problem solving skills in nursing practice

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Making Decisions and Solving Problems

CHAPTER 6 Making Decisions and Solving Problems Rose Aguilar Welch This chapter describes the key concepts related to problem solving and decision making. The primary steps of the problem-solving and decision-making processes, as well as analytical tools used for these processes, are explored. Moreover, strategies for individual or group problem solving and decision making are presented. Objectives •  Apply a decision-making format to list options to solve a problem, identify the pros and cons of each option, rank the options, and select the best option. •  Evaluate the effect of faulty information gathering on a decision-making experience. •  Analyze the decision-making style of a nurse leader/manager. •  Critique resources on the Internet that focus on critical thinking, problem solving, and decision making. Terms to Know autocratic creativity critical thinking decision making democratic optimizing decision participative problem solving satisficing decision The Challenge Vickie Lemmon RN, MSN Director of Clinical Strategies and Operations, WellPoint, Inc., Ventura, California Healthcare managers today are faced with numerous and complex issues that pertain to providing quality services for patients within a resource-scarce environment. Stress levels among staff can escalate when problems are not resolved, leading to a decrease in morale, productivity, and quality service. This was the situation I encountered in my previous job as administrator for California Children Services (CCS). When I began my tenure as the new CCS administrator, staff expressed frustration and dissatisfaction with staffing, workload, and team communications. This was evidenced by high staff turnover, lack of teamwork, customer complaints, unmet deadlines for referral and enrollment cycle times, and poor documentation. The team was in crisis, characterized by in-fighting, blaming, lack of respectful communication, and lack of commitment to program goals and objectives. I had not worked as a case manager in this program. It was hard for me to determine how to address the problems the staff presented to me. I wanted to be fair but thought that I did not have enough information to make immediate changes. My challenge was to lead this team to greater compliance with state-mandated performance measures. What do you think you would do if you were this nurse? Introduction Problem solving and decision making are essential skills for effective nursing practice. Carol Huston (2008) identified “expert decision-making skills” as one of the eight vital leadership competencies for 2020. These processes not only are involved in managing and delivering care but also are essential for engaging in planned change. Myriad technologic, social, political, and economic changes have dramatically affected health care and nursing. Increased patient acuity, shorter hospital stays, shortage of healthcare providers, increased technology, greater emphasis on quality and patient safety, and the continuing shift from inpatient to ambulatory and home health care are some of the changes that require nurses to make rational and valid decisions. Moreover, increased diversity in patient populations, employment settings, and types of healthcare providers demands efficient and effective decision making and problem solving. More emphasis is now placed on involving patients in decision making and problem solving and using multidisciplinary teams to achieve results. Nurses must possess the basic knowledge and skills required for effective problem solving and decision making. These competencies are especially important for nurses with leadership and management responsibilities. Definitions Problem solving and decision making are not synonymous terms. However, the processes for engaging in both processes are similar. Both skills require critical thinking, which is a high-level cognitive process, and both can be improved with practice. Decision making is a purposeful and goal-directed effort that uses a systematic process to choose among options. Not all decision making begins with a problem situation. Instead, the hallmark of decision making is the identification and selection of options or alternatives. Problem solving, which includes a decision-making step, is focused on trying to solve an immediate problem, which can be viewed as a gap between “what is” and “what should be.” Effective problem solving and decision making are predicated on an individual’s ability to think critically. Although critical thinking has been defined in numerous ways, Scriven and Paul (2007) refer to it as “ the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action.” Effective critical thinkers are self-aware individuals who strive to improve their reasoning abilities by asking “why,” “what,” or “how.” A nurse who questions why a patient is restless is thinking critically. Compare the analytical abilities of a nurse who assumes a patient is restless because of anxiety related to an upcoming procedure with those of a nurse who asks if there could be another explanation and proceeds to investigate possible causes. It is important for nurse leaders and managers to assess staff members’ ability to think critically and enhance their knowledge and skills through staff-development programs, coaching, and role modeling. Establishing a positive and motivating work environment can enhance attitudes and dispositions to think critically. Creativity is essential for the generation of options or solutions. Creative individuals can conceptualize new and innovative approaches to a problem or issue by being more flexible and independent in their thinking. It takes just one person to plant a seed for new ideas to generate . The model depicted in Figure 6-1 demonstrates the relationship among related concepts such as professional judgment, decision making, problem solving, creativity, and critical thinking. Sound clinical judgment requires critical or reflective thinking. Critical thinking is the concept that interweaves and links the others. An individual, through the application of critical-thinking skills, engages in problem solving and decision making in an environment that can promote or inhibit these skills. It is the nurse leader’s and manager’s task to model these skills and promote them in others. FiGURE 6-1 Problem-solving and decision-making model. Decision Making This section presents an overview of concepts related to decision models, decision-making styles, factors affecting decision making, group decision making (advantages and challenges), and strategies and tools. The phases of the decision-making process include defining objectives, generating options, identifying advantages and disadvantages of each option, ranking the options, selecting the option most likely to achieve the predefined objectives, implementing the option, and evaluating the result. Box 6-1 contains a form that can be used to complete these steps. BOX 6-1    Decision-Making Format Objective: _____________________________________ Options Advantages Disadvantages Ranking                                 Add more rows as necessary. Rank priority of options, with “1” being most preferred. Select the best option. Implementation plan: ______________________________________________________________________________ Evaluation plan: __________________________________________________________________________________ A poor-quality decision is likely if the objectives are not clearly identified or if they are inconsistent with the values of the individual or organization. Lewis Carroll illustrates the essential step of defining the goal, purpose, or objectives in the following excerpt from Alice’s Adventures in Wonderland: One day Alice came to a fork in the road and saw a Cheshire Cat in a tree. “Which road do I take?” she asked. His response was a question: “Where do you want to go?” “I don’t know,” Alice answered. “Then,” said the cat, “it doesn’t matter.” Decision Models The decision model that a nurse uses depends on the circumstances. Is the situation routine and predictable or complex and uncertain? Is the goal of the decision to make a decision conservatively that is just good enough or one that is optimal? If the situation is fairly routine, nurse leaders and managers can use a normative or prescriptive approach. Agency policy, standard procedures, and analytical tools can be applied to situations that are structured and in which options are known. If the situation is subjective, non-routine, and unstructured or if outcomes are unknown or unpredictable, the nurse leader and manager may need to take a different approach. In this case, a descriptive or behavioral approach is required. More information will need to be gathered to address the situation effectively. Creativity, experience, and group process are useful in dealing with the unknown. In the business world, Camillus described complex problems that are difficult to describe or resolve as “wicked” (as cited in Huston, 2008 ). This term is apt in describing the issues that nurse leaders face. In these situations, it is especially important for nurse leaders to seek expert opinion and involve key stakeholders. Another strategy is satisficing. In this approach, the decision maker selects the solution that minimally meets the objective or standard for a decision. It allows for quick decisions and may be the most appropriate when time is an issue. Optimizing is a decision style in which the decision maker selects the option that is best, based on an analysis of the pros and cons associated with each option. A better decision is more likely using this approach, although it does take longer to arrive at a decision. For example, a nursing student approaching graduation is contemplating seeking employment in one of three acute care hospitals located within a 40-mile radius of home. The choices are a medium-size, not-for-profit community hospital; a large, corporate-owned hospital; and a county facility. A satisficing decision might result if the student nurse picked the hospital that offered a decent salary and benefit packet or the one closest to home. However, an optimizing decision is more likely to occur if the student nurse lists the pros and cons of each acute care hospital being considered such as salary, benefits, opportunities for advancement, staff development, and mentorship programs. Decision-Making Styles The decision-making style of a nurse manager is similar to the leadership style that the manager is likely to use. A manager who leans toward an autocratic style may choose to make decisions independent of the input or participation of others. This has been referred to as the “decide and announce” approach, an authoritative style. On the other hand, a manager who uses a democratic or participative approach to management involves the appropriate personnel in the decision-making process. It is imperative for managers to involve nursing personnel in making decisions that affect patient care. One mechanism for doing so is by seeking nursing representation on various committees or task forces. Participative management has been shown to increase work performance and productivity, decrease employee turnover, and enhance employee satisfaction. Any decision style can be used appropriately or inappropriately. Like the tenets of situational leadership theory, the situation and circumstances should dictate which decision-making style is most appropriate. A Code Blue is not the time for managers to democratically solicit volunteers for chest compressions! The autocratic method results in more rapid decision making and is appropriate in crisis situations or when groups are likely to accept this type of decision style. However, followers are generally more supportive of consultative and group approaches. Although these approaches take more time, they are more appropriate when conflict is likely to occur, when the problem is unstructured, or when the manager does not have the knowledge or skills to solve the problem. Exercise 6-1 Interview colleagues about their most preferred decision-making model and style. What barriers or obstacles to effective decision making have your colleagues encountered? What strategies are used to increase the effectiveness of the decisions made? Based on your interview, is the style effective? Why or why not? Factors Affecting Decision Making Numerous factors affect individuals and groups in the decision-making process. Tanner (2006) conducted an extensive review of the literature to develop a Clinical Judgment Model. Out of the research, she concluded that five principle factors influence decision making. (See the Literature Perspective below.) Literature Perspective Resource: Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45 (6), 204-211. Tanner engaged in an extensive review of 200 studies focusing on clinical judgment and clinical decision making to derive a model of clinical judgment that can be used as a framework for instruction. The first review summarized 120 articles and was published in 1998. The 2006 article reviewed an additional 71 studies published since 1998. Based on an analysis of the entire set of articles, Tanner proposed five conclusions which are listed below. The reader is referred to the article for detailed explanation of each of the five conclusions. The author considers clinical judgment as a “problem-solving activity.” She notes that the terms “clinical judgment,” “problem solving,” “decision making,” and “critical thinking” are often used interchangeably. For the purpose of aiding in the development of the model, Tanner defined clinical judgment as actions taken based on the assessment of the patient’s needs. Clinical reasoning is the process by which nurses make their judgments (e.g., the decision-making process of selecting the most appropriate option) ( Tanner, 2006 , p. 204): 1.  Clinical judgments are more influenced by what nurses bring to the situation than the objective data about the situation at hand. 2.  Sound clinical judgment rests to some degree on knowing the patient and his or her typical pattern of responses, as well as an engagement with the patient and his or her concerns. 3.  Clinical judgments are influenced by the context in which the situation occurs and the culture of the nursing care unit. 4.  Nurses use a variety of reasoning patterns alone or in combination. 5.  Reflection on practice is often triggered by a breakdown in clinical judgment and is critical for the development of clinical knowledge and improvement in clinical reasoning. The Clinical Judgment Model developed through the review of the literature involves four steps that are similar to problem-solving and decision-making steps described in this chapter. The model starts with a phase called “Noticing.” In this phase, the nurse comes to expect certain responses resulting from knowledge gleaned from similar patient situations, experiences, and knowledge. External factors influence nurses in this phase such as the complexity of the environment and values and typical practices within the unit culture. The second phase of the model is “Interpreting,” during which the nurse understands the situation that requires a response. The nurse employs various reasoning patterns to make sense of the issue and to derive an appropriate action plan. The third phase is “Responding,” during which the nurse decides on the best option for handling the situation. This is followed by the fourth phase, “Reflecting,” during which the nurse assesses the patient’s responses to the actions taken. Tanner emphasized that “reflection-in-action” and “reflection-on-action” are major processes required in the model. Reflection-in-action is real-time reflection on the patient’s responses to nursing action with modifications to the plan based on the ongoing assessment. On the other hand, reflection-on-action is a review of the experience, which promotes learning for future similar experiences. Nurse educators and managers can employ this model with new and experienced nurses to aid in understanding thought processes involved in decision making. As Tanner (2006) so eloquently concludes, “If we, as nurse educators, help our students understand and develop as moral agents, advance their clinical knowledge through expert guidance and coaching, and become habitual in reflection-on-practice, they will have learned to think like a nurse” ( p. 210 ). Implications for Practice Nurse educators and managers can employ this model with new and experienced nurses to aid in understanding thought processes involved in decision making. For example, students and practicing nurses can be encouraged to maintain reflective journals to record observations and impressions from clinical experiences. In clinical post-conferences or staff development meetings, the nurse educator and manager can engage them in applying to their lived experiences the five conclusions Tanner proposed. The ultimate goal of analyzing their decisions and decision-making processes is to improve clinical judgment, problem-solving, decision-making, and critical-thinking skills. Internal and external factors can influence how the situation is perceived. Internal factors include variables such as the decision maker’s physical and emotional state, personal philosophy, biases, values, interests, experience, knowledge, attitudes, and risk-seeking or risk-avoiding behaviors. External factors include environmental conditions, time, and resources. Decision-making options are externally limited when time is short or when the environment is characterized by a “we’ve always done it this way” attitude. Values affect all aspects of decision making, from the statement of the problem/issue through the evaluation. Values, determined by one’s cultural, social, and philosophical background, provide the foundation for one’s ethical stance. The steps for engaging in ethical decision making are similar to the steps described earlier; however, alternatives or options identified in the decision-making process are evaluated with the use of ethical resources. Resources that can facilitate ethical decision making include institutional policy; principles such as autonomy, nonmaleficence, beneficence, veracity, paternalism, respect, justice, and fidelity; personal judgment; trusted co-workers; institutional ethics committees; and legal precedent. Certain personality factors, such as self-esteem and self-confidence, affect whether one is willing to take risks in solving problems or making decisions. Keynes (2008) asserts that individuals may be influenced based on social pressures. For example, are you inclined to make decisions to satisfy people to whom you are accountable or from whom you feel social pressure? Characteristics of an effective decision maker include courage, a willingness to take risks, self-awareness, energy, creativity, sensitivity, and flexibility. Ask yourself, “Do I prefer to let others make the decisions? Am I more comfortable in the role of ‘follower’ than leader? If so, why?” Exercise 6-2 Identify a current or past situation that involved resource allocation, end-of-life issues, conflict among healthcare providers or patient/family/significant others, or some other ethical dilemma. Describe how the internal and external factors previously described influenced the decision options, the option selected, and the outcome. Group Decision Making There are two primary criteria for effective decision making. First, the decision must be of a high quality; that is, it achieves the predefined goals, objectives, and outcomes. Second, those who are responsible for its implementation must accept the decision. Higher-quality decisions are more likely to result if groups are involved in the problem-solving and decision-making process. In reality, with the increased focus on quality and safety, decisions cannot be made alone. When individuals are allowed input into the process, they tend to function more productively and the quality of the decision is generally superior. Taking ownership of the process and outcome provides a smoother transition. Multidisciplinary teams should be used in the decision-making process, especially if the issue, options, or outcome involves other disciplines. Research findings suggest that groups are more likely to be effective if members are actively involved, the group is cohesive, communication is encouraged, and members demonstrate some understanding of the group process. In deciding to use the group process for decision making, it is important to consider group size and composition. If the group is too small, a limited number of options will be generated and fewer points of view expressed. Conversely, if the group is too large, it may lack structure, and consensus becomes more difficult. Homogeneous groups may be more compatible; however, heterogeneous groups may be more successful in problem solving. Research has demonstrated that the most productive groups are those that are moderately cohesive. In other words, divergent thinking is useful to create the best decision. For groups to be able to work effectively, the group facilitator or leader should carefully select members on the basis of their knowledge and skills in decision making and problem solving. Individuals who are aggressive, are authoritarian, or manifest self-oriented behaviors tend to decrease the effectiveness of groups. The nurse leader or manager should provide a nonthreatening and positive environment in which group members are encouraged to participate actively. Using tact and diplomacy, the facilitator can control aggressive individuals who tend to monopolize the discussion and can encourage more passive individuals to contribute by asking direct, open-ended questions. Providing positive feedback such as “You raised a good point,” protecting members and their suggestions from attack, and keeping the group focused on the task are strategies that create an environment conducive to problem solving. Advantages of Group Decision Making The advantages of group decision making are numerous. The adage “two heads are better than one” illustrates that when individuals with different knowledge, skills, and resources collaborate to solve a problem or make a decision, the likelihood of a quality outcome is increased. More ideas can be generated by groups than by individuals functioning alone. In addition, when followers are directly involved in this process, they are more apt to accept the decision, because they have an increased sense of ownership or commitment to the decision. Implementing solutions becomes easier when individuals have been actively involved in the decision-making process. Involvement can be enhanced by making information readily available to the appropriate personnel, requesting input, establishing committees and task forces with broad representation, and using group decision-making techniques. The group leader must establish with the participants what decision rule will be followed. Will the group strive to achieve consensus, or will the majority rule? In determining which decision rule to use, the group leader should consider the necessity for quality and acceptance of the decision. Achieving both a high-quality and an acceptable decision is possible, but it requires more involvement and approval from individuals affected by the decision. Groups will be more committed to an idea if it is derived by consensus rather than as an outcome of individual decision making or majority rule. Consensus requires that all participants agree to go along with the decision. Although achieving consensus requires considerable time, it results in both high-quality and high-acceptance decisions and reduces the risk of sabotage. Majority rule can be used to compromise when 100% agreement cannot be achieved. This method saves time, but the solution may only partially achieve the goals of quality and acceptance. In addition, majority rule carries certain risks. First, if the informal group leaders happen to fall in the minority opinion, they may not support the decision of the majority. Certain members may go so far as to build coalitions to gain support for their position and block the majority choice. After all, the majority may represent only 51% of the group. In addition, group members may support the position of the formal leader, although they do not agree with the decision, because they fear reprisal or they wish to obtain the leader’s approval. In general, as the importance of the decision increases, so does the percentage of group members required to approve it. To secure the support of the group, the leader should maintain open communication with those affected by the decision and be honest about the advantages and disadvantages of the decision. The leader should also demonstrate how the advantages outweigh the disadvantages, suggest ways the unwanted outcomes can be minimized, and be available to assist when necessary.

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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.

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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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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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10 Essential Soft Skills in Nursing

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You’ve probably heard during your nursing school days that nursing is both an art and a science. But what does that really mean? One way to think of this is by the types of skills you amass while learning how to become a nurse .

On one hand, you have the science-based skills like learning how to insert catheters, draw blood, and give injections. These are examples of hard skills.

But there’s another side to nursing — the art of it. The more artful or soft skills in nursing help you connect with patients, collaborate effectively in teams, and navigate the challenges of healthcare. These skills can be trickier to absorb.

Let’s explore the most important soft skills for nurses, ways you can practice them, and ultimately, how they enhance patient care.

What Are Hard Skills vs. Soft Skills in Nursing?

Hard skills are the technical abilities like administering medications , performing head-to-toe assessments , and documenting changes in a patient’s condition , while soft skills are interpersonal abilities — like personality traits — that support your professionalism and contribute to a healing environment where a patient feels safe and comfortable.

The importance of soft skills in nursing can’t be underestimated. They are essential for building trust with patients and ensuring their well-being. While technical proficiency ensures competent care, it’s the soft skills — like empathy, communication, and collaboration — that elevate patient experiences and outcomes.

10 Essential Soft Skills in Nursing:

• Empathy and compassion
• Effective communication
• Creative problem-solving
• Time management
• Cultural competence
• Stress management
• Professionalism
• Critical thinking
• Open-mindedness

1. Empathy and Compassion

Compassion is at the heart of nursing. When nurses empathize with a patient and adopt a compassionate and caring attitude in their work, they create a supportive environment for patients, where they feel understood, valued, and respected.

Ways you can demonstrate empathy and compassion:

• Provide reassurance during difficult times.
• Offer small gestures like a smile or holding a hand.
• Spend time with patients, showing them that you care about their well-being.

2. Effective Communication

Effective communication isn’t just about transmitting information — it’s about building connections, promoting collaboration, and, ultimately, delivering patient-centered care. Clear and concise communication helps prevent misunderstandings , reduces errors , and promotes patient safety .

Ways you can demonstrate effective communication:

• Relay information clearly, using language that is easily understood by everyone involved.
• Pay attention to body language, facial expressions, and tone of voice, as these can convey additional meaning.
• Use the teach-back method when educating patients, as it assesses how well they understood the information.

3. Creative Problem-Solving

This quality can help you navigate any unexpected situation that may arise at your workplace. For example, you might run out of important supplies or be unable to reach a patient’s doctor to communicate a change in health status. In such situations, you need to think outside the box and adapt quickly to new circumstances.

Ways you can demonstrate creative problem-solving:

• Find alternative solutions when faced with shortages of supplies or equipment.
• Identify inefficiencies and implement creative solutions to enhance patient care.
• Adjust teaching methods to meet the patient’s educational needs.

4. Time Management

Effective time management allows nurses to dedicate sufficient time for each patient, address urgent needs in a timely manner, and minimize delays in care delivery. Without this skill, practicing other soft skills in nursing will be difficult — they require time. By prioritizing what’s important and efficiently organizing your time , you can also reduce stress and maintain a better work-life balance.

Ways you can manage your time effectively:

• Identify and prioritize tasks based on patient needs and urgency.
• Develop daily schedules or to-do lists to allocate time for different tasks and responsibilities.
• Combine activities that can be completed simultaneously.

5. Cultural Competence

This skill builds bridges between patients and caregivers, fostering a healing environment where everyone feels valued and heard. Nurses encounter people from diverse backgrounds daily, each with unique beliefs, values, and traditions. Being culturally competent means recognizing and honoring these differences, which leads to better communication, trust, and improved health outcomes.

Ways you can demonstrate cultural competence:

• Educate yourself about different cultures, customs, and traditions.
• Respect cultural norms regarding privacy and modesty, especially in procedures requiring physical touch.
• Use language services to ensure effective communication with patients who speak languages other than English.

6. Stress Management

Nurses face intense pressure every day, from heavy workloads to emotional demands. Without effective stress management , burnout can sneak up and steal the joy from caring for patients and you won’t be able to practice all other essential soft skills in nursing. Practicing self-care can help nurses to decompress and maintain their passion for helping others, creating a win-win for everyone involved.

Ways you can manage your stress:

• Get enough sleep, eat healthily, exercise regularly, and engage in activities that promote relaxation outside of work.
• Practice mindfulness techniques such as deep breathing, meditation, or yoga.
• Set clear boundaries between work and personal life to prevent burnout, including scheduling regular breaks and days off.

7. Autonomy

Autonomy is all about having the confidence and ability to make decisions independently, based on knowledge, experience, and best practices. Nurses with strong autonomy skills can take initiative in critical situations, advocate for patients, and take independent actions to ensure the well-being of those under their care.

Ways you can demonstrate autonomy:

• Make independent decisions within your professional boundaries.
• Advocate for patients’ rights and preferences.
• Take the initiative to address issues in the clinical setting, such as identifying gaps in care delivery and implementing solutions to address them.

8. Professionalism

Professionalism is about showing up with the right attitude and approach, treating patients and colleagues with respect, and maintaining integrity in all interactions. Did you make a promise to the patient? Make sure you do it. You can also demonstrate professionalism by attending to the details: your appearance, conduct, language, and punctuality.

Ways you can demonstrate professionalism:

• Follow dress code policies and maintain personal hygiene.
• Adhere to ethical principles and professional standards in all aspects of patient care, respecting confidentiality and privacy at all times.
• Demonstrate reliability by fulfilling responsibilities promptly.

9. Critical Thinking

In nursing, critical thinking means questioning, reasoning, and predicting outcomes. In your work, you are likely to encounter situations where you need to analyze situations and make sound decisions, sometimes in split seconds. This skill helps to anticipate complications, navigate uncertainties, and adapt to changing circumstances.

Ways you can demonstrate critical thinking:

• Identify problems in patient care, analyze root causes, and develop effective solutions to address them.
• Make informed decisions based on assessment data, evidence-based practice guidelines, and clinical judgment.
• Anticipate potential complications or changes in patient condition and take proactive measures to address them.

10. Open-Mindedness

Nursing field is ever-changing, and open-minded nurses are better equipped to adapt to embrace innovation and continuously improve their practice. Among all soft skills in nursing, open-mindedness is like the key that unlocks new possibilities in nursing. It’s about being receptive to new perspectives, ideas, and approaches to patient care.

Ways you can demonstrate open-mindedness:

• Pursue continuing education programs that focus on enhancing soft skills for nursing professionals.
• Learn from other members of the healthcare team with more experience.
• Consider multiple perspectives and seek new information to make informed decisions.

It’s Time to Find Your Job Match

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Problem solving in clinical nursing practice

Affiliation.

• 1 School of Nursing, Deakin University, Victoria, Australia.
• PMID: 9292367
• DOI: 10.1046/j.1365-2648.1997.1997026329.x

Problem solving in clinical nursing practice is the essence of good care delivery. This paper gives an overview of a research study which identified the cognitive problem solving process nurses use while delivering care. The study was conducted in the clinical setting and used a qualitative research methodology of observation, followed by in-depth semi-structured interview. The analysis of the study revealed diagnostic reasoning is the process used by clinicians. Information regarding the differences between novices and experts is offered as topics for discussion throughout the paper, and recommendations for changes to educational processes are made.

• Clinical Competence*
• Nurse-Patient Relations
• Nursing Care / methods*
• Nursing Methodology Research
• Nursing Process*
• Nursing Staff, Hospital / psychology*
• Problem Solving*
• Socialization
• Surveys and Questionnaires

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Factors Influencing on Problem Solving Ability of Nursing Students Experiencing Simulation Practice

Hyun hee jo.

1 Department of Nursing, Hyejeon College, 19 Daehak 1-gil, Hongseong-eup, Hongseong-gun 32244, Korea

Won Ju Hwang

2 College of Nursing Science, East-West Nursing Research Institute, Kyung Hee University, 26 Kyunghee-Daero, Dongdaemun-gu, Seoul 02447, Korea

Associated Data

The data presented in this study are available on request from the corresponding author.

It has become important for nurses to implement self-leadership and exercise critical thinking in problem-solving to address the health issues of patients. This has led to a need for nursing education programs in which nursing students learn to embrace self-leadership and self-evaluation approaches to develop their skills. Within 260 nursing undergraduates with experience in simulation practice as study subjects, a self-reporting survey was conducted on self-leadership, goal commitment, critical thinking, and problem-solving skills. An analysis was conducted using the SPSS/WIN 21.0 program. t -test and ANOVA were conducted to validate the difference between problem-solving abilities. Multiple regression was conducted to examine the impact of these variables on problem-solving skills. The variables of religion, satisfaction with major, goal commitment, and critical thinking were found to have a significant impact on problem-solving abilities. The results were as follows: critical thinking (β = 0.36, p < 0.05), goal commitment (β = 0.28, p < 0.05), and explanatory power of 41%. To improve the nursing undergraduates’ problem-solving abilities through simulation practice, there needs to be a method that supports them in setting goals with self-leadership and enhance goal commitment. The method also needs to support the development of their critical thinking and curiosity for questions deriving from experiencing diverse programs in order to deliver effective outcomes.

1. Introduction

1.1. background.

In recent nursing environments, complex and strategic practices are required, and the role of nurses is recognized for its importance. In order to effectively respond to the patients’ demands, it has become important for nurses to equip themselves with specialized skills [ 1 , 2 ].

Such change requires nurses to build not only a high level of knowledge and skills, but also self-leadership to actively solve problems with independence and autonomy, as well as critical thinking to set the best goals and to identify strategies and grounds for apply clinical judgment and decision [ 3 , 4 ]. To this effect, nursing education must provide a learning environment that reflects actual practices and supports students to ultimately equip themselves with problem-solving abilities by coming up with their own measures, as well as searching and collecting the required data in order to exercise leadership and make logical and critical decisions in various situations, thereby ultimately carrying out nursing at a technical level [ 5 ]. Problem-solving abilities are an essential quality and the most notable characteristic of nursing professionals, in which they utilize their knowledge, explore and arrange information, and use it to serve the intended purposes under complex and unpredictable circumstances [ 6 ]. However, the traditional top-down education systems have limitations in teaching such practical skills and are inadequate to prepare students for many challenges in the field [ 7 ]. For nursing graduates, attitudes that are active, autonomous, responsible, and such are required in clinical practice, and many of them face difficulties to meet the requirements as they have developed passive and dependent approaches during early school years centered on university entrance exams [ 8 ].

Insufficient training on practice at nursing colleges leads to the decline in clinical practice capability of new nurses after their graduation. To complement this, more universities are adopting a high-performance simulator to enhance their training on practice [ 7 , 9 ]. The training simulators provide benefits by reproducing simulated situations which are similar to actual clinical environments, motivating the learning of students and providing direct learning effects by having students engage in activities in simulated situations. They also provide additional learning effects through post-learning evaluation and a re-design process. Furthermore, it has been reported that such practice-oriented training provides benefits of enhancing students’ critical thinking skills, allowing them to experience the outcomes of their clinical intervention, and to share with other students and reflect on their experience through de-briefing [ 10 ]. In simulated situations, trainees must apply in a critical way the theories learned to address patient issues and set their priorities to make decisions in a self-directed manner [ 11 , 12 ]. If students lack self-leadership, which is underscored in the simulated training on practice, they may not be able to improve problem-solving skills the essential skill required for change [ 13 , 14 ].

Due to the characteristics of nursing training, the result of training is directly related to practice in the field, and this has led to more attention being given to the design of training courses involving skills development and training experience for nurses aiming to develop and promote their critical-thinking and problem-solving abilities [ 15 , 16 ]. However, there is an insufficient number of studies on the relationship between self-leadership, goal commitment, critical thinking, and problem-solving abilities in nursing students. Thereby, the study results may be used as basic data for developing and operating training programs to enhance nursing undergraduates’ problem-solving skills.

1.2. Study Purpose

The purpose of this study was to identify the relationship between self-leadership, goal commitment, critical thinking, and problem-solving abilities in nursing undergraduates who experienced simulation training on practice and the impact of these variables on problem-solving processes. This involved (1) investigating the relationship between self-leadership, goal commitment, critical thinking, and problem-solving abilities; and (2) identifying the impact of self-leadership, goal commitment, and critical thinking on problem-solving abilities.

2. Methodology

2.1. study design.

This is a descriptive investigation study conducted to identify the relationship between self-leadership, goal commitment, critical thinking, and problem-solving abilities of nursing undergraduates with the experience of simulation practice training.

2.2. Sampling Strategy

The participants of this study consisted of nursing undergraduates (juniors and seniors) at 4 universities who received 30 to 60 h of simulated practice training. The training was provided in one of the following two ways; one day of simulated practice training during clinical practice or five-day simulated practice training. All universities were equipped with high-performance simulators and used them in practice training. Though equipment and materials used varied by subject, high-performance simulators and dummies were used for most subjects.

2.3. Ethical Considerations

For the bioethics and safety of study subjects, this study was conducted after deliberation by the Institutional Review Board of University and the approval (No: KHSIRB-14-059(EA)) was obtained. During study period, the guidelines of the IRB were complied with. The description of the study was provided to study subjects and the purpose and methods of the study were explained. The survey was handed out to be filled-out by subjects who agreed to participate and they were informed the data they provided would be used solely for the study’s purpose. Study subjects were provided with a small amount of compensation in appreciation of their participation.

2.4. Study Methods

• (1) Demographics

General characteristics included university, age, grade, religion, personal relationships, academic grades, major satisfaction, leadership training experience, and need for leadership. The age groups were divided into two: subjects of 22 years of age or below and subjects of 23 years of age or above. The personal relationships were classified into average, good, and very good. The major satisfaction was classified into unsatisfactory, average, satisfactory, and highly satisfactory.

• (2) Self-leadership

To measure the self-leadership of nursing undergraduates, RSLQ (Revised Self-Leadership Questionnaire) developed by Houghton and Neck [ 17 ] was used after being modified and complemented by Shin et al. [ 18 ] for Korean participants. It consists of 35 items under 3 main categories and 9 sub-categories. The Cronbach’s α by item ranged from 0.74 to 0.88 and the Cronbach’s α value in this study was between 0.72 and 0.85.

• (3) Goal commitment

To measure the goal commitment of nursing undergraduates, the tool suggested by Klein et al. [ 19 ] was used. The tool consisted of 5 items measured with the 5-point Likert scale. The higher score meant a greater goal commitment. Items 1, 2, and 3 were reverse items. The Cronbach’s α was 0.83 and the value in this study was 0.75.

• (4) Critical thinking disposition

To measure the critical thinking disposition of nursing undergraduates, the tool suggested by Yoon [ 3 ] was used. The tool consisted of a total of 27 items under 7 categories of intellectual eagerness/curiosity, prudence, self-confidence, systematicity, intellectual fairness, healthy skepticism, and objectivity. In the study by Yoon [ 3 ], the Cronbach’s α was 0.84 and the value in this study was 0.74.

• (5) Problem-solving abilities

The Social Problem Solving Inventory-Revised (SPSI-R) modified by D’Zurilla and Maydeu-Olivares [ 20 ] and translated by Choi [ 21 ] were used to measure problem-solving abilities. SPSI-R consisted of two major scales to measure the problem-solving orientation and problem-solving skills, as well as 5 sub-categories of positive problem orientation, negative problem orientation, rational problem-solving, impulsive/careless style, and avoidance coping style. The Cronbach’s α was 0.78 and the value ranged from 0.68 to 0.91 in this study.

2.5. Data Collection Method

The study data were collected from 18 September 2014 to 4 November 2014. The data were collected from juniors and seniors with an experience of simulated practice training from nursing departments at 4 universities in Seoul, and upon agreement for participation. The surveys were then handed out, filled-in, and retrieved straight away. A total of 280 copies were distributed and 276 copies were retrieved. With 16 surveys with insincere responses excluded, a total of 260 copies were used for final analysis.

2.6. Data Analysis

The data collected were analyzed using SPSS/WIN 21.0 program (IBM Corp., Armonk, NY, USA). The variables of mistakes, average, and percentage were used to identify general characteristics. The difference in problem-solving abilities by general characteristic was validated through t -test and ANOVA with additional validation through Scheffe test and Fisher’s exact test. The relationship between the subjects’ self-leadership, goal commitment, critical thinking, and problem-solving abilities was analyzed using Pearson’s correlation coefficient. A multiple regression was used to identify the impact of these variables on problem-solving abilities.

3.1. General Characteristics of Study Participants

The subjects of this study comprised 260 juniors and seniors in the nursing department with the experience of 30 to 60 h of simulated training on practice. The juniors accounted for 72.3% and the good personal relationships accounted for 56.5%. The major satisfaction was 55.4% and no leadership training experience was 61.9%. The results were as follows: self-leadership of 3.59 ± 0.71, goal commitment of 3.68 ± 0.57, critical thinking of 3.57 ± 0.57, and problem-solving abilities of 3.14 ± 0.58 ( Table 1 ).

Mean of Dependent and Independent Variables (N = 260).

M = Mean, SD = Standard Deviation

3.2. Problem-Solving Abilities According to General Characteristics

The difference in problem-solving abilities according to the general characteristics of the study subjects showed significance in grades, personal relationships, academic grades, and major satisfaction. The juniors (2.75 ± 0.62) showed higher numbers of impulsive style (t = 1.30, p = 0.003) than seniors (2.62 ± 0.46) in relation to grades. The seniors showed higher numbers of positive problem orientation (t = −0.55, p = 0.013) and rational problem-solving (t = 0.00, p = 0.039). There were significant differences in positive problem orientation (F = 5.68, p = 0.004) and negative problem orientation (F = 7.96, p < 0.001) in relation to personal relationships. The result of post-validation shows that subjects with “average (3.65 ± 0.53)” personal relationships showed a lower positive problem orientation than subjects with “very good (2.51 ± 0.72)” personal relationships. The subjects with “very good (2.51 ± 0.72)” personal relationships showed a lower negative problem orientation than subjects with “average (3.09 ± 0.66)” and “good (2.97 ± 0.71)” personal relationships. Subjects with higher academic grades showed a lower negative problem orientation (F = 3.77, p = 0.024), impulsive careless style (F = 3.78, p = 0.024), and evasive style (F = 4.65, p = 0.010) than subjects with lower academic grades. There was a significant difference in all sub-categories of problem-solving abilities in relation to major satisfaction. For positive problem orientation (F = 5.35, p < 0.001), subjects with “average (3.62 ± 0.48)” showed lower problem-solving abilities than subjects with “very satisfactory (4.10 ± 0.47)”. For negative problem orientation (F = 6.32, p < 0.001), subjects with “average (3.18 ± 0.68)” showed higher problem-solving abilities than subjects with “satisfactory (2.84 ± 0.69)” and “very satisfactory (2.59 ± 0.76)”. For rational problem solving (F = 5.10, p = 0.001), subjects with “very satisfactory (3.82 ± 0.36)” showed higher problem-solving abilities than subjects with “average (3.43 ± 0.40)” and “unsatisfactory (3.48 ± 0.69)”. For impulsive/careless style (F = 4.24, p = 0.002), subjects with “unsatisfactory (2.95 ± 0.50)” showed higher problem-solving abilities than subjects with “satisfactory (2.65 ± 0.51)” and “very satisfactory (2.45 ± 0.63)”. While there was a significant difference observed in relation to evasive style (F = 2.99 p = 0.019), no difference was observed in the post validation. ( Table 2 )

General Characteristics of Subjects’ Problem-solving Abilities (N = 260).

§ PPO = Positive Problem Orientation, ‖ NPO = Negative Problem Orientation, ¶ RPS Rational Problem Solving, # ICS = Impulsive Careless Style, ** ACS = Avoidance Coping Style, * = Fisher’s exact test. a,b,c = scheffe

3.3. Correlation between Subjects’ Self-Leadership, Goal Commitment, Critical Thinking, and Problem-Solving Abilities

A Pearson’s correlation was used to identify the correlation between general characteristics, self-leadership, goal commitment, critical thinking, and problem-solving abilities of nursing undergraduates with the experience of simulated practice training and the result shows that there was a positive correlation between problem-solving abilities and the variables of critical thinking (r = 0.54, p < 0.01), goal commitment (r = 0.47, p < 0.01), and self-leadership (r = 0.43, p < 0.05). For general characteristics, a positive correlation was observed in major satisfaction (r = 0.29, p < 0.01) and personal relationships (r = 0.21, p < 0.01; Table 3 ).

Correlations Between Problem-solving abilities and Other Variables in Participants (N = 260).

* p < 0.05. 1. Problem Solving Skills, 2. Self-Leadership, 3. Goal Commitment, 4. Critical Thinking, 5. University, 6. Age, 7. Grade, 8. Religion, 9. Interpersonal, 10. Academic Achievement, 11. Major Satisfaction, 12. Leadership Training Experience, 13. Leadership Training Needs.

3.4. Influential Factors on Problem-Solving Abilities of Nursing Undergraduates with the Experience of Simulated Practice Training

To identify the influential factors on the problem-solving abilities of nursing undergraduates with the experience of simulated practice training, the variables that showed significance difference of p < 0.5 in relation to the subjects’ general characteristics were designated as potential influential factors. These variables were self-leadership, goal commitment, critical thinking, age, religion, personal relationships, major satisfaction, and leadership training experience. A multiple regression analysis was conducted and the results were as follows: For the analysis, the general characteristics of the subjects’ age, having or not having a religious belief, having a good or not good personal relationships, and being satisfied or unsatisfied about the major were processed as dummy-coded variables. First, as a result of testing the assumptions of regression analysis, it was found that all of them were satisfied.

Having a religious belief, major satisfaction, goal commitment, and critical thinking were observed to be significant influential factors on problem-solving abilities. The results were as follows: critical thinking (β = 0.36) and goal commitment (β = 0.28). Self-leadership, age, personal relationships, and leadership training experience showed no significance, with the value of p > 0.05. The regression equation used to analyze the influential factors showed the following results: R = 0.65, R 2 = 0.42, modified R 2 = 0.41, F = 23.17, p < 0.01, and Durbin–Watson = 1.97. The Durbin–Watson value was 1.97 and close to 2, ensuring the independence of error, and the explanatory power was 41%. The tolerance limit was 1 or below and the variance inflation factor (VIF) was lower than 10, showing no problem for multi-collinearity ( Table 4 ). Next, as a result of analyzing influence using Cook’s D statistics, there was no more than 1.0 discrete in 260 subjects. Following a result of residual analysis, linearity of the model, normality of the error term, and homoscedasticity were confirmed.

The Influencing Factors on the Problem-Solving Abilities (N = 260).

SE = Standard Error, VIF = Variance Inflation Factor.

4. Discussion

Nursing education and training must provide a learning environment that reflects actual practice and enables students to set up alternative measures to solve learning problems, search and obtain required data, and equip themselves with problem-solving abilities. However, the traditional top-down education systems have limitations in teaching such practical skills and are inadequate to prepare students for many challenges in the field [ 7 ]. This study aimed to analyze the relationship between the self-leadership, goal commitment, critical thinking, and problem-solving abilities of nursing undergraduates with the experience of simulated practice training and to obtain basic data to improve the quality of simulated practice training.

The results of the study are similar to the previous studies; an average mean of 3.14 points for problem-solving skills, 3.36 points for problem-solving orientation, and 2.98 points for problem-solving abilities [ 22 ]. This suggests that nursing undergraduates evaluated their problem-solving abilities to be of intermediate level and perceived themselves as an intermediate-level problem solver. For sub-categories, the positive problem orientation showed the highest point, followed by rational problem-solving and evasive style. This implies that nursing undergraduates showed a comparatively positive emotional state when faced with problems, but had a tendency to evade problems for as long as possible rather than confront them. According to the study by Cha et al. [ 22 ], nursing undergraduates who believed they were ineffective problem-solvers tended to imagine more hardships than there actually were, when faced with problems. To address this problem, the study also stressed out the need for measures to support nursing undergraduates to experience various situations and respond in objective, rational, and cognitive manners. Problem-solving abilities refer to a process of making decisions using effective problem-solving strategies based on one’s knowledge and are regarded as very important skills for professional nurses. A study by Yang [ 23 ] stated that the current nursing education and training courses provide content and methods that are not effective in teaching nursing undergraduates about the understanding or skills of the problem-solving process, and results in many undergraduates experiencing hardships when faced with various challenges in the clinical field. As insufficient training on practice leads to a decline in the clinical practice capability of new nurses after graduation; therefore, various teaching methods should be applied to enhance students’ problem-solving abilities and to enable nursing undergraduates to solve problems in a positive, active, and rational manner.

The difference in problem-solving abilities according to the general characteristics was partially significant for grades, personal relationships, and academic grades. The major satisfaction exhibited significant differences in all sub-categories. For positive problem orientation and rational problem-solving, the subjects with a greater major satisfaction showed a higher level of problem-solving skills. For negative problem orientation and impulsive/careless style, subjects with less major satisfaction showed a higher point. These results are consistent with the results of another study [ 24 ] on critical thinking disposition, problem-solving ability, and clinical competence of nursing students in that the subjects with a lower major satisfaction had lower problem-solving skills. This means that the subjects with a greater major satisfaction had more effective, intellectual, and creative problem-solving abilities than those with less major satisfaction. This is believed to be due to factors such as academic achievement, active attitude toward problem-solving, and such, according to their level of major satisfaction.

The influential factors for problem-solving abilities were goal commitment and critical thinking. Although the general characteristics of age, satisfaction with nursing major, and personal relationships showed correlations with problem-solving skills, no significant result was observed in the regression analysis. In a study by Aubé et al. [ 25 ], a virtual management project was implemented for undergraduates to examine the data provision and goal commitment. The results showed that subjects with a higher goal commitment had a higher problem-solving performance. The study also stated that subjects could develop actual capabilities required in the field only by having a deep understanding of situations and that they could acquire problem-solving abilities required in the field by committing to the situation not as an observer, but as a learner. Therefore, to enhance problem-solving skills, various programs should be developed and implemented to improve students’ goal commitment. In addition, team projects or action-based learning programs should be implemented to promote interactions between different learning programs and enhance students’ commitment to the study. In this way, the programs may enhance the problem-solving abilities of students by motivating them.

According to the study by Han and Park [ 26 ], greater critical thinking leads to higher problem-solving skills, which in turn enhances one’s confidence in problem-solving and improves the problem-solving skills. The study found that nursing undergraduates must develop critical thinking skills in order to explore problems in diverse aspects and seek solutions in a discreet manner. Training using simulators is an effective educational method as it motivates students’ learning and provides direct learning effects through simulated activities. Furthermore, it enhances the students’ critical abilities and allows them to experience the outcomes of their clinical intervention, as well as to share with other students and reflect on their experience through de-briefing [ 10 ].

Tucker et al. [ 27 ] stated that problems can be solved through a regular method based on guidelines and algorithms, and that such guidelines and algorithms are the result of such efforts. To develop problem-solving skills, which is an essential quality for nurses, one must develop a strong goal commitment and critical thinking abilities. To this effect, nursing undergraduates should be subjected to various nursing situations and be able to establish their own goals and commitment. They should also develop an accurate understanding of situations and critical thinking abilities to accurately identify, analyze, consolidate, and utilize data. To this effect, various simulated practice trainings, action-based learning, and problem-solving-oriented teaching programs, which support a natural learning process through a repetitive process, should be implemented to have learners actively engage in learning and develop a sense of commitment as well as critical thinking.

This study suggests that, while self-leadership showed no significant impact on problem-solving skills, it had impact on the problem-solving abilities of nursing undergraduates [ 28 , 29 ]. It was also suggested that self-leadership affected the goal commitment, which impacted the problem-solving abilities and improved it. This was due to the fact that not all nursing undergraduates exercised self-leadership and the level of self-leadership varied according to the individuals’ ability, environmental factors, function, and task structure [ 17 ]. Self-leadership involves a behavior strategy and cognitive strategy. Nursing students need to be committed to this process to solve problems and must put efforts to address problems on their own in order for their problem-solving abilities to develop. To enhance problem-solving skills, they must be committed to achieving their goals. Educational and training programs should be developed and implemented to provide nursing students with circumstances in which they are able to exercise self-leadership and in which they are encouraged to develop self-leadership skills.

This study holds significance in that it suggests the need for the development and implementation of various programs involving simulated practice training to enhance the problem-solving abilities of nursing undergraduates. It also suggests the need for measures to make students set their own goals and improve the level of their goal commitment, as well as the fact that the use of self-leadership may enhance the effectiveness of the process. Furthermore, it suggests the possible synergetic effects on developing critical thinking abilities by allowing students to build critical curiosity over questions they face by experiencing various programs. On the other hand, this study had limitations in that the scope of sample was limited to nursing undergraduates with the experience of simulated practice training at certain universities in Seoul city who agreed to participate in the study, suggesting that the study results should not be used for generalization. In addition, there are limitations to defining the correlation in that a cross-sectional study method was used in which the cause and outcome variables of the collected data were measured at the same time point for analysis.

5. Conclusions

This study was conducted to identify the relationship between the self-leadership, goal commitment, critical thinking, and problem-solving abilities of nursing undergraduates with the experience of simulated practice training. The multiple regression analysis results show that the variables of goal commitment and critical thinking had a significant impact on the nursing undergraduates’ problem-solving abilities (F = 23.17, p < 0.01), with the explanatory power of 41%. In order to enhance the problem-solving abilities of nursing undergraduates, various education programs which involve discussions with simulated training on practice to demonstrate a step-by-step approach to problematic situations, an establishment of hypothesis, and team cooperation must be developed and implemented [ 30 , 31 , 32 ]. At this stage, measures are required to encourage students to set up their own goals and enhance goal commitment; the effectiveness is expected to increase if the process involves self-leadership. In addition, there may be synergetic effects from students participating in various programs, through training and classes, and developing questions and critical thinking as well as curiosity. Based on the study results, the following suggestions are made. There is a need for repetitive studies on nursing undergraduates and professional nurses under various circumstances and on self-leadership, which was explained as a parameter for problem-solving skills. In addition, a comprehensive program must be developed in which simulated practice training involves not only enhancing the learners’ problem-solving abilities and critical thinking, but also developing self-leadership and goal commitment.

Funding Statement

This research was supported by Basic Science Research Program through the National Research Foundation of Korea funded by the Ministry of Science, ICT & Future Planning (No. 2017R1A2B4008496). It was also funded by the Korea Health Industry Development Institute (KHIDI) through the Ministry of Health & Welfare, Republic of Korea (grant number: HI18C1317). The funding agencies had no role in the study design, the collection, analysis, or interpretation of data, the writing of the report, or the decision to submit the article for publication (PI: WJ Hwang).

Author Contributions

(1) H.H.J.: Study conception and design, data collection, data analysis, and interpretation, and writing the manuscript. (2) W.J.H.: Study conception and design, development of design, drafting of the article, supervision, and writing of the manuscript. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

For the bioethics and safety of study subjects, this study was conducted after deliberation by the Institutional Review Board of Kyung Hee University and the approval (No: KHSIRB-14-059(EA)) was obtained.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

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