skills.

The reliability assessed by repeated tests is between 0.68 and 0.91, and its alpha coefficient between 0.69 and 0.95 was reported [ 26 ]. The structural validity of questionnaire has also been confirmed. All validity analyses have confirmed SPSI as a social problem - solving scale.

In Iran, the alpha coefficient of 0.85 is measured for five factors, and the retest reliability coefficient was obtained 0.88. All of the narratives analyzes confirmed SPSI as a social problem- solving scale [ 29 ].

California critical thinking skills test- form B(CCTST; 1994): This test is a standard tool for assessing the basic skills of critical thinking at the high school and higher education levels (Facione & Facione, 1992, 1998) [ 27 ].

This tool has 34 multiple-choice questions which assessed analysis, inference, and argument evaluation. Facione and Facione (1993) reported that a KR-20 range of 0.65 to 0.75 for this tool is acceptable [ 27 ].

In Iran, the KR-20 for the total scale was 0.62. This coefficient is acceptable for questionnaires that measure the level of thinking ability of individuals.

After changing the English names of this questionnaire to Persian, its content validity was approved by the Board of Experts.

The subscale analysis of Persian version of CCTST showed a positive high level of correlation between total test score and the components (analysis, r = 0.61; evaluation, r = 0.71; inference, r = 0.88; inductive reasoning, r = 0.73; and deductive reasoning, r = 0.74) [ 28 ].

A decision-making questionnaire with 20 questions was used to measure decision-making skills. This questionnaire was made by a researcher and was prepared under the supervision of a professor with psychometric expertise. Five professors confirmed the face and content validity of this questionnaire. The reliability was obtained at 0.87 which confirmed for 30 students using the test-retest method at a time interval of 2 weeks. Each question had four levels and a score from 0.25 to 1. The minimum score of this questionnaire was 5, and the maximum score was 20 [ 30 ].

Statistical analysis

For analyzing the applied data, the SPSS Version 16, and descriptive statistics tests, independent sample T-test, paired T-test, Pearson correlation coefficient, and square chi were used. The significant level was taken P  < 0.05.

The average age of students was 21.7 ± 1.34, and the academic average total score was 16.32 ± 2.83. Other demographic characteristics are presented in Table  2 .

None of the students had a history of psychiatric illness or psychiatric drug use. Findings obtained from the chi-square test showed that there is not any significant difference between the two groups statistically in terms of demographic variables.

The mean scores in social decision making, critical thinking, and decision-making in whole samples before intervention showed no significant difference between the two groups statistically ( P  > 0.05), but showed a significant difference after the intervention ( P  < 0.05) (Table  3 ).

Scores in Table  4 showed a significant positive difference before and after intervention in the “experimental” group ( P  < 0.05), but this difference was not seen in the control group ( P  > 0.05).

Among the demographic variables, only a positive relationship was seen between marital status and decision-making skills (r = 0.72, P  < 0.05).

Also, the scores of critical thinking skill’ subgroups and social problem solving’ subgroups are presented in Tables  5 and 6 which showed a significant positive difference before and after intervention in the “experimental” group (P < 0.05), but this difference was not seen in the control group ( P  > 0.05).

In the present study conducted by some studies, problem-solving and critical thinking and decision-making scores of nursing students are moderate [ 5 , 24 , 31 ].

The results showed that problem-solving skills, critical thinking, and decision-making in nursing students were promoted through a social problem-solving training course. Unfortunately, no study has examined the effect of teaching social problem-solving skills on nursing students’ critical thinking and decision-making skills.

Altun (2018) believes that if the values of truth and human dignity are promoted in students, it will help them acquire problem-solving skills. Free discussion between students and faculty on value topics can lead to the development of students’ information processing in values. Developing self-awareness increases students’ impartiality and problem-solving ability [ 5 ]. The results of this study are consistent to the results of present study.

Erozkan (2017), in his study, reported there is a significant relationship between social problem solving and social self-efficacy and the sub-dimensions of social problem solving [ 32 ]. In the present study, social problem -solving skills training has improved problem -solving skills and its subdivisions.

The results of study by Moshirabadi (2015) showed that the mean score of total problem-solving skills was 89.52 ± 21.58 and this average was lower in fourth-year students than other students. He explained that education should improve students’ problem-solving skills. Because nursing students with advanced problem-solving skills are vital to today’s evolving society [ 22 ]. In the present study, the results showed students’ weakness in the skills in question, and holding a social problem-solving skills training course could increase the level of these skills.

Çinar (2010) reported midwives and nurses are expected to use problem-solving strategies and effective decision-making in their work, using rich basic knowledge.

These skills should be developed throughout one’s profession. The results of this study showed that academic education could increase problem-solving skills of nursing and midwifery students, and final year students have higher skill levels [ 23 ].

Bayani (2012) reported that the ability to solve social problems has a determining role in mental health. Problem-solving training can lead to a level upgrade of mental health and quality of life [ 33 ]; These results agree with the results obtained in our study.

Conducted by this study, Kocoglu (2016) reported nurses’ understanding of their problem-solving skills is moderate. Receiving advice and support from qualified nursing managers and educators can enhance this skill and positively impact their behavior [ 31 ].

Kashaninia (2015), in her study, reported teaching critical thinking skills can promote critical thinking and the application of rational decision-making styles by nurses.

One of the main components of sound performance in nursing is nurses’ ability to process information and make good decisions; these abilities themselves require critical thinking. Therefore, universities should envisage educational and supportive programs emphasizing critical thinking to cultivate their students’ professional competencies, decision-making, problem-solving, and self-efficacy [ 34 ].

The study results of Kirmizi (2015) also showed a moderate positive relationship between critical thinking and problem-solving skills [ 35 ].

Hong (2015) reported that using continuing PBL training promotes reflection and critical thinking in clinical nurses. Applying brainstorming in PBL increases the motivation to participate collaboratively and encourages teamwork. Learners become familiar with different perspectives on patients’ problems and gain a more comprehensive understanding. Achieving these competencies is the basis of clinical decision-making in nursing. The dynamic and ongoing involvement of clinical staff can bridge the gap between theory and practice [ 36 ].

Ancel (2016) emphasizes that structured and managed problem-solving training can increase students’ confidence in applying problem-solving skills and help them achieve self-confidence. He reported that nursing students want to be taught in more innovative ways than traditional teaching methods which cognitive skills training should be included in their curriculum. To this end, university faculties and lecturers should believe in the importance of strategies used in teaching and the richness of educational content offered to students [ 17 ].

The results of these recent studies are adjusted with the finding of recent research and emphasize the importance of structured teaching cognitive skills to nurses and nursing students.

Based on the results of this study on improving critical thinking and decision-making skills in the intervention group, researchers guess the reasons to achieve the results of study in the following cases:

In nursing internationally, problem-solving skills (PS) have been introduced as a key strategy for better patient care [ 17 ]. Problem-solving can be defined as a self-oriented cognitive-behavioral process used to identify or discover effective solutions to a special problem in everyday life. In particular, the application of this cognitive-behavioral methodology identifies a wide range of possible effective solutions to a particular problem and enhancement the likelihood of selecting the most effective solution from among the various options [ 27 ].

In social problem-solving theory, there is a difference among the concepts of problem-solving and solution implementation, because the concepts of these two processes are different, and in practice, they require different skills.

In the problem-solving process, we seek to find solutions to specific problems, while in the implementation of solution, the process of implementing those solutions in the real problematic situation is considered [ 25 , 26 ].

The use of D’zurilla and Goldfride’s social problem-solving model was effective in achieving the study results because of its theoretical foundations and the usage of the principles of cognitive reinforcement skills. Social problem solving is considered an intellectual, logical, effort-based, and deliberate activity [ 26 , 32 ]; therefore, using this model can also affect other skills that need recognition.

In this study, problem-solving training from case studies and group discussion methods, brainstorming, and activity in small groups, was used.

There are significant educational achievements in using small- group learning strategies. The limited number of learners in each group increases the interaction between learners, instructors, and content. In this way, the teacher will be able to predict activities and apply techniques that will lead students to achieve high cognitive taxonomy levels. That is, confront students with assignments and activities that force them to use cognitive processes such as analysis, reasoning, evaluation, and criticism.

In small groups, students are given the opportunity to the enquiry, discuss differences of opinion, and come up with solutions. This method creates a comprehensive understanding of the subject for the student [ 36 ].

According to the results, social problem solving increases the nurses’ decision-making ability and critical thinking regarding identifying the patient’s needs and choosing the best nursing procedures. According to what was discussed, the implementation of this intervention in larger groups and in different levels of education by teaching other cognitive skills and examining their impact on other cognitive skills of nursing students, in the future, is recommended.

Social problem- solving training by affecting critical thinking skills and decision-making of nursing students increases patient safety. It improves the quality of care because patients’ needs are better identified and analyzed, and the best solutions are adopted to solve the problem.

In the end, the implementation of this intervention in larger groups in different levels of education by teaching other cognitive skills and examining their impact on other cognitive skills of nursing students in the future is recommended.

Study limitations

This study was performed on fourth-year nursing students, but the students of other levels should be studied during a cohort from the beginning to the end of course to monitor the cognitive skills improvement.

The promotion of high-level cognitive skills is one of the main goals of higher education. It is very necessary to adopt appropriate approaches to improve the level of thinking. According to this study results, the teachers and planners are expected to use effective approaches and models such as D’zurilla and Goldfride social problem solving to improve problem-solving, critical thinking, and decision-making skills. What has been confirmed in this study is that the routine training in the control group should, as it should, has not been able to improve the students’ critical thinking skills, and the traditional educational system needs to be transformed and reviewed to achieve this goal.

Availability of data and materials

The datasets used and analyzed during the present study are available from the corresponding author on reasonable request.

Abbreviations

California critical thinking skills test

Social problem-solving inventory – revised

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Acknowledgments

This article results from research project No. 980 approved by the Research and Technology Department of Shahrekord University of Medical Sciences. We would like to appreciate to all personnel and students of the Borujen Nursing School. The efforts of all those who assisted us throughout this research.

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Community-Oriented Nursing Midwifery Research Center, Shahrekord University of Medical Sciences, Shahrekord, Iran

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SA and SSH conceptualized the study, developed the proposal, coordinated the project, completed initial data entry and analysis, and wrote the report. SSH conducted the statistical analyses. SA and SSH assisted in writing and editing the final report. All authors read and approved the final manuscript.

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This study was reviewed and given exempt status by the Institutional Review Board of the research and technology department of Shahrekord University of Medical Sciences (IRB No. 08–2017-109). Before the survey, students completed a research consent form and were assured that their information would remain confidential. After the end of the study, a training course for the control group students was held.

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Ahmady, S., Shahbazi, S. Impact of social problem-solving training on critical thinking and decision making of nursing students. BMC Nurs 19 , 94 (2020). https://doi.org/10.1186/s12912-020-00487-x

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DOI : https://doi.org/10.1186/s12912-020-00487-x

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• Social problem solving
• Decision making
• Critical thinking

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• Critical Thinking

Q&A: What is critical thinking and when would you use critical thinking in the clinical setting?

(Write 2-3 paragraphs)

In literature ‘critical thinking’ is often used, and perhaps confused, with problem-solving and clinical decision-making skills and clinical reasoning. In practice, problem-solving tends to focus on the identification and resolution of a problem, whilst critical thinking goes beyond this to incorporate asking skilled questions and critiquing solutions.

Critical thinking has been defined in many ways, but is essentially the process of deliberate, systematic and logical thinking, while considering bias or assumptions that may affect your thinking or assessment of a situation. In healthcare, the clinical setting whether acute care sector or aged care critical thinking has generally been defined as reasoned, reflective thinking which can evaluate the given evidence and its significance to the patient’s situation. Critical thinking occasionally involves suspension of one’s immediate judgment to adequately evaluate and appraise a situation, including questioning whether the current practice is evidence-based. Skills such as interpretation, analysis, evaluation, inference, explanation, and self-regulation are required to interpret thinking and the situation. A lack of critical thinking may manifest as a failure to anticipate the consequences of one’s actions.

Critical thinking is that mode of thinking – about any subject, content, or problem — in which the thinker improves the quality of his or her thinking by skillfully taking charge of the structures inherent in thinking and imposing intellectual standards upon them.

The Paul-Elder framework has three components:

• The elements of thought (reasoning)
• The intellectual standards that should be applied to the elements of reasoning
• The intellectual traits associated with a cultivated critical thinker that result from the consistent and disciplined application of the intellectual standards to the elements of thought.

Critical thinking can be defined as, “the art of analysing and evaluating thinking with a view to improving it”. The eight Parts or Elements of Thinking involved in critical thinking:

• All reasoning has a purpose (goals, objectives).
• All reasoning is an attempt to figure something out, to settle some question, to solve some problem .
• All reasoning is based on assumptions (line of reasoning, information taken for granted).
• All reasoning is done from some point of view.
• All reasoning is based on data, information and evidence .
• All reasoning is expressed through, and shaped by, concepts and ideas .
• All reasoning contains inferences or interpretations by which we draw conclusions and give meaning to data.
• All reasoning leads somewhere or has implications and consequence.

Q&A: To become a nurse requires that you learn to think like a nurse. What makes the thinking of a nurse different from a doctor, a dentist or an engineer?

It is how we view the health care consumer or aged care consumer, and the type of problems nurses deal with in clinical practice when we engage in health care patient centred care. To think like a nurse requires that we learn the content of nursing; the ideas, concepts, ethics and theories of nursing and develop our intellectual capacities and skills so that we become disciplined, self-directed, critical thinkers.

As a nurse you are required to think about the entire patient/s and what you have learnt as a nurse including; ideas, theories, and concepts in nursing. It is important that we develop our skills so that we become highly proficient critical thinkers in nursing.

In nursing, critical thinkers need to be:

Nurses need to use language that will clearly communicate a lot of information that is key to good nursing care, for handover and escalation of care for improving patient safety and reducing adverse outcomes, some organisations use the iSoBAR (identify–situation–observations–background–agreed plan–read back) format. Firstly, the “i”, for “identify yourself and the patient”, placed the patient’s identity, rather than the diagnosis, in primary position and provided a method of introduction. (This is particularly important when teams are widely spread geographically.) The prompt, “S” (“situation”) “o” for “observations”, was included to provide an adequate baseline of factual information on which to devise a plan of care. and “B” (“background”), “A” “agreed plan” and “R” “read back” to reinforce the transfer of information and accountability.

In clinical practice experienced nurses engage in multiple clinical reasoning episodes for each patient in their care. An experienced nurse may enter a patient’s room and immediately observe significant data, draw conclusions about the patient and initiate appropriate care. Because of their knowledge, skill and experience the expert nurse may appear to perform these processes in a way that seems automatic or instinctive. However, clinical reasoning is a learnt skill.

Key critical thinking skills – the clinical reasoning cycle / critical thinking process

To support nursing students in the clinical setting, breakdown the critical thinking process into phases;

• Decide/identify

This is a dynamic process and nurses often combine one or more of the phases, move back and forth between them before reaching a decision, reaching outcomes and then evaluating outcomes.

For nursing students to learn to manage complex clinical scenarios effectively, it is essential to understand the process and steps of clinical reasoning. Nursing students need to learn rules that determine how cues shape clinical decisions and the connections between cues and outcomes.

Start with the Patient – what is the issue? Holistic approach – describe or list the facts, people.

Collect information – Handover report, medical and nursing, allied health notes. Results, patient history and medications.

• New information – patient assessment

Process Information – Interpret- data, signs and symptoms, normal and abnormal.

• Analyse – relevant from non-relevant information, narrow down the information
• Evaluate – deductions or form opinions and outcomes

Identify Problems – Analyse the facts and interferences to make a definitive diagnosis of the patients’ problem.

Establish Goals – Describe what you want to happen, desired outcomes and timeframe.

Take action – Select a course of action between alternatives available.

Evaluate Outcomes – The effectiveness of the actions and outcomes. Has the situation changed or improved?

Reflect on process and new learning – What have you learnt and what would you do differently next time.

Scenario: Apply the clinical reasoning cycle, see below, to a scenario that occurred with a patient in your clinical practice setting. This could be the doctor’s orders, the patient’s vital signs or a change in the patient’s condition.

(Write 3-5 paragraphs)

Important skills for critical thinking

Some skills are more important than others when it comes to critical thinking. The skills that are most important are:

• Interpreting – Understanding and explaining the meaning of information, or a particular event.
• Analysing – Investigating a course of action, that is based upon data that is objective and subjective.
• Evaluating – This is how you assess the value of the information that you have. Is the information relevant, reliable and credible?

This skill is also needed to determine if outcomes have been fully reached.

Based upon those three skills, you can use clinical reasoning to determine what the problem is.

These decisions have to be based upon sound reasoning:

• Explaining – Clearly and concisely explaining your conclusions. The nurse needs to be able to give a sound rationale for their answers.
• Self-regulating – You have to monitor your own thought processes. This means that you must reflect on the process that lead to the conclusion. Be on alert for bias and improper assumptions.

Critical thinking pitfalls

Errors that occur in critical thinking in nursing can cause incorrect conclusions. This is particularly dangerous in nursing because an incorrect conclusion can lead to incorrect clinical actions.

Illogical Processes

A common illogical thought process is known as “appeal to tradition”. This is what people are doing when they say it’s always been done like this. Creative, new approaches are not tried because of tradition.

All people have biases. Critical thinkers are able to look at their biases and not let them compromise their thinking processes.

Biases can complicate decision making, communication and ultimately effect patient care.

Closed Minded

Being closed-minded in nursing is dangerous because it ignores other team members points of view. Essential input from other experts, as well as patients and their families are also ignored which ultimately impacts on patient care. This means that fewer clinical options are explored, and fewer innovative ideas are used for critical thinking to guide decision making.

So, no matter if you are an intensive care nurse, community health nurse or a nurse practitioner, you should always keep in mind the importance of critical thinking in the nursing clinical setting.

It is essential for nurses to develop this skill: not only to have knowledge but to be able to apply knowledge in anticipation of patients’ needs using evidence-based care guidelines.

American Management Association (2012). ‘AMA 2012 Critical Skills Survey: Executive Summary’. (2012). American Management Association. http://playbook.amanet.org/wp-content/uploads/2013/03/2012-Critical-Skills-Survey-pdf.pdf   Accessed 5 May 2020.

Korn, M. (2014). ‘Bosses Seek ‘Critical Thinking,’ but What Is That?,’ The Wall Street Journal . https://www.wsj.com/articles/bosses-seek-critical-thinking-but-what-is-that-1413923730?tesla=y&mg=reno64-wsj&url=http://online.wsj.com/article/SB12483389912594473586204580228373641221834.html#livefyre-comment Accessed 5 May 2020.

School of Nursing and Midwifery Faculty of Health, University of Newcastle. (2009). Clinical reasoning. Instructors resources. https://www.newcastle.edu.au/__data/assets/pdf_file/0010/86536/Clinical-Reasoning-Instructor-Resources.pdf  Accessed 11 May 2020

The Value of Critical Thinking in Nursing + Examples. Nurse Journal social community for nurses worldwide. 2020.  https://nursejournal.org/community/the-value-of-critical-thinking-in-nursing/ Accessed 8 May 2020.

Paul And Elder (2009) Have Defined Critical Thinking As: The Art of Analysing And Evaluating …

https://www.chegg.com/homework-help/questions-and-answers/paul-elder-2009-defined-critical-thinking-art-analyzing-evaluating-thinking-view-improving-q23582096 Accessed 8 May 2020 .

Cody, W.K. (2002). Critical thinking and nursing science: judgment, or vision? Nursing Science Quarterly, 15(3), 184-189.

Facione, P. (2011). Critical thinking: What it is and why it counts. Insight Assessment , ISBN 13: 978-1-891557-07-1.

McGrath, J. (2005). Critical thinking and evidence- based practice. Journal of Professional Nursing, 21(6), 364-371.

Porteous, J., Stewart-Wynne, G., Connolly, M. and Crommelin, P. (2009). iSoBAR — a concept and handover checklist: the National Clinical Handover Initiative. Med J Aust 2009; 190 (11): S152.

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Problem-Solving and Communication Skills of Undergraduate Nursing Students

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Background:

Problem-solving and effective communication are essential skills for daily nursing duties. Despite several studies highlighting those concepts, few examined the relationship between these concepts among nursing students. This study aimed to investigate undergraduate nursing students' problem-solving and communication skills.

A cross-sectional correlational design was used. A sizeable convenient sample of 489 undergraduate nursing students was recruited from six nursing schools in Jordan. Data were collected using an online self-administered survey. The Arabic version of the Problem-Solving Inventory and a translated version of the Communication Skills Attitude Scale were used. Descriptive statistics and multiple linear regression were used to analyze the data.

The sample included 64.4% females. The mean total score of the problem-solving scale was 96.63 (SD=16.99). Gender, considering self as an initiative person, and negative attitude toward communication were significant negative predictors, while positive attitude toward communication was a positive predictor of nursing students' problem-solving skills.

Implications:

Educational programs that improve nursing students' attitudes toward communication and mental health courses that focus on positive personality traits are needed to improve nursing students' problem-solving skills.

Conclusion:

The results indicated a moderate level of problem-solving skills, a high level of positive attitudes toward communication skills, and a low level of negative attitudes toward communication skills among undergraduate nursing students.

1. INTRODUCTION

Nurses work in a highly complex and unpredictable environment, where they face changes in patients' needs and work circumstances. They must retain adequate problem-solving abilities to determine the most suitable resolutions to the stressful situations they experience through their day-to-day work [ 1 , 2 ]. Problem-solving is a critical part of the nursing daily working duties. When encountering a problem, nurses have to apply their intellectual and cognitive abilities to examine and recognize the situation and construct a proposed solution supported by evidence [ 3 , 4 ].

Problem-solving proficiency is an intellectual and behavioral process requiring an advanced level of questioning that can help the nurse analyze the situation, suggest the most suitable solution, and apply it to solve the problem [ 5 ]. Therefore, problem-solving abilities are necessary for formatting, performing, and assessing nursing care [ 6 ], and this expertise can be boosted by academic education [ 7 ]. Education is the continuous development of individual and professional competency that prepares individuals to face daily life needs. This entails that the individuals be inspired and capable of constructing operative resolutions to their problems. Nursing students should learn to appraise the situations they encounter critically and apply nursing knowledge and skills to solve emerging problems effectively [ 8 ]. Problem-based learning (PBL) in nursing is a method of learning that enhances nursing students' abilities to utilize nursing theories in clinical practice through active involvement, problem-solving, and critical thinking. It requires nursing learners to use their knowledge and skills in new situations to achieve their goals [ 9 ].

Nursing students' acquisition of problem-solving skills is impeded by many factors, such as gender, personality traits, and the opportunities to practice problem-solving skills [ 10 - 12 ]. It is essential to exercise problem-solving by gathering information and producing knowledge regarding the problems [ 4 ]. Therefore, nursing students must identify the significance of communication skills and obtain sufficient capabilities in communication during their education process [ 4 ]. Communication is the process of information generating and exchanging between two or more individuals, which is crucial for nurses to provide high-quality and safe healthcare services to patients. Moreover, communication skills are essential to empower nurses to present their knowledge and exhibit it in practice [ 13 ]. Previous studies indicated that good communication skills are linked to nursing students' problem-solving abilities [ 1 , 14 ].

Studying problem-solving and communication skills among nursing students will provide an attempt to offer a better understanding of both problem-solving abilities and communication skills, which will provide an opportunity to enhance nursing education. Although some studies investigated the relationship between nursing students' communication skills and problem-solving skills, this relationship has not been adequately addressed [ 14 ]. Therefore, this study aimed (1) to determine the problem-solving abilities and communication skills of undergraduate nursing students and (2) to identify predictors of the problem-solving skills of undergraduate nursing students.

2.1. Design

A cross-sectional correlational design was used.

2.2. Sample and Sampling

The target population in this study was undergraduate nursing students enrolled in the nursing program. The number of nursing students in Jordan in 2020 -2021 was 8983 [ 15 ]. The sample size was calculated using Raosoft (sample size calculator), with a margin error of 5% and a confidence level of 95%. The minimum required sample size was 368 nursing students. A convenient sampling technique was used to recruit nursing students from six nursing schools in Jordan from April 2021 to September 2021. The inclusion criteria included students enrolled in the nursing program from all academic years.

2.3. Study Procedure

Data were collected using an online self-administered survey. Google forms were used to create the online survey. Target universities' websites and social media groups were used to provide the questionnaire link for the target population. Networking and snowballing techniques were used to include students. Further, the contact details of the researchers were provided to participants in case they had any questions.

2.4. Ethical Considerations

Ethical approval was obtained from the Scientific and Research Committee at the Faculty of Nursing, Al-Ahliyya Amman University. Also, permissions from the tool developers were obtained before data collection started. Students who agreed to participate in the study were asked to check the consent statement before starting the survey. The participation was voluntary, and students were informed that they had the right to withdraw from the study without any consequences.

2.5. Measures

Socio-demographic variables included ten questions about age, gender, marital status, academic year, previous hospital clinical experience for bridging students, initiative, and previous hospital training.

2.5.1. Problem-solving

The Arabic version of the Problem-Solving Inventory (PSI) was used to measure problem-solving skills [ 16 ]. It is a Likert-type self-assessment questionnaire consisting of 35 items (3 filler items) measuring the individual's self-perception regarding his/her problem-solving skills. The PSI consists of three subscales: Problem-Solving Confidence (PSC), Approach-Avoidance Style (AAS), and Personal Control (PC). The PSC subscale (11 items) assesses self-confidence and belief in the ability to solve problems effectively ( e.g. , “I make decisions and I am happy with them later.”). The AAS subscale (16 items) assesses approaching versus avoiding problems ( e.g. , “Even though I work on a problem, sometimes I feel like I am groping or wondering, and I am not getting down to the real issue.”). The PC subscale (5 items) assesses the degree of self-control ( e.g. , “I have a systematic method for comparing alternatives and making decisions.”). The PSI is scored using a 6-point Likert scale ranging from strongly agree (1) to strongly disagree (6). The possible PSI score range is from 32 to 192. Low scores on the PSI reflect a positive self-appraisal of problem-solving abilities. The Arabic version showed an excellent internal consistency level of .89 [ 16 ].

2.5.2. Communication Skills

The Communication Skills Attitude Scale (CSAS) was used to collect students’ attitudes about communication skills learning developed by Rees, Sheard, and Davies [ 17 ]. The scale consists of two subscales: The Positive Attitude Scale (PAS) and the Negative Attitude Scale (NAS). Each subscale has 13 items using a 5-point Likert scale ranging from 'strongly agree' (1) to 'strongly disagree' (5). The possible scores for each subscale range from 13 to 65. Higher scores of the subscale indicate stronger positive or negative attitudes toward communication skills. The English version of the CSAS was translated into Arabic by two independent bilingual nursing professors. Both professors were fluent in both Arabic and English. Then, the CSAS was back-translated into English by another professor specializing in translation. The translated version was evaluated by four nursing experts who have experience in tool translation and validation. The goal of the translation process was to produce an Arabic version of the CSAS with items that were equivalent in meaning to the original English version [ 18 ].

2.6. Data Analysis

Statistical Package for Social Science (SPSS) version 21 was used to analyze the data [ 19 ]. Descriptive statistics, including percentages, mean, and standard deviation, were calculated to describe demographics, including age, gender, marital status, and other defining characteristics of the students. In addition, range, mean and standard deviation were calculated for the PSI and its three subscales, the PAS and the NAS subscales. Two-step multiple linear regression was used to identify predictors of problem-solving skills. All assumptions of this analysis were met, and multicollinearity was tested. Alpha level was set at 0.05.

3.1. Sample Characteristics

A total sample of 489 nursing students participated in the study. The students' average age was 22 years (SD=3.76) and ranged from 18 to 43. The sample included 64.4% females. Most of the sample (83.6%) considered themselves initiative persons. Of the study sample, 71.6% received training in a hospital see Table 1 .

3.2. Problem Solving and Communication Skills

The mean score for the problem-solving scale was 96.63 (SD=16.99). PSC subscale mean score was 31.87 (SD=9.54), the PC subscale mean score was 17.21 (SD=3.66), and the AAS subscale mean score was 47.54 (SD=8.98). The PAS subscale mean score was 50.71 (SD=11.49), and the NAS subscale mean score was 35.06 (SD=9.26) (Table 2 ).

3.3. Predictors of Nursing Students' Problem-Solving Skills

Two-step multiple hierarchal linear regression was generated to assess predictors of nursing students' problem-solving skills, controlling for selected demographics (Table 3 ). The analysis showed that model 1, which included age, gender, and marital status as covariates, was significant (F = 4.36, p = 0.005) and explained 2% (R2 = .020) of the variance in problem-solving skills. In this model, gender was a significant negative predictor (p =.018), meaning male nursing students are expected to have significantly less problem-solving skills than female nursing students. In model 2, the covariates (academic year, previous clinical experience in hospitals, considering yourself an initiative person, previous training in the hospital during the nursing study, PAS, and NAS) were entered into the model. With these covariates, the model remained significant (F = 47.934, p < .001). The model explained 46.4% (R2 = .464) of the variance in problem-solving skills. In the second model, considering yourself an initiative person and PAS were significant negative predictors, while NAS positively predicted nursing students' problem-solving skills. The effect of gender in the second model attenuated and became insignificant.

4. DISCUSSION

This study investigated predictors of problem-solving skills of undergraduate nursing students. A cross-sectional correlational design was used on a large convenient sample of 489 undergraduate nursing students from six nursing schools in Jordan. The results showed that nursing students have a moderate level of problem-solving skills. They reported high positive and low negative attitudes toward communication skills. Male nursing students and students with negative attitudes toward communication skills have significantly lower problem-solving skills. Nursing students who consider themselves initiative and who have positive attitudes toward communication skills have significantly higher problem-solving skills.

The levels of problem-solving skills in this study were consistent with prior studies in Turkey [ 4 , 20 ]. Another study conducted in Korea and included a convenience sample of 161 nursing students found that the total mean score for PSI was 119.23. Compared to the current study, nursing students in Jordan reported higher problem-solving skills [ 21 ]. A study conducted in Turkey examined the critical thinking and problem-solving skills of 93 nursing students. The study found that the mean total score of PSI was 87. 55(SD=2.65) and 86.32(SD=2.50) in two groups of nursing students [ 22 ]. In addition, a study conducted in Iran that included 322 undergraduate nursing students found that the mean score of PSI was 89.52 (SD=21.58) [ 23 ]. Compared to the current study, nursing students in Jordan reported lower problem-solving skills.

Nursing students in the current study reported high positive and low negative attitudes toward communication skills. Another study was conducted in Turkey included 170 nurses and 413 students studying at the nursing school. The study found that both groups had moderately good communication [ 24 ]. Another study conducted with 246 nursing students in Turkey found that nursing students reported moderate communication skills of 77.325(SD=11.33) [ 4 ]. A Finnish study was conducted to examine the effect of a pilot communication skills course on second-year medical students. Using the same tool as in this study, Koponen, Pyörälä & Isotalus [ 25 ] found that the median PAS and NAS scores before the course were 45 and 31, respectively. In another study in Spain, PAS and NAS mean scores were examined in a group of first-year medical and nursing students. The results showed that PAS and NAS mean scores were 51.43 and 23.05, respectively [ 26 ]. Compared to these results, nursing students in the current study had a comparable PAS mean score; however, these students had higher negative attitudes toward communication skills.

The female gender predicted better problem-solving skills than the male gender. On the contrary, Koc et al . [ 20 ] found that the problem-solving skills of male students were higher than those of female students, while no significant differences were found based on gender in other studies [ 4 , 21 , 23 ]. The finding that female students showed better problem-solving skills might be explained in a cultural context as women in the Arab culture face several challenges in the workplace. Despite the higher enrollment rates of females in Jordanian universities, the male-dominant community demands females to make further efforts in their tasks to prove themselves [ 27 , 28 ]. Nursing students who considered themselves to be initiative reported better problem-solving skills as being initiative is a personality trait that facilitates creative problem-solving [ 29 ]. In this study, positive attitudes toward communication predicted higher problem-solving abilities, while negative attitudes toward communication predicted lower problem-solving abilities of nursing students. Kim and Sim [ 1 ] found that communication skills significantly affected problem-solving skills among clinical nurses. In addition, communication skills enhance nurses' understanding of patients' conditions and their perception of professionalism. Another study that included undergraduate nursing students also found that good communication skills improve students' problem-solving abilities [ 14 ].

4.1. Study Limitations

This study is not without limitations. First, the instruments used in this study were online self-administered questionnaires. Second, the cross-sectional design limited the investigation of causal relationships between study variables. Further research studies are needed to understand better how nursing students improve their problem-solving skills.

4.2. Implications

Several studies examined undergraduate nursing students' problem-solving and communication skills, but few were in Jordan. This was one of the very few studies that examined important concepts for nursing practice in Jordan. Developing communication and problem-solving skills in nursing students is an investment for the profession's future. The findings indicated the need for developing educational programs that improve nursing students' attitudes toward communication. In addition, the study showed an essential effect of a personality trait on problem-solving skills among nursing students. Implementing mental health courses that focus on positive personality traits is one of the approaches that can enhance nursing students' problem-solving skills.

The results indicated a moderate level of problem-solving skills, a high level of positive attitudes toward communication skills, and a low level of negative attitudes toward communication skills. Male gender and having higher negative attitudes toward communication skills were significant predictors of lower problem-solving skills while being an initiative having positive attitudes toward communication skills were significant predictors of higher problem-solving skills.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

The ethical approval was obtained from the Scientific and Research Committee at the Faculty of Nursing, Al-Ahliyya Amman University.

HUMAN AND ANIMAL RIGHTS

No animals were used in this research. All procedures performed in studies involving human participants were in accordance with the ethical standards of institutional and/or research committee and with the 1975 Declaration of Helsinki, as revised in 2013.

CONSENT FOR PUBLICATION

Informed consent was obtained from all participants.

STANDARDS OF REPORTING

STROBE guidelines were followed.

AVAILABILITY OF DATA AND MATERIALS

The details are available within the article.

CONFLICT OF INTEREST

The authors declare no conflict of interest financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

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‘These three individuals will leave very big shoes to fill’

STEVE FORD, EDITOR

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Thinking your way to successful problem-solving

13 September, 2001 By NT Contributor

VOL: 97, ISSUE: 37, PAGE NO: 36

Jacqueline Wheeler, DMS, MSc, RGN, is a lecturer at Buckinghamshire Chilterns University College

Problems - some people like them, some do not think they have any, while others shy away from them as if they were the plague. Opportunities, in the form of problems, are part of your life.

The most difficult decision is deciding to tackle a problem and implement a solution, especially as it is sometimes easier to ignore its existence. Problem-solving takes time and effort, but once a problem has been addressed the nurse can feel satisfied that the issue has been resolved and is therefore less likely to re-emerge.

Nurses make clinical decisions using two different approaches. The first is the rationalist approach, which involves an analysis of a situation so that subsequent actions are rational, logical and based on knowledge and judgement. The second approach is based on a phenomenological perspective, where a fluid, flexible and dynamic approach to decision-making is required, such as when dealing with an acutely ill patient.

Types of problems

Problems come in different guises and the solver can perceive them either as a challenge or a threat. One of the most common types of problem is when the unexpected happens. As a nurse you plan and implement care for a patient based on your knowledge and experience, only to find that the patient’s reaction is totally different from that expected but without any apparent reason.

Another type of problem is an assignment where others set a goal or task. Throughout your working life you will be required to undertake duties on behalf of other people. For some this is difficult as they feel unable to control their workload. Others see it as an opportunity to develop new skills or take on additional responsibilities. Opportunities can be perceived as problems by those who fear failure.

A third type of problem is when a dilemma arises. This is when it is difficult to choose the best solution to a problem because the nurse is confronted with something that challenges his or her personal and/or professional values.

Diagnosing problems

The sooner a problem is identified and solutions devised, the better for all involved. So try to anticipate or identify problems when they occur through continuously monitoring staff performance and patient outcomes.

Listening to and observing junior staff will help you to detect work or organisational concerns, because when there are problems staff are likely to behave in an unusual or inconsistent manner.

Initial analysis

Remember that people view things differently, so what you perceive as a problem may not be one to anyone else. So before you begin thinking about what to do - whether to keep it under surveillance, contain it or find a solution - you should undertake an initial analysis. This will help you to understand the problem more clearly.

An analysis will also enable you to prioritise its importance in relation to other problems as problems do not occur one at a time.

Routine problems often need little clarification, so an initial analysis is recommended for non-routine problems only. Even then, not all problems justify the same degree of analysis. But where it is appropriate, an initial analysis will provide a basis from which to generate solutions.

Perception is also important when dealing with patients’ problems. For example, if a patient gives up reading because he or she cannot hold the book (objective), the nurse may assume it is because the patient has lost interest (subjective, one’s own view).

Generating solutions

It is essential for the problem-solver to remember that, where possible, solutions must come from those connected with the problem. If it is to be resolved, agreement must be owned by those involved as they are probably the best and only people who can resolve their differences. The manager should never feel that he or she must be on hand to deal with all disputes.

To solve a problem you need to generate solutions. However, the obvious solution may not necessarily be the best. To generate solutions, a mixture of creative and analytical thinking is needed (Bransford, 1993).

Creativity is about escaping from preconceived ideas that block the way to finding an innovative solution to a problem. An effective tool for assisting in this process is the technique of lateral thinking, which is based largely on the work of Edward de Bono, who regards thinking as a skill.

There are several ways to encourage creative decision-making. One method that works best for specific or simple problems is brainstorming. If the ground rules of confidentiality and being non-judgemental are applied, it will produce a free flow of ideas generated without fear of criticism (Rawlinson, 1986).

Time constraints and staff availability may make it difficult for all those involved in a problem to meet. In such cases an adaptation of brainstorming - where a blank piece of paper is given to those involved and each writes down four solutions to the problem - may be the answer. A similar technique is the collective notebook, where people are asked to record their thoughts and ideas about a problem for a specified period.

An alternative is where one person writes down a list of solutions in order of priority, which is then added to by others. This helps to prioritise the ideas generated. All these methods produce data that can then be analysed by the problem-solver.

When the problem affects people in different geographical areas, solutions can be generated by obtaining the opinion of experts through the use of a questionnaire, which is known as the Delphi technique (McKenna, 1994).

When an apparently insurmountable problem presents itself, it is often useful to divide it into smaller pieces. This is known as convergent thinking. Using divergent thinking - where you consider a problem in different ways to expand your view - may also help. 

A final alternative is the stepladder technique, which is time-consuming but effective if the issue is stirring up strong feelings. This requires the people involved in the problem to be organised into groups. First, two people try to solve the problem, then a third member is drawn in, to whom the solution reached by the first two is presented. All three then try to agree a solution. More people are added to the group, if necessary, in a similar way, until there is agreement of all involved. Provided the individuals are motivated to solve the problem, this technique creates ownership and commitment to implementing the agreed solution.

Analytical thinking, which follows a logical process of eliminating ideas, will enable you to narrow the range down to one feasible solution.

Although someone has to make the ultimate decision on which solution to implement, there are advantages to group decision-making: a greater number of possible solutions are generated and conflicts are resolved, resulting in decisions being reached through rational discussion.

This does, however, require the group to be functioning well or the individuals involved may feel inhibited in contributing to the decision-making. One individual may dominate the group or competition between individuals may result in the need to win taking precedence over deciding on an agreed practical solution.

As nursing becomes less bureaucratic individuals are being encouraged to put forward their own ideas, but social pressures to conform may inhibit the group. We do not solve problems and make decisions in isolation, but are influenced by the environment in which we work and the role we fulfil in that environment. If group members lack commitment and/or motivation, they may accept the first solution and pay little attention to other solutions offered.

Making a decision

There are three types of decision-making environments: certain, risk and uncertain. The certain environment, where we have sufficient information to allow us to select the best solution, is the most comfortable within which to make a decision, but it is the least often encountered.

We usually encounter the risk environment, where we lack complete certainty about the outcomes of various courses of action.

Finally, the uncertain environment is the least comfortable within which to make decisions as we are almost forced to do this blind. We are unable to forecast the possible outcomes of alternative courses of action and, therefore, have to rely heavily on creative intuition and the educated guess.

Taking this into consideration, you should not contemplate making a decision until you have all the information needed. Before you make your decision, remind yourself of the objective, reassess the priorities, consider the options and weigh up the strengths, weaknesses, opportunities and threats of each solution.

An alternative is to use the method that Thomas Edison used to solve the problem of the electric light bulb. Simply focus on your problem as you drift off to sleep, and when you wake up your subconscious mind will have presented you with the answer. But bear in mind that this is not a scientific way of solving problems - your subconscious can be unreliable.

If you are not sure about your decision, test the solution out on others who do not own the problem but may have encountered a similar dilemma. Once you have made your choice stick to it, or you may find it difficult to implement because those involved will never be sure which solution is current. They will also be reluctant to become involved in any future decision-making because of your uncertainty.

The next step is to ensure that all the people involved know what decision has been made. Where possible, brief the group and follow this up with written communication to ensure everyone knows what is expected of them. You may need to sell the decision to some, especially if they were not involved in the decision-making process or the solution chosen is not theirs.

Implementing the solution

Finally, to ensure the solution is implemented, check that the people involved know who is to do what, by when and that it has happened. Review the results of implementing your solution (see Box) and praise and thank all those involved.

- Part 1 of this series was published in last week’s issue: Wheeler, J. (2001) How to delegate your way to a better working life. Nursing Times; 97: 36, 34-35.

Next week. Part three: a step-by-step guide to effective report writing.

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The influencing factors of clinical nurses’ problem solving dilemma: a qualitative study

a Department of Nursing, Shanghai Pulmonary Hospital, Tongji University, Shanghai, China

b Tongji University School of Medicine, Shanghai, China

c Beijing Tiantan Hospital, Capital Medical University, Beijing, China

Problem solving has been defined as “a goal-directed sequence of cognitive and affective operations as well as behavioural responses to adapting to internal or external demands or challenges. Studies have shown that some nurses lack rational thinking and decision-making ability to identify patients’ health problems and make clinical judgements, and have poor cognition and response to some clinical problems, easy to fall into problem-solving dilemma. This study aimed to understand the influencing factors of clinical nurses’ problem solving dilemma, to provide a basis for developing training strategies and improving the ability of clinical nurses in problem solving.

A qualitative research was conducted using in-depth interviews from August 2020 to December 2020. A total of 14 participants from a tertiary hospital in Shanghai, China were recruited through purposive sampling combined with a maximum variation strategy. Data were analysed with the conventional content analysis method.

Three themes and seven subthemes were extracted: nurse’s own factors (differences in knowledge structure and thinking, differences in professional values, poor strain capacity); improper nursing management (low sense of organizational support, contradiction between large workload and insufficient manpower allocation); patient factors (the concept of emphasizing medicine and neglecting to nurse, individual differences of patients).

The influencing factors of clinical nurses’ problem-solving dilemma are diverse. Hospital managers and nursing educators should pay attention to the problem-solving of clinical nurses, carry out a series of training and counselling of nurses by using the method of situational simulation, optimize the nursing management mode, learn to use new media technology to improve the credibility of nurses to provide guarantee for effective problem-solving of clinical nurses.

Introduction

Nursing education in China can be divided into two main levels: vocational education and higher education. Vocational education includes technical secondary schools and junior colleges, while higher education includes undergraduate, master’s and doctoral education. Vocational education aims at training students to master basic nursing service skills and to be able to take the post to engage in daily nursing work (Sun & Zong, 2017 ). Higher nursing education started late, and undergraduate education has always followed the “three-stage” education model of clinical medicine (basic medical courses, specialized courses and clinical practice). Most courses are centred on subject knowledge, and all clinical practice takes the form of centralized practice (Li, 2012 ). The training goal of nursing postgraduates is gradually expanding from academic master to professional master. The curriculum mainly includes classroom teaching and clinical practice. The classroom teaching contents include public courses (political theory, foreign languages, etc.), professional basic courses (advanced health assessment, pharmacotherapy, pathophysiology, evidence-based nursing, medical statistics or clinical epidemiology), specialized courses (advanced nursing practice theory) and Academic activities . The goal of nursing doctoral training is to cultivate high-level nursing research talents, focusing on the cultivation of scientific research ability rather than clinical practice ability. The curriculum includes ideology and politics, basic theory, research methods, specialized courses, development frontier, scientific writing, etc (Luo et al., 2018 ). There are some problems in the training mode and curriculum, such as theory and practice are out of touch, traditional lecture-based classroom teaching makes students passively accept knowledge, students attach importance to theory over practice, knowledge input to ability output, professional study to humanities knowledge. Nursing students receive no theoretical and/or practical training in problem solving before entering the clinical setting, so there is not a starting point for these nurses to clinical dilemmas in their professional life.

With the development of medicine, people pay more attention to health and have higher requirements for nursing service ability (Yang, Ning, et al., 2018). The National Nursing Development Plan (National Development and Reform Commission, 2017 ) points out that it is necessary to strengthen the construction of nurse teams, establish nurse training mechanisms and improve the professional quality and service ability of nurses. However, in the face of increasingly complex and changeable clinical environment, nurses are still lacking in problem-solving thinking and ability, and often fall into the dilemma of problem solving (Li et al., 2020 ).

Typical decision theory approaches to the identification of problem solving in nursing have viewed the process as a series of decision formulations that include: decisions about what observations should be made in the patient situation; decisions about deriving meaning from the data observed (clinical inferences); and decisions regarding the selection of action to be taken that will be of optimal benefit to the patient (McGuire, 1985 ). Information processing theory describes problem solving as an interaction between the information processing system (the problem-solver) and a task environment, which can be analysed as two simultaneously occurring sub-processes of “understanding” and “search” (VanLehn, 1989 ). Individuals collect the stimulus that poses the problem in the understanding process, forming the internal representation of the problem, transforming the problem stimulus into the initial information needed in the search process, and then producing mental information structures for the understanding of the problem, which making individuals distinguish the nature of the problem and clarify the goal of the problem. The mental information structures drive the search process that enables the individual to find or calculate the solution to the problem. This process starts with the nurse identifying the clinical problem and continues until the decision is made to resolve the problem (Taylor, 2000 ). Clinical problem solving requires nurses to have a variety of cognitive strategies, which involves nurses’ knowledge, experience, and memory process. Nurses must recognize the current problem and use all available knowledge and experience to transform the problem into their internal problem representation, and then set goals and search for strategies that can achieve the goal (Mayer & Wittrock, 1992 ). In today’s complex clinical environment, nurses need to be able to solve problems accurately, thoroughly, and quickly. Nurses who can solve problems efficiently have fewer medical errors (Babaei et al., 2018 ), and the level of nursing skills and empathy are higher (Ay et al., 2020 ; Bayindir Çevik & Olgun, 2015 ). To cultivate nurses’ problem solving thinking and ability, it is necessary to better understand the influencing factors of problem solving dilemma. However, these cannot be obtained by observing nurses’ behaviour in their work, and cannot be obtained through quantitative research either. Exploring the thinking process involved in nurses’ work through qualitative interviews is an effective way to understand the influencing factors of nurses’ problem solving. Given this, this study used qualitative research methods to deeply analyse the influencing factors of clinical front-line nurses’ problem solving dilemma, to provide a basis for making relevant strategies to cultivate nurses’ thinking and ability of problem solving.

Study design

A qualitative study based on in-depth interviews was conducted to obtain influencing factors of nurses’ problem-solving dilemma.

Settings and participants

Purposive sampling combined with a maximum variation strategy was used to identify and select information-rich participants related to the research phenomenon. Maximum variation was achieved in terms of participants’ gender, education level, professional title, marital status, seniority, and administrative office, respectively. The study was conducted between August 2020 to December 2020 in a tertiary hospital in Shanghai, China. The inclusion criteria were a nurse practicing certificate of the People’s Republic of China and within the valid registration period; having been engaged in clinical nursing work for at least 1 year and still engaged in clinical nursing work; clear language expression, able to clearly describe the solution and feelings of clinical problem solving; informed consent to this study and voluntary participation. The exclusion criterion were on leave during the study period (personal leave, maternity leave, sick leave, etc.); out for further study or came to the hospital for further study; confirmed or suspected mental illness and psychotropic medicine users. Purposive sampling continued until thematic saturation was reached during data analysis.

Data collection

Face-to-face, a semi-structured interview was used to collect information. All interviews were conducted in the lounge to ensure quiet and undisturbed by a female postgraduate nursing student with the guidance of her master tutor. Initially, an interview guide was developed based on literature review and expert consultation including about five predetermined questions: What thorny problems have you encountered in clinical work or have a great impact on you? How did you solve it? Why take such a solution? What is the biggest difficulty encountered in the process of problem solving? How does it affect you? How do you feel in the process of problem solving? Before the interview, the consent of the interviewee was obtained and then the researcher fully explains to the interviewees and starts with a friendly chat to allay the interviewees’ worries. During the interview, the researcher listened carefully and responded in time, always maintaining a neutral attitude, without any inducement or hint, if necessary, giving encouragement and praise to support the expression of the interviewees, and to record the interviewees’ facial expressions, physical movements and emotional responses in time. At the same time, a recording pen was used to ensure that the interview content was recorded accurately and without omission. The interview time for each person was 30 to 40 minutes.

Data analysis

After each interview, the researcher wrote an interview diary in time to reflect on the interview process and transcribed the interview content into words within 24 hours, then the researcher made a return visit by phone the next day to confirm that the information is correct. The seven-step method of Colaizzi’s phenomenological analysis method ( Table I ) was adopted to analyse the collected data(Colaizzi, 1978 ). Two researchers collated the original data, independently coded, summarized this information as themes, and organized a research group meeting once a week to discuss and reach a consensus.

7 steps of Colaizzi’s phenomenological analysis method.

Ethical considerations

This study was approved by the Ethics Committee of the Shanghai Pulmonary Hospital, Affiliated to Tongji University, project number: K16-252. Before the interview, the researcher explained the purpose and significance of the study to each interviewee in detail and obtained the informed consent of them on a voluntary basis and all of the interviewees signed informed consent forms. To protect the privacy of each interviewee, their names are replaced by numbers (e.g., N1, N2), and the original materials and transcribed text materials involved are kept by the first author himself, and all materials are destroyed after the completion of the study.

There was no new point of view when the 13th nurse was interviewed, and there was still no new point of view when one more nurse was interviewed, the interview was over, 14 nurses were interviewed. Three themes and seven subthemes were extracted. The characteristics of the participants ( N = 14) are provided in Table II .

Participant characteristics (N = 14).

Nurses’ own factors

Differences in knowledge structure and thinking.

Differences in the structure of prior knowledge and way of thinking will affect nurses’ processing of clinical data, thus affecting their clinical decision-making. The nurses made a wrong judgement of the condition because of the solidified thinking that postoperative nausea and vomiting symptoms were side effects of narcotic drugs and the lack of overall control and understanding of the patient’s condition.

There was a patient who came back after surgery with nausea and vomiting, the first thing that went through my mind, is the drug side effects, so I didn’t pay much attention, as is often the case, the most common cause of postoperative nausea and vomiting is anesthetic drug side effects, but later found to be cerebral infarction, this kind of situation I find it hard to recognize.

Differences in professional values

Professional values of nurses are accepted codes of conduct internalized by nursing professionals through training and learning (Pan, 2016 ). Negative professional values are easy to lead to problem solving dilemma. Some nurses think nursing is just a service.

The work is difficult to do, everything is the nurse’s fault, the nurse must apologize and put up with the patient’s scolding, nursing is a service industry, sometimes I am really wronged.” There are also nurses who believe that nursing work can reflect their personal value, and solving problems successfully will bring them a sense of achievement.

Although the nursing work is very intense, I live a full life every day. I feel a sense of accomplishment and pride that I can solve the problems of patients and discharge them smoothly through my work.

Poor strain capacity

Nursing work is patient-centred holistic nursing, the current clinical situation is complex and changeable, requiring nurses must have good strain capacity, and can “be anxious about what the patient needs, think what the patient thinks, and solve the patient’s difficulties.”

All patients are self-centered, and they don’t care whether you (the nurse) are busy or not. For example, once I gave oral medicine to a patient, a patient in the same ward was in a hurry and asked me to help him call his son. I was busy handing out the medicine and did not help. As a result, the patient was very dissatisfied and complained to the head nurse.

The 20-bed patient went through the discharge formalities but was still lying in the hospital bed. when the new patient arrived and she didn’t leave, I went to urge her to leave the hospital, she suddenly got angry and scolded me, I don’t know what to do.

Improper nursing management

Low sense of organizational support.

Organizational support is an important resource for clinical nurses in the process of problem solving (Poghosyan et al., 2020 ). Low sense of organizational support will hinder nurses’ problem solving.

The style of leadership and the atmosphere of the department are very important. in a department I rotated before, the leader was too strict to listen to your explanation, and the atmosphere of the department was not good. I couldn’t find help when I encountered problems. When I have a conflict with a patient, the leader will only criticize me, which makes me feel helpless.

Sometimes there will be a conflict with patients due to the bed turnover problem, and the patient will not listen to your explanation and turn around to complain, the nurse will be responsible for such things. In severe cases, even violent incidents will be encountered and the personal safety can not be guaranteed.

Insufficient allocation of manpower

Although the total number of nurses has increased substantially, there is still a shortage of human resources under the rapidly increasing workload (Guo et al., 2021 ).

When I was on the night shift and I encountered the critical moment of rescuing patients, I had to call an anesthesiologist, a doctor on duty, a nurse on duty simultaneously, an observation of the patient’s condition to prevent accidents was needed, I also have to race against time to give the patient ECG monitoring and oxygen inhalation. When the doctor came, he also criticized me that the first-aid equipment was not in place (crying).

According to the normal nurse-patient ratio, each nurse takes care of eight patients, and now there are not only eight patients, but also with extra beds and a fast turnover, and sometimes a nurse is responsible for more than 12 patients

Patient factors

The concept of emphasizing medicine and neglecting to nurse.

There is a deviation in society’s cognition of the profession of nurses, which believes that nurses are the “legs” of doctors, and nurses’ work is to help doctors run errands, give injections and give fluids. This concept not only leads to nurses’ lack of due respect, but also hinders nurses’ professional identity, and has a great negative impact on nurses’ problem-solving (Gao et al., 2015 ).

The patient did not dare to tell the doctor something he was not satisfied with, but complained directly to the nurse. For example, if the patient did not want to do some tests, he would scold the nurse. The nurse explained to him that he would not listen. But when the doctor came, he smiled and refused to admit that he cursed nurses, and he would frame the nurse. 90% of the patients would be willing to listen to the doctor.

Sometimes the patient says he was not feeling well, and I know the patient’s condition. I will give her some reasonable explanations, but the patient does not accept it. She is satisfied only when the doctor come to see her. In the final analysis, the patient just don’t believe us. No matter how much I explain to her, it is not as effective as the doctor’s glance at her.

Individual differences of patients

There are differences in patients’ personality characteristics, cultural background, views on nurses and state of an illness, these individual differences are also the reasons for nurses’ problem-solving dilemma (Chan et al., 2018 ).

Some cancer patients are in a period of anger, and it is very difficult to communicate with him. When I see him angry and lose his temper, I will not talk to him and just leave.”

Patients have different cultural levels and different social backgrounds. Sometimes I can’t talk too deeply. If patients are a little more educated, it will be easier for us to communicate with them, and some patients can’t understand anything we say.”

Multiple factors affecting clinical nurses’ problem-solving dilemma

The reasons for nurses’ failure in problem solving are mainly in the process of understanding the problem, the search process driven by the psychological information structure, and the problem or loss of balance in the process of implementing the plan. In the process, the three factors of nurses, management and patients all played an important role. Nurses’ knowledge structure and thinking loopholes led to the deviation of nurses’ internal representation of the problem (Jonassen, 2005 ). Poor professional values and low sense of organizational support can lead to nurses’ negative orientation and attitude towards problems (Poghosyan et al., 2020 ; X. Wang et al., 2018 ). The manpower allocation of nurses, patients’ emphasis on medical treatment over nursing care, and individual differences mainly increase the complexity and difficulty of nurses’ problem-solving task environment as external factors. The three factors work together on the problem-solving of clinical nurses, which leads to the dilemma of problem-solving.

Implementing situational simulation training to improve the comprehensive quality of nurses

At present, the overall quality and ability of nurses cannot meet the requirements of systematic, effective and rapid problem-solving. It is necessary to strengthen the construction of nurses to improve nurses’ problem-solving ability. Some studies have shown that situational simulation class can improve students’ knowledge, experience, psychological quality and other abilities (Mohammad, 2020 ). It is suggested that nursing educators should explore targeted situational simulation teaching and strengthen the relationship between classroom teaching and clinical practice through situational simulation, and to build a novel, perfect and clinical knowledge network for nurses. Secondly, emergency situational simulation teaching should be carried out to enable nurses to experience emergency situations from different angles, so as to improve their thinking, skills and timeliness in dealing with emergencies (Zhang et al., 2019 ). The content of professional values training should also be added to the situational simulation class in order to cultivate nurses’ positive, accessible and stable professional values and promote their positive orientation and attitude when facing problems (Skeriene, 2019 ).

Optimize nursing management and improve nurses’ working experience

Through interviews, it is found that nursing management factors have caused nurses’ problem-solving dilemma to a certain extent, which needs to be optimized according to the specific problems existing in nursing management to help nurses deal with the problems and solve the dilemma effectively. The total number of registered nurses in China exceeded 4.7 million in 2021, an increase of 1.46 million from 3.24 million in 2015, an increase of 45% (Deng et al., 2019 ]. However, there is still a large workload and underallocation of manpower, which may be due to the unreasonable distribution of human resources between time periods and departments. Hospitals and nursing managers can use the hospital information system to evaluate the nursing workload, and allocate nursing human resources reasonably according to the evaluation results (H. Yang et al., 2019 ), so as to avoid nurses falling into the dilemma of problem solving due to long-term overloaded work. In addition, it is necessary to create a harmonious departmental atmosphere for nurses, create a supportive departmental environment (Aghaei et al., 2020 ), and strictly ensure the safety of nurses’ practice and put an end to the occurrence of violence. Timely and strong organizational support can reduce the painful feelings of nurses caused by adverse events (Stone, 2020 ). and help them to solve problems actively.

Using new media to improve the image and credibility of nurses

There is a bias in social cognition of the profession of nurses, and some negative media reports mislead patients, resulting in social stereotypes of nurses (L. Q. Wang et al., 2021 ). It is necessary to make full use of new media to objectively introduce the nursing profession to the public, publicize outstanding nursing figures and typical deeds, make the public realize the important role of nurses in health care, and create an atmosphere of understanding and supporting nurses in the whole society to enhance the image and credibility of nurses and help nurses deal with problems and solve difficulties effectively (Falkenstrom, 2017 ).

Limitations and strengths of the study

The limitation is that the transferability of this study’s results may be limited as a result of including a small number of participants and the participants all worked in the same hospital in Shanghai. More participants in different cities and hospitals could have increased the variety of the descriptions and experiences. The strength is that the use of purposive sampling facilitated inclusion of participants from a range of demographic groups. The use of maximum variation strategy facilitated that the participants covered different gender, education level, professional title, marital status, seniority and department, which helped to increase the representativeness of sample.

Implications for practice

This study provides an in-depth exploration of the problem solving dilemmas of clinical nurses in China and provides valuable insights into the continuing education of nurses. These insights shine a light on areas that warrant further investigation and need to be improved in continuing education of nurses. It is of great significance to improve nurses’ problem-solving ability, improve nurses’ professional quality, effectively solve patients’ medical treatment and health problems, and improve patients’ experience of seeking medical treatment.

Through the semi-structured interview, it is found that the problem-solving dilemma of clinical nurses is affected by many factors. Nurses themselves should be confident, self-improvement, constantly learning and enterprising to improve their own ability, and be good at using new media to improve nurses’ image and credibility. Hospitals, nursing administrators and nursing educators should take corresponding measures to improve the knowledge structure of nurses, cultivate nurses’ positive professional values and adaptability, and give full organizational support to nurses. optimize the allocation of nursing human resources to provide a strong guarantee for nurses to deal with problems solving dilemma.

Biographies

Yu Mei Li : associate chief nurse, master degree, master supervisor, engaged in nursing of tumor patients.

Yifan Luo : nurse, master degree, engaged in clinical nursing.

Funding Statement

This work was supported by the Graduate Education Research and Reform Education Management program of Tongji University [2021YXGL09].

Disclosure statement

No potential conflict of interest was reported by the author(s).

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Home » Degrees » RN to MSN » Registered Nurse to Master of Science in Nursing in Administrative Leadership in Nursing » How Leaders Approach Problem-Solving

How Leaders Approach Problem-Solving

• Published On: July 12, 2022

No environment is free from problems. But, some require more creative solutions than others.

Healthcare, in particular, presents almost unlimited opportunities for things to go wrong — both in terms of patient care and inter-staff/intra-staff relationships. The problems present within healthcare settings are often a matter of life and death.

It takes effective leadership to keep all issues to a minimum and patient safety remains a priority.

What Makes a Great Leader?

If we think about the great leaders throughout time, they share a few common characteristics. Specific to nurse leaders, Indeed.com lists the following as core qualities for leaders:

• compassion/empathy
• critical thinking
• dedication to excellence
• communication
• collaboration/team building
• open-mindedness
• forward-thinking
• accessibility

Another valuable quality in leadership is being proactive in problem-solving. Good leaders handle issues as they arrive. They are capable of “putting out fires,” and that’s important. Yet, great leaders anticipate problems before they come to a head.

Core Skills Nurse Leaders Need to Possess

While some of the above resonates as more intuitive, emotional intelligence — as opposed to procedural — can be learned. Of course, there are practical skills nurse leaders need to develop as well.

Examples of these skills are healthcare finance and economics. Mastering budgets and efficiently allocating resources is important for nurse leaders. Nurses also need to know how to communicate financial demands to upper administration.

The online Registered Nurse (RN) to Master of Science in Nursing (MSN) in Administrative Leadership program from Northeastern State University (NSU) dedicates a course to heightening nurses’ skills and knowledge surrounding this responsibility.

NSU’s program also includes a course titled Organizational and Systems Management in Nursing. The course description states that nurses will learn about “contemporary influences, theories, principles, and functional strategies related to management/administration and organizational systems at the micro, meso, and macrosystem levels.”

Leadership’s Role in Addressing Lateral and Horizontal Violence (LHV)

While nurse leaders don’t necessarily need to be experts in human resources, it’s a substantial knowledge base. Human resources knowledge is especially relevant given the persistence of lateral and horizontal violence (LHV) within the nursing profession. The World Health Organization (WHO), International Council of Nurses and Public Services International have recognized this issue as a significant global public health priority.

Just how dangerous is LHV to nursing? A study published by Nurse Management describes LHV as: “all acts of meanness, hostility, disruption, discourtesy, backbiting, divisiveness, criticism, lack of unison, verbal or mental abuse, and scapegoating. [These] behaviors taint healthcare organizations; cause irreparable harm to workplace culture; breakdown team communication; and severely impact the quality of the care provided, thereby jeopardizing patient safety.”

With a solid leadership foundation, nurses can handle toxic behaviors that damage the work environment. In doing so, they change the workplace culture and guiding others to follow in their footsteps.

Empowerment Sets Everyone Up for Success

Perhaps the greatest responsibility of a nurse leader is to empower those in their charge. John Quincy Adams said, “If your actions inspire others to dream more, learn more, do more and become more, you are a leader.”

Northeastern State University recognizes empowerment as an essential skill. In the Leadership Development for the Advanced Nursing Professional course, students learn to “effectively manage change, empower others, and influence political processes.”

What Type of Leader Do You Aspire to Be?

It takes much more than “putting in your time” to become an effective leader. Nurses might rise through the ranks based on experience, but are they actually effecting change in the nursing profession? Unless they possess a robust leadership skill set, the answer is likely no. So, what kind of leader do you want to be?

Learn more about Northeastern State University’s online RN to MSN in Administrative Leadership program .

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