rational problem solving and nursing process

The Nursing Process: A Comprehensive Guide

In 1958, Ida Jean Orlando began developing the nursing process still evident in nursing care today. According to Orlando’s theory, the patient’s behavior sets the nursing process in motion. Through the nurse’s knowledge to analyze and diagnose the behavior to determine the patient’s needs.

Application of the fundamental principles of critical thinking, client-centered approaches to treatment, goal-oriented tasks, evidence-based practice (EBP) recommendations, and nursing intuition, the nursing process functions as a systematic guide to client-centered care with five subsequent steps. These are assessment , diagnosis, planning, implementation, and evaluation ( ADPIE ).

Table of Contents

What is the nursing process.

• What is the purpose of the nursing process? 

Characteristics of the nursing process

Nursing process steps, collecting data, objective data or signs, subjective data or symptoms, verbal data, nonverbal data, primary source, secondary source, tertiary source, health interview, physical examination, observation, validating data, documenting data.

• 2. Diagnosis: “What is the problem?” 

Initial Planning

Ongoing planning, discharge planning, developing a nursing care plan, behavioral nursing interventions, community nursing interventions, family nursing interventions, health system nursing interventions, physiological nursing interventions, safety nursing interventions, skills used in implementing nursing care, 1. reassessing the client, 2. determining the nurse’s need for assistance, nursing intervention categories, independent nursing interventions, dependent nursing interventions, interdependent nursing interventions, 4. supervising the delegated care, 5. documenting nursing activities, 1. collecting data, 2. comparing data with desired outcomes, 3. analyzing client’s response relating to nursing activities, 4. identifying factors contributing to success or failure, 5. continuing, modifying, or terminating the nursing care plan, 6. discharge planning.

The nursing process is defined as a systematic, rational method of planning that guides all nursing actions in delivering holistic and patient-focused care. The nursing process is a form of scientific reasoning and requires the nurse’s critical thinking to provide the best care possible to the client.

What is the purpose of the nursing process?

The following are the purposes of the nursing process:

• To identify the client’s health status and actual or potential health care problems or needs (through assessment).
• To establish plans to meet the identified needs.
• To deliver specific nursing interventions to meet those needs.
• To apply the best available caregiving evidence and promote human functions and responses to health and illness (ANA, 2010).
• To protect nurses against legal problems related to nursing care when the standards of the nursing process are followed correctly.
• To help the nurse perform in a systematically organized way their practice.
• To establish a database about the client’s health status, health concerns, response to illness, and the ability to manage health care needs.

The following are the unique characteristics of the nursing process: 

• Patient-centered . The unique approach of the nursing process requires care respectful of and responsive to the individual patient’s needs, preferences, and values. The nurse functions as a patient advocate by keeping the patient’s right to practice informed decision-making and maintaining patient-centered engagement in the health care setting.
• Interpersonal . The nursing process provides the basis for the therapeutic process in which the nurse and patient respect each other as individuals, both of them learning and growing due to the interaction. It involves the interaction between the nurse and the patient with a common goal.
• Collaborative . The nursing process functions effectively in nursing and inter-professional teams, promoting open communication, mutual respect, and shared decision-making to achieve quality patient care.
• Dynamic and cyclical .The nursing process is a dynamic, cyclical process in which each phase interacts with and is influenced by the other phases.
• Requires critical thinking . The use of the nursing process requires critical thinking which is a vital skill required for nurses in identifying client problems and implementing interventions to promote effective care outcomes.

The nursing process consists of five steps: assessment, diagnosis, planning, implementation, and evaluation. The acronym ADPIE is an easy way to remember the components of the nursing process. Nurses need to learn how to apply the process step-by-step. However, as critical thinking develops through experience, they learn how to move back and forth among the steps of the nursing process.

The steps of the nursing process are not separate entities but overlapping, continuing subprocesses. Apart from understanding nursing diagnoses and their definitions, the nurse promotes awareness of defining characteristics and behaviors of the diagnoses, related factors to the selected nursing diagnoses, and the interventions suited for treating the diagnoses.

The steps of the nursing process are detailed below:

1. Assessment: “What data is collected?”

The first phase of the nursing process is assessment . It involves collecting, organizing, validating, and documenting the clients’ health status. This data can be obtained in a variety of ways. Usually, when the nurse first encounters a patient, the nurse is expected to assess to identify the patient’s health problems as well as the physiological, psychological, and emotional state and to establish a database about the client’s response to health concerns or illness and the ability to manage health care needs. Critical thinking skills are essential to the assessment, thus requiring concept-based curriculum changes.

Data collection is the process of gathering information regarding a client’s health status. The process must be systematic and continuous in collecting data to prevent the omission of important information concerning the client.

The best way to collect data is through head-to-toe assessment. Learn more about it at our guide: Head to Toe Assessment: Complete Physical Assessment Guide

Types of Data

Data collected about a client generally falls into objective or subjective categories, but data can also be verbal and nonverbal. 

Objective data are overt, measurable, tangible data collected via the senses, such as sight, touch, smell, or hearing, and compared to an accepted standard, such as vital signs, intake and output , height and weight, body temperature, pulse, and respiratory rates, blood pressure, vomiting , distended abdomen, presence of edema , lung sounds, crying, skin color, and presence of diaphoresis.

Subjective data involve covert information, such as feelings, perceptions, thoughts, sensations, or concerns that are shared by the patient and can be verified only by the patient, such as nausea , pain , numbness, pruritus, attitudes, beliefs, values, and perceptions of the health concern and life events.

Verbal data are spoken or written data such as statements made by the client or by a secondary source. Verbal data requires the listening skills of the nurse to assess difficulties such as slurring, tone of voice, assertiveness, anxiety , difficulty in finding the desired word, and flight of ideas.

Nonverbal data are observable behavior transmitting a message without words, such as the patient’s body language, general appearance, facial expressions, gestures, eye contact, proxemics (distance), body language, touch, posture, clothing. Nonverbal data obtained can sometimes be more powerful than verbal data, as the client’s body language may not be congruent with what they really think or feel. Obtaining and analyzing nonverbal data can help reinforce other forms of data and understand what the patient really feels.

Sources of Data

Sources of data can be primary, secondary, and tertiary . The client is the primary source of data, while family members, support persons, records and reports, other health professionals, laboratory and diagnostics fall under secondary sources.

The client is the only primary source of data and the only one who can provide subjective data. Anything the client says or reports to the members of the healthcare team is considered primary.

A source is considered secondary data if it is provided from someone else other than the client but within the client’s frame of reference. Information provided by the client’s family or significant others are considered secondary sources of data if the client cannot speak for themselves, is lacking facts and understanding, or is a child. Additionally, the client’s records and assessment data from other nurses or other members of the healthcare team are considered secondary sources of data.

Sources from outside the client’s frame of reference are considered tertiary sources of data . Examples of tertiary data include information from textbooks, medical and nursing journals, drug handbooks, surveys, and policy and procedural manuals.

Methods of Data Collection

The main methods used to collect data are health interviews, physical examination, and observation.

The most common approach to gathering important information is through an interview. An interview is an intended communication or a conversation with a purpose, for example, to obtain or provide information, identify problems of mutual concern, evaluate change, teach, provide support, or provide counseling or therapy. One example of the interview is the nursing health history, which is a part of the nursing admission assessment. Patient interaction is generally the heaviest during the assessment phase of the nursing process so rapport must be established during this step.

Aside from conducting interviews, nurses will perform physical examinations, referencing a patient’s health history, obtaining a patient’s family history, and general observation can also be used to gather assessment data. Establishing a good physical assessment would, later on, provide a more accurate diagnosis, planning, and better interventions and evaluation.

Observation is an assessment tool that depends on the use of the five senses (sight, touch, hearing, smell, and taste) to learn information about the client. This information relates to characteristics of the client’s appearance, functioning, primary relationships, and environment. Although nurses observe mainly through sight, most of the senses are engaged during careful observations such as smelling foul odors, hearing or auscultating lung and heart sounds and feeling the pulse rate and other palpable skin deformations.

Validation is the process of verifying the data to ensure that it is accurate and factual. One way to validate observations is through “double-checking,” and it allows the nurse to complete the following tasks:

• Ensures that assessment information is double-checked, verified, and complete. For example, during routine assessment, the nurse obtains a reading of 210/96 mm Hg of a client with no history of hypertension . To validate the data, the nurse should retake the blood pressure and if necessary, use another equipment to confirm the measurement or ask someone else to perform the assessment.
• Ensure that objective and related subjective data are valid and accurate. For example, the client’s perceptions of “feeling hot” need to be compared with the measurement of the body temperature.
• Ensure that the nurse does not come to a conclusion without adequate data to support the conclusion. A nurse assumes tiny purple or bluish-black swollen areas under the tongue of an older adult client to be abnormal until reading about physical changes of aging.
• Ensure that any ambiguous or vague statements are clarified. For example, a 86-year-old female client who is not a native English speaker says that “I am in pain on and off for 4 weeks,” would require verification for clarity from the nurse by asking “Can you describe what your pain is like? What do you mean by on and off?”
• Acquire additional details that may have been overlooked. For example, the nurse is asking a 32-year-old client if he is allergic to any prescription or non-prescription medications. And what would happen if he takes these medications.
• Distinguish between cues and inferences. Cues are subjective or objective data that can be directly observed by the nurse; that is, what the client says or what the nurse can see, hear, feel, smell, or measure. On the other hand, inferences are the nurse’s interpretation or conclusions made based on the cues. For example, the nurse observes the cues that the incision is red, hot, and swollen and makes an inference that the incision is infected.

Once all the information has been collected, data can be recorded and sorted. Excellent record-keeping is fundamental so that all the data gathered is documented and explained in a way that is accessible to the whole health care team and can be referenced during evaluation. 

2. Diagnosis: “What is the problem?”

The second step of the nursing process is the nursing diagnosis . The nurse will analyze all the gathered information and diagnose the client’s condition and needs. Diagnosing involves analyzing data, identifying health problems, risks, and strengths, and formulating diagnostic statements about a patient’s potential or actual health problem. More than one diagnosis is sometimes made for a single patient. Formulating a nursing diagnosis by employing clinical judgment assists in the planning and implementation of patient care.

The types, components, processes, examples, and writing nursing diagnosis are discussed more in detail here “ Nursing Diagnosis Guide: All You Need To Know To Master Diagnosing ”

3. Planning: “How to manage the problem?”

Planning is the third step of the nursing process. It provides direction for nursing interventions. When the nurse, any supervising medical staff, and the patient agree on the diagnosis, the nurse will plan a course of treatment that takes into account short and long-term goals. Each problem is committed to a clear, measurable goal for the expected beneficial outcome. 

The planning phase is where goals and outcomes are formulated that directly impact patient care based on evidence-based practice (EBP) guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual’s unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum.

Types of Planning

Planning starts with the first client contact and resumes until the nurse-client relationship ends, preferably when the client is discharged from the health care facility.

Initial planning is done by the nurse who conducts the admission assessment. Usually, the same nurse would be the one to create the initial comprehensive plan of care.

Ongoing planning is done by all the nurses who work with the client. As a nurse obtain new information and evaluate the client’s responses to care, they can individualize the initial care plan further. An ongoing care plan also occurs at the beginning of a shift. Ongoing planning allows the nurse to:

• determine if the client’s health status has changed
• set priorities for the client during the shift
• decide which problem to focus on during the shift
• coordinate with nurses to ensure that more than one problem can be addressed at each client contact

Discharge planning is the process of anticipating and planning for needs after discharge. To provide continuity of care, nurses need to accomplish the following:

• Start discharge planning for all clients when they are admitted to any health care setting.
• Involve the client and the client’s family or support persons in the planning process.
• Collaborate with other health care professionals as needed to ensure that biopsychosocial, cultural, and spiritual needs are met.

A nursing care plan (NCP) is a formal process that correctly identifies existing needs and recognizes potential needs or risks. Care plans provide communication among nurses, their patients, and other healthcare providers to achieve health care outcomes. Without the nursing care planning process, the quality and consistency of patient care would be lost.

The planning step of the nursing process is discussed in detail in Nursing Care Plans (NCP): Ultimate Guide and Database .

4. Implementation : “Putting the plan into action!”

The implementation phase of the nursing process is when the nurse puts the treatment plan into effect. It involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care. This typically begins with the medical staff conducting any needed medical interventions. 

Interventions should be specific to each patient and focus on achievable outcomes. Actions associated with a nursing care plan include monitoring the patient for signs of change or improvement, directly caring for the patient or conducting important medical tasks such as medication administration , educating and guiding the patient about further health management, and referring or contacting the patient for a follow-up.

A taxonomy of nursing interventions referred to as the Nursing Interventions Classification (NIC) taxonomy, was developed by the Iowa Intervention Project. The nurse can look up a client’s nursing diagnosis to see which nursing interventions are recommended. 

Nursing Interventions Classification (NIC) System

There are more than 550 nursing intervention labels that nurses can use to provide the proper care to their patients. These interventions are categorized into seven fields or classes of interventions according to the Nursing Interventions Classification system.

These are interventions designed to help a patient change their behavior. With behavioral interventions, in contrast, patient behavior is the key and the goal is to modify it. The following measures are examples of behavioral nursing interventions:

• Encouraging stress and relaxation techniques
• Providing support to quit smoking
• Engaging the patient in some form of physical activity , like walking, to reduce the patient’s anxiety, anger, and hostility

These are interventions that refer to the community-wide approach to health behavior change. Instead of focusing mainly on the individual as a change agent, community interventionists recognize a host of other factors that contribute to an individual’s capacity to achieve optimal health, such as:

• Implementing an education program for first-time mothers
• Promoting diet and physical activities
• Initiating HIV awareness and violence-prevention programs
• Organizing a fun run to raise money for breast cancer research 

These are interventions that influence a patient’s entire family.

• Implementing a family-centered approach in reducing the threat of illness spreading when one family member is diagnosed with a communicable disease
• Providing a nursing woman support in breastfeeding her new baby
• Educating family members about caring for the patient

These are interventions that designed to maintain a safe medical facility for all patients and staff, such as:

• Following procedures to reduce the risk of infection for patients during hospital stays.
• Ensuring that the patient’s environment is safe and comfortable, such as repositioning them to avoid pressure ulcers in bed

These are interventions related to a patient’s physical health to make sure that any physical needs are being met and that the patient is in a healthy condition. These nursing interventions are classified into two types: basic and complex.

• Basic. Basic interventions regarding the patient’s physical health include hands-on procedures ranging from feeding to hygiene assistance.
• Complex. Some physiological nursing interventions are more complex, such as the insertion of an IV line to administer fluids to a dehydrated patient.

These are interventions that maintain a patient’s safety and prevent injuries, such as:

• Educating a patient about how to call for assistance if they are not able to safely move around on their own
• Providing instructions for using assistive devices such as walkers or canes, or how to take a shower safely.

When implementing care, nurses need cognitive, interpersonal, and technical skills to perform the care plan successfully.

• Cognitive Skills are also known as Intellectual Skills are skills involve learning and understanding fundamental knowledge including basic sciences, nursing procedures, and their underlying rationale before caring for clients. Cognitive skills also include problem-solving, decision-making, critical thinking, clinical reasoning, and creativity.
• Interpersonal Skills are skills that involve believing, behaving, and relating to others. The effectiveness of a nursing action usually leans mainly on the nurse’s ability to communicate with the patient and the members of the health care team.
• Technical Skills are purposeful “hands-on” skills such as changing a sterile dressing, administering an injection, manipulating equipment, bandaging, moving, lifting, and repositioning clients. All of these activities require safe and competent performance.

Process of Implementing

The process of implementing typically includes the following:

Prior to implementing an intervention, the nurse must reassess the client to make sure the intervention is still needed. Even if an order is written on the care plan, the client’s condition may have changed.

Other nursing tasks or activities may also be performed by non-RN members of the healthcare team. Members of this team may include unlicensed assistive personnel (UAP) and caregivers , as well as other licensed healthcare workers, such as licensed practical nurses/licensed vocational nurses (LPNs/LVNs). The nurse may need assistance when implementing some nursing intervention, such as ambulating an unsteady obese client, repositioning a client, or when a nurse is not familiar with a particular model of traction equipment needs assistance the first time it is applied.

3. Implementing the nursing interventions

Nurses must not only have a substantial knowledge base of the sciences, nursing theory , nursing practice, and legal parameters of nursing interventions but also must have the psychomotor skills to implement procedures safely. It is necessary for nurses to describe, explain, and clarify to the client what interventions will be done, what sensations to anticipate, what the client is expected to do, and what the expected outcome is. When implementing care, nurses perform activities that may be independent, dependent, or interdependent.

Nursing interventions are grouped into three categories according to the role of the healthcare professional involved in the patient’s care:

A registered nurse can perform independent interventions on their own without the help or assistance from other medical personnel, such as: 

• routine nursing tasks such as checking vital signs
• educating a patient on the importance of their medication so they can administer it as prescribed

A nurse cannot initiate dependent interventions alone. Some actions require guidance or supervision from a physician or other medical professional, such as:

• prescribing new medication
• inserting and removing a urinary catheter
• providing diet
• Implementing wound or bladder irrigations

A nurse performs as part of collaborative or interdependent interventions that involve team members across disciplines.

• In some cases, such as post- surgery , the patient’s recovery plan may require prescription medication from a physician, feeding assistance from a nurse, and treatment by a physical therapist or occupational therapist.
• The physician may prescribe a specific diet to a patient. The nurse includes diet counseling in the patient care plan. To aid the patient, even more, the nurse enlists the help of the dietician that is available in the facility.

Delegate specific nursing interventions to other members of the nursing team as appropriate. Consider the capabilities and limitations of the members of the nursing team and supervise the performance of the nursing interventions. Deciding whether delegation is indicated is another activity that arises during the nursing process.

The American Nurses Association and the National Council of State Boards of Nursing (2006) define delegation as “the process for a nurse to direct another person to perform nursing tasks and activities.” It generally concerns the appointment of the performance of activities or tasks associated with patient care to unlicensed assistive personnel while retaining accountability for the outcome.

Nevertheless, registered nurses cannot delegate responsibilities related to making nursing judgments. Examples of nursing activities that cannot be delegated to unlicensed assistive personnel include assessment and evaluation of the impact of interventions on care provided to the patient.

Record what has been done as well as the patient’s responses to nursing interventions precisely and concisely.

5. Evaluation : “Did the plan work?”

Evaluating is the fifth step of the nursing process. This final phase of the nursing process is vital to a positive patient outcome. Once all nursing intervention actions have taken place, the team now learns what works and what doesn’t by evaluating what was done beforehand. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. The possible patient outcomes are generally explained under three terms: the patient’s condition improved, the patient’s condition stabilized, and the patient’s condition worsened.

Steps in Evaluation

Nursing evaluation includes (1) collecting data, (2) comparing collected data with desired outcomes, (3) analyzing client’s response relating to nursing activities, (4) identifying factors that contributed to the success or failure of the care plan, (5) continuing, modifying, or terminating the nursing care plan, and (6) planning for future nursing care.

The nurse recollects data so that conclusions can be drawn about whether goals have been fulfilled. It is usually vital to collect both objective and subjective data. Data must be documented concisely and accurately to facilitate the next part of the evaluating process.

The documented goals and objectives of the nursing care plan become the standards or criteria by which to measure the client’s progress whether the desired outcome has been met, partially met, or not met.

• The goal was met , when the client response is the same as the desired outcome.
• The goal was partially met , when either a short-term outcome was achieved but the long-term goal was not, or the desired goal was incompletely attained.
• The goal was not met.

It is also very important to determine whether the nursing activities had any relation to the outcomes whether it was successfully accomplished or not.

It is required to collect more data to confirm if the plan was successful or a failure. Different factors may contribute to the achievement of goals. For example, the client’s family may or may not be supportive, or the client may be uncooperative to perform such activities. 

The nursing process is dynamic and cyclical. If goals were not sufficed, the nursing process begins again from the first step. Reassessment and modification may continually be needed to keep them current and relevant depending upon general patient condition. The plan of care may be adjusted based on new assessment data. Problems may arise or change accordingly. As clients complete their goals, new goals are set. If goals remain unmet, nurses must evaluate the reasons these goals are not being achieved and recommend revisions to the nursing care plan.

Discharge planning is the process of transitioning a patient from one level of care to the next. Discharge plans are individualized instructions provided as the client is prepared for continued care outside the healthcare facility or for independent living at home. The main purpose of a discharge plan is to improve the client’s quality of life by ensuring continuity of care together with the client’s family or other healthcare workers providing continuing care.

The following are the key elements of IDEAL discharge planning according to the Agency for Healthcare Research and Quality:

• I nclude the patient and family as full partners in the discharge planning process.
• Describe what life at home will be like
• Review medications
• Highlight warning signs and problems
• Explain test results
• Schedule follow-up appointments
• E ducate the patient and family in plain language about the patient’s condition, the discharge process, and next steps throughout the hospital stay.
• A ssess how well doctors and nurses explain the diagnosis, condition, and next steps in the patient’s care to the patient and family and use teach back.
• L isten to and honor the patient’s and family’s goals, preferences, observations, and concerns. 

A discharge plan includes specific components of client teaching with documentation such as:

• Equipment needed at home. Coordinate home-based care and special equipment needed.
• Dietary needs or special diet . Discuss what the patient can or cannot eat at home.
• Medications to be taken at home. List the patient’s medications and discuss the purpose of each medicine, how much to take, how to take it, and potential side effects.
• Resources such as contact numbers and addresses of important people. Write down the name and contact information of someone to call if there is a problem.
• Emergency response: Danger signs. Identify and educate patients and families about warning signs or potential problems.
• Home care activities. Educate patient on what activities to do or avoid at home.
• Summary. Discuss with the patient and family about the patient’s condition, the discharge process, and follow-up checkups.

38 thoughts on “The Nursing Process: A Comprehensive Guide”

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

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

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

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

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

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

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

Conclusions

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

Peer Review reports

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

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

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

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

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

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

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

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

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

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

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

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

Setting and sample

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

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

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

Intervention

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

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

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

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

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

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

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

Instruments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Statistical analysis

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Study limitations

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

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

Availability of data and materials

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

Abbreviations

California critical thinking skills test

Social problem-solving inventory – revised

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Acknowledgments

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

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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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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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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?

Critical Thinking and the Nursing Process

In today’s health care arena, the nurse is faced with increasingly complex issues and situations resulting from advanced technology, greater acuity of patients in hospital and community settings, an aging population, and complex disease processes, as well as ethical and cultural factors.  Traditionally, nurses have used a problem-solving approach in planning and providing nursing care. Today the decision-making part of problem solving has become increasingly complex and requires critical thinking.

Definition of Critical thinking

Critical thinking is a multidimensional skill, a cognitive or mental process or set of procedures. It involves reasoning and purposeful, systematic, reflective, rational, outcome-directed thinking based on a body of knowledge, as well as examination and analysis of all available information and ideas. Critical thinking leads to the formulation of conclusions and the most appropriate, often creative, decisions, options, or alternatives. Critical thinking includes metacognition, the examination of one’s own reasoning or thought processes while thinking, to help strengthen and refine thinking skills. Independent judgments and decisions evolve from a sound knowledge base and the ability to synthesize information within the context in which it is presented. Nursing practice in today’s society mandates the use of high-level critical thinking skills within the nursing process. Critical thinking enhances clinical decision making, helping to identify patient needs and to determine the best nursing actions that will assist the patient in meeting those needs. Critical thinking and critical thinkers have distinctive characteristics. As indicated in the above definition, critical thinking is a conscious, outcome-oriented activity; it is purposeful and intentional. The critical thinker is an inquisitive, fair-minded truth seeker with an open-mindedness to the alternative solutions that might surface.

Critical thinking Process: Rationality and Insight

Critical thinking is systematic and organized. The skills involved in critical thinking are developed over time through effort, practice, and experience. Skills needed in critical thinking include interpretation, analysis, evaluation, inference, explanation, and self-regulation. Critical thinking requires background knowledge and knowledge of key concepts as well as standards of good thinking. The critical thinker uses reality-based deliberation to validate the accuracy of data and the reliability of sources, being mindful of and questioning inconsistencies. Interpretation is used to determine the significance of data that are gathered, and analysis is used to identify patient problems indicated by the data. The nurse uses inference to draw conclusions. Explanation is the justification of actions or interventions used to address patient problems and to help a patient move toward desired outcomes. Evaluation is the process of determining whether outcomes have been or are being met, and self-regulation is the process of examining the care provided and adjusting the interventions as needed. Critical thinking is also reflective, involving metacognition, active evaluation, and refinement of the thinking process. The critical thinker considers the possibility of personal bias when interpreting data and determining appropriate actions. The critical thinker must be insightful and have a sense of fairness and integrity, the courage to question personal ethics, and the perseverance to strive continuously to minimize the effects of egocentricity, ethnocentricity, and other biases on the decision making process.

Components of Critical thinking

Certain cognitive or mental activities can be identified as key components of critical thinking. When thinking critically, a person will do the following:

• Ask questions to determine the reason why certain developments have occurred and to see whether more information is needed to understand the situation accurately.
• Gather as much relevant information as possible to consider as many factors as possible.
• Validate the information presented to make sure that it is accurate (not just supposition or opinion), that it makes sense, and that it is based on fact and evidence.
• Analyze the information to determine what it means and to see whether it forms clusters or patterns that point to certain conclusions.
• Draw on past clinical experience and knowledge to explain what is happening and to anticipate what might happen next, acknowledging personal bias and cultural influences.
• Maintain a flexible attitude that allows the facts to guide thinking and takes into account all possibilities.
• Consider available options and examine each in terms of its advantages and disadvantages.
• Formulate decisions that reflect creativity and independent decision making.

Critical thinking requires going beyond basic problem solving into a realm of inquisitive exploration, looking for all relevant factors that affect the issue, and being an “out-of-the-box” thinker. It includes questioning all findings until a comprehensive picture emerges that explains the phenomenon, possible solutions, and creative methods for proceeding. Critical thinking in nursing practice results in a comprehensive patient plan of care with maximized potential for success.

Critical thinking In Nursing Practice

Using critical thinking to develop a plan of nursing care requires considering the human factors that might influence the plan. The nurse interacts with the patient, family, and other health care providers in the process of providing appropriate, individualized nursing care. The culture, attitude, and thought processes of the nurse, the patient, and others will affect the critical thinking process from the data-gathering stage through the decision-making stage; therefore, aspects of the nurse-patient interaction must be considered. Nurses must use critical thinking skills in all practice settings—acute care, ambulatory care, extended care, and in the home and community. Regardless of the setting, each patient situation is viewed as unique and dynamic. The unique factors that the patient and nurse bring to the health care situation are considered, studied, analyzed, and interpreted. Interpretation of the information presented then allows the nurse to focus on those factors that are most relevant and mostsignificant to the clinical situation. Decisions about what to do and how to do it are then developed into a plan of action.

Fonteyn (1998) identified 12 predominant thinking strategies used by nurses, regardless of their area of clinical practice:

Recognizing a pattern

• Setting priorities
• Searching for information
• Generating hypotheses
• Making predictions
• Forming relationships
• Stating a proposition (“if–then”)
• Asserting a practice rule
• Making choices (alternative actions)
• Judging the value
• Drawing conclusions
• Providing explanations

Fonteyn further identified other, less prominent thinking strategies the nurse might use:

• Posing a question
• Making assumptions (supposing)
• Making generalizations

These thought processes are consistent with the characteristics of critical thinking and cognitive activities discussed earlier. Fonteyn asserted that exploring how these thinking strategies are used in various clinical situations, and practicing using the strategies, might assist the nurse–learner in examining and refining his or her own thinking skills.

Throughout the critical thinking process, a continuous flow of questions evolves in the thinker’s mind. Although the questions will vary according to the particular clinical situation, certain general inquiries can serve as a basis for reaching conclusions and determining a course of action. When faced with a patient situation, it is often helpful to seek answers to some or all of the following questions in an attempt to determine those actions that are most appropriate:

• What relevant assessment information do I need, and how do I interpret this information? What does this information tell me?
• To what problems does this information point? Have I identified the most important ones? Does the information point to any other problems that I should consider?
• Have I gathered all the information I need (signs/symptoms, laboratory values, medication history, emotional factors, mental status)? Is anything missing?
• Is there anything that needs to be reported immediately? Do I need to seek additional assistance?
• Does this patient have any special risk factors? Which ones are most significant? What must I do to minimize these risks?
• What possible complications must I anticipate?
• What are the most important problems in this situation? Do the patient and the patient’s family recognize the same problems?
• What are the desired outcomes for this patient? Which have the highest priority? Does the patient see eye to eye with me on these points?
• What is going to be my first action in this situation? How can I construct a plan of care to achieve the goals?
• Are there any age-related factors involved, and will they require some special approach? Will I need to make some change in the plan of care to take these factors into account?
•  How do the family dynamics affect this situation, and will this have an affect on my actions or the plan of care?
• Are there cultural factors that I must address and consider?
• Am I dealing with an ethical problem here? If so, how am I going to resolve it?
• Has any nursing research been conducted on this subject?

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4.2: Basic Concepts

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• Chippewa Valley Technical College via OpenRN

Before learning how to use the nursing process, it is important to understand some basic concepts related to critical thinking and nursing practice. Let’s take a deeper look at how nurses think.

Critical Thinking and Clinical Reasoning

Nurses make decisions while providing patient care by using critical thinking and clinical reasoning. Critical thinking is a broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.” [1] Using critical thinking means that nurses take extra steps to maintain patient safety and don’t just “follow orders.” It also means the accuracy of patient information is validated and plans for caring for patients are based on their needs, current clinical practice, and research.

“Critical thinkers” possess certain attitudes that foster rational thinking. These attitudes are as follows:

• Independence of thought: Thinking on your own
• Fair-mindedness: Treating every viewpoint in an unbiased, unprejudiced way
• Insight into egocentricity and sociocentricity: Thinking of the greater good and not just thinking of yourself. Knowing when you are thinking of yourself (egocentricity) and when you are thinking or acting for the greater good (sociocentricity)
• Intellectual humility: Recognizing your intellectual limitations and abilities
• Nonjudgmental: Using professional ethical standards and not basing your judgments on your own personal or moral standards
• Integrity: Being honest and demonstrating strong moral principles
• Perseverance: Persisting in doing something despite it being difficult
• Confidence: Believing in yourself to complete a task or activity
• Interest in exploring thoughts and feelings: Wanting to explore different ways of knowing
• Curiosity: Asking “why” and wanting to know more

Clinical reasoning is defined as, “A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.” [2] To make sound judgments about patient care, nurses must generate alternatives, weigh them against the evidence, and choose the best course of action. The ability to clinically reason develops over time and is based on knowledge and experience. [3]

Inductive and Deductive Reasoning and Clinical Judgment

Inductive and deductive reasoning are important critical thinking skills. They help the nurse use clinical judgment when implementing the nursing process.

Inductive reasoning involves noticing cues, making generalizations, and creating hypotheses. Cues are data that fall outside of expected findings that give the nurse a hint or indication of a patient’s potential problem or condition. The nurse organizes these cues into patterns and creates a generalization. A generalization is a judgment formed from a set of facts, cues, and observations and is similar to gathering pieces of a jigsaw puzzle into patterns until the whole picture becomes more clear. Based on generalizations created from patterns of data, the nurse creates a hypothesis regarding a patient problem. A hypothesis is a proposed explanation for a situation. It attempts to explain the “why” behind the problem that is occurring. If a “why” is identified, then a solution can begin to be explored.

No one can draw conclusions without first noticing cues. Paying close attention to a patient, the environment, and interactions with family members is critical for inductive reasoning. As you work to improve your inductive reasoning, begin by first noticing details about the things around you. A nurse is similar to the detective looking for cues in Figure 4.1. [4] Be mindful of your five primary senses: the things that you hear, feel, smell, taste, and see. Nurses need strong inductive reasoning patterns and be able to take action quickly, especially in emergency situations. They can see how certain objects or events form a pattern (i.e., generalization) that indicates a common problem (i.e., hypothesis).

Example: A nurse assesses a patient and finds the surgical incision site is red, warm, and tender to the touch. The nurse recognizes these cues form a pattern of signs of infection and creates a hypothesis that the incision has become infected. The provider is notified of the patient’s change in condition, and a new prescription is received for an antibiotic. This is an example of the use of inductive reasoning in nursing practice.

Deductive reasoning is another type of critical thinking that is referred to as “top-down thinking.” Deductive reasoning relies on using a general standard or rule to create a strategy. Nurses use standards set by their state’s Nurse Practice Act, federal regulations, the American Nursing Association, professional organizations, and their employer to make decisions about patient care and solve problems.

Example: Based on research findings, hospital leaders determine patients recover more quickly if they receive adequate rest. The hospital creates a policy for quiet zones at night by initiating no overhead paging, promoting low-speaking voices by staff, and reducing lighting in the hallways. (See Figure 4.2). [5] The nurse further implements this policy by organizing care for patients that promotes periods of uninterrupted rest at night. This is an example of deductive thinking because the intervention is applied to all patients regardless if they have difficulty sleeping or not.

Clinical judgment is the result of critical thinking and clinical reasoning using inductive and deductive reasoning. Clinical judgment is defined by the National Council of State Boards of Nursing (NCSBN) as, “The observed outcome of critical thinking and decision-making. It uses nursing knowledge to observe and assess presenting situations, identify a prioritized patient concern, and generate the best possible evidence-based solutions in order to deliver safe patient care.” [6] The NCSBN administers the national licensure exam (NCLEX) that measures nursing clinical judgment and decision-making ability of prospective entry-level nurses to assure safe and competent nursing care by licensed nurses.

Evidence-based practice (EBP) is defined by the American Nurses Association (ANA) as, “A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer’s history and condition, as well as health care resources; and patient, family, group, community, and population preferences and values.” [7]

Nursing Process

The nursing process is a critical thinking model based on a systematic approach to patient-centered care. Nurses use the nursing process to perform clinical reasoning and make clinical judgments when providing patient care. The nursing process is based on the Standards of Professional Nursing Practice established by the American Nurses Association (ANA). These standards are authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently. [8] The mnemonic ADOPIE is an easy way to remember the ANA Standards and the nursing process. Each letter refers to the six components of the nursing process: A ssessment, D iagnosis, O utcomes Identification, P lanning, I mplementation, and E valuation.

The nursing process is a continuous, cyclic process that is constantly adapting to the patient’s current health status. See Figure 4.3 [9] for an illustration of the nursing process.

Review Scenario A in the following box for an example of a nurse using the nursing process while providing patient care.

Patient Scenario A: Using the Nursing Process [10]

A hospitalized patient has a prescription to receive Lasix 80mg IV every morning for a medical diagnosis of heart failure. During the morning assessment, the nurse notes that the patient has a blood pressure of 98/60, heart rate of 100, respirations of 18, and a temperature of 98.7F. The nurse reviews the medical record for the patient’s vital signs baseline and observes the blood pressure trend is around 110/70 and the heart rate in the 80s. The nurse recognizes these cues form a pattern related to fluid imbalance and hypothesizes that the patient may be dehydrated. The nurse gathers additional information and notes the patient’s weight has decreased 4 pounds since yesterday. The nurse talks with the patient and validates the hypothesis when the patient reports that their mouth feels like cotton and they feel light-headed. By using critical thinking and clinical judgment, the nurse diagnoses the patient with the nursing diagnosis Fluid Volume Deficit and establishes outcomes for reestablishing fluid balance. The nurse withholds the administration of IV Lasix and contacts the health care provider to discuss the patient’s current fluid status. After contacting the provider, the nurse initiates additional nursing interventions to promote oral intake and closely monitor hydration status. By the end of the shift, the nurse evaluates the patient status and determines that fluid balance has been restored.

In Scenario A, the nurse is using clinical judgment and not just “following orders” to administer the Lasix as scheduled. The nurse assesses the patient, recognizes cues, creates a generalization and hypothesis regarding the fluid status, plans and implements nursing interventions, and evaluates the outcome. Additionally, the nurse promotes patient safety by contacting the provider before administering a medication that could cause harm to the patient at this time.

The ANA’s Standards of Professional Nursing Practice associated with each component of the nursing process are described below.

The “Assessment” Standard of Practice is defined as, “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.” [11] A registered nurse uses a systematic method to collect and analyze patient data. Assessment includes physiological data, as well as psychological, sociocultural, spiritual, economic, and lifestyle data. For example, a nurse’s assessment of a hospitalized patient in pain includes the patient’s response to pain, such as the inability to get out of bed, refusal to eat, withdrawal from family members, or anger directed at hospital staff. [12]

The “Assessment” component of the nursing process is further described in the “ Assessment ” section of this chapter.

The “Diagnosis” Standard of Practice is defined as, “The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues.” [13] A nursing diagnosis is the nurse’s clinical judgment about the client's response to actual or potential health conditions or needs. Nursing diagnoses are the bases for the nurse’s care plan and are different than medical diagnoses. [14]

The “Diagnosis” component of the nursing process is further described in the “ Diagnosis ” section of this chapter.

Outcomes Identification

The “Outcomes Identification” Standard of Practice is defined as, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.” [15] The nurse sets measurable and achievable short- and long-term goals and specific outcomes in collaboration with the patient based on their assessment data and nursing diagnoses.

The “Outcomes Identification” component of the nursing process is further described in the “ Outcomes Identification ” section of this chapter.

The “Planning” Standard of Practice is defined as, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.” [16] Assessment data, diagnoses, and goals are used to select evidence-based nursing interventions customized to each patient’s needs and concerns. Goals, expected outcomes, and nursing interventions are documented in the patient’s nursing care plan so that nurses, as well as other health professionals, have access to it for continuity of care. [17]

The “Planning” component of the nursing process is further described in the “ Planning ” section of this chapter.

Nursing Care Plans

Creating nursing care plans is a part of the “Planning” step of the nursing process. A nursing care plan is a type of documentation that demonstrates the individualized planning and delivery of nursing care for each specific patient using the nursing process. Registered nurses (RNs) create nursing care plans so that the care provided to the patient across shifts is consistent among health care personnel. Some interventions can be delegated to Licensed Practical Nurses (LPNs) or trained Unlicensed Assistive Personnel (UAPs) with the RN’s supervision. Developing nursing care plans and implementing appropriate delegation are further discussed under the “ Planning ” and “ Implementing ” sections of this chapter.

Implementation

The “Implementation” Standard of Practice is defined as, “The nurse implements the identified plan.” [18] Nursing interventions are implemented or delegated with supervision according to the care plan to assure continuity of care across multiple nurses and health professionals caring for the patient. Interventions are also documented in the patient’s electronic medical record as they are completed. [19]

The “Implementation” Standard of Professional Practice also includes the subcategories “Coordination of Care” and “Health Teaching and Health Promotion” to promote health and a safe environment. [20]

The “Implementation” component of the nursing process is further described in the “ Implementation ” section of this chapter.

The “Evaluation” Standard of Practice is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.” [21] During evaluation, nurses assess the patient and compare the findings against the initial assessment to determine the effectiveness of the interventions and overall nursing care plan. Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated and modified as needed. [22]

The “Evaluation” component of the nursing process is further described in the “ Evaluation ” section of this chapter.

Benefits of Using the Nursing Process

Using the nursing process has many benefits for nurses, patients, and other members of the health care team. The benefits of using the nursing process include the following:

• Promotes quality patient care
• Decreases omissions and duplications
• Provides a guide for all staff involved to provide consistent and responsive care
• Encourages collaborative management of a patient’s health care problems
• Improves patient safety
• Improves patient satisfaction
• Identifies a patient’s goals and strategies to attain them
• Increases the likelihood of achieving positive patient outcomes
• Saves time, energy, and frustration by creating a care plan or path to follow

By using these components of the nursing process as a critical thinking model, nurses plan interventions customized to the patient’s needs, plan outcomes and interventions, and determine whether those actions are effective in meeting the patient’s needs. In the remaining sections of this chapter, we will take an in-depth look at each of these components of the nursing process. Using the nursing process and implementing evidence-based practices are referred to as the “science of nursing.” Let’s review concepts related to the “art of nursing” while providing holistic care in a caring manner using the nursing process.

Holistic Nursing Care

The American Nurses Association (ANA) recently updated the definition of nursing as, “Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in the recognition of the connection of all humanity.” [23]

The ANA further describes nursing is a learned profession built on a core body of knowledge that integrates both the art and science of nursing. The art of nursing is defined as, “Unconditionally accepting the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care.” [24]

Nurses care for individuals holistically, including their emotional, spiritual, psychosocial, cultural, and physical needs. They consider problems, issues, and needs that the person experiences as a part of a family and a community as they use the nursing process. Review a scenario illustrating holistic nursing care provided to a patient and their family in the following box.

Holistic Nursing Care Scenario

A single mother brings her child to the emergency room for ear pain and a fever. The physician diagnoses the child with an ear infection and prescribes an antibiotic. The mother is advised to make a follow-up appointment with their primary provider in two weeks. While providing discharge teaching, the nurse discovers that the family is unable to afford the expensive antibiotic prescribed and cannot find a primary care provider in their community they can reach by a bus route. The nurse asks a social worker to speak with the mother about affordable health insurance options and available providers in her community and follows up with the prescribing physician to obtain a prescription for a less expensive generic antibiotic. In this manner, the nurse provides holistic care and advocates for improved health for the child and their family.

Review how to provide culturally responsive care and reduce health disparities in the “ Diverse Patients ” chapter.

Caring and the Nursing Process

The American Nurses Association (ANA) states, “The act of caring is foundational to the practice of nursing.” [25] Successful use of the nursing process requires the development of a care relationship with the patient. A care relationship is a mutual relationship that requires the development of trust between both parties. This trust is often referred to as the development of rapport and underlies the art of nursing. While establishing a caring relationship, the whole person is assessed, including the individual’s beliefs, values, and attitudes, while also acknowledging the vulnerability and dignity of the patient and family. Assessing and caring for the whole person takes into account the physical, mental, emotional, and spiritual aspects of being a human being. [26] Caring interventions can be demonstrated in simple gestures such as active listening, making eye contact, touching, and verbal reassurances while also respecting and being sensitive to the care recipient’s cultural beliefs and meanings associated with caring behaviors. [27] See Figure 4.4 [28] for an image of a nurse using touch as a therapeutic communication technique to communicate caring.

Review how to communicate with patients using therapeutic communication techniques like active listening in the “ Communication ” chapter.

Dr. Jean Watson is a nurse theorist who has published many works on the art and science of caring in the nursing profession. Her theory of human caring sought to balance the cure orientation of medicine, giving nursing its unique disciplinary, scientific, and professional standing with itself and the public. Dr. Watson’s caring philosophy encourages nurses to be authentically present with their patients while creating a healing environment. [29]

Read more about Dr. Watson’s theory of caring at the Watson Caring Science Institute .

Now that we have discussed basic concepts related to the nursing process, let’s look more deeply at each component of the nursing process in the following sections.

• Klenke-Borgmann, L., Cantrell, M. A., & Mariani, B. (2020). Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development. Nursing Education Perspectives, 41 (4), 215-221. ↵
• Powers, L., Pagel, J., & Herron, E. (2020). Nurse preceptors and new graduate success. American Nurse Journal, 15 (7), 37-39. ↵
• “ The Detective ” by paurian is licensed under CC BY 2.0 ↵
• “ In the Quiet Zone… ” by C.O.D. Library is licensed under CC BY-NC-SA 2.0 ↵
• NCSBN. (n.d.). NCSBN clinical judgment model . https://www.ncsbn.org/14798.htm ↵
• American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
• “ The Nursing Process ” by Kim Ernstmeyer at Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
• “Patient Image in LTC.JPG” by ARISE project is licensed under CC BY 4.0 ↵
• American Nurses Association. (n.d.). The nursing process. https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/ ↵
• American Nurses Association. (n.d.). The nursing process . https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/ ↵
• American Nurses Association. (2021). Nursing: Scope and standards of practice (3rd ed.). American Nurses Association. ↵
• American Nurses Association. (n.d.) The nursing process. https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process / ↵
• American Nurses Association. (n.d.). The nursing process. https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process / ↵
• Walivaara, B., Savenstedt, S., & Axelsson, K. (2013). Caring relationships in home-based nursing care - registered nurses’ experiences. The Open Journal of Nursing, 7 , 89-95. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3722540/pdf/TONURSJ-7-89.pdf ↵
• “ hospice-1793998_1280.jpg ” by truthseeker08 is licensed under CC0 ↵
• Watson Caring Science Institute. (n.d.). Watson Caring Science Institute. Jean Watson, PHD, RN, AHN-BC, FAAN, (LL-AAN) . https://www.watsoncaringscience.org/jean-bio/ ↵

The nursing process

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• Peggy Martin  

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The nursing process provides a problem-solving approach to nursing care based on the needs and problems of the individual patient. Whenever possible, the patient and his relatives are encouraged to participate in decisions relating to his care.

‘ Hopefully nurses will soon learn that nursing is a special case of loving. ’ (Jourard, 1971).

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Martin, P. (1987). The nursing process. In: Martin, P. (eds) Psychiatric Nursing. Palgrave, London. https://doi.org/10.1007/978-1-349-09408-0_8

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Problem solving in clinical nursing practice

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• 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.

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

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

b Tongji University School of Medicine, Shanghai, China

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

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

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

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

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

Introduction

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

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

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

Study design

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

Settings and participants

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

Data collection

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

Data analysis

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

7 steps of Colaizzi’s phenomenological analysis method.

Ethical considerations

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

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

Participant characteristics (N = 14).

Nurses’ own factors

Differences in knowledge structure and thinking.

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

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

Differences in professional values

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

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

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

Poor strain capacity

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

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

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

Improper nursing management

Low sense of organizational support.

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

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

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

Insufficient allocation of manpower

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

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

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

Patient factors

The concept of emphasizing medicine and neglecting to nurse.

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

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

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

Individual differences of patients

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

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

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

Multiple factors affecting clinical nurses’ problem-solving dilemma

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

Implementing situational simulation training to improve the comprehensive quality of nurses

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

Optimize nursing management and improve nurses’ working experience

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

Using new media to improve the image and credibility of nurses

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

Limitations and strengths of the study

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

Implications for practice

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

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

Biographies

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

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

Funding Statement

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

Disclosure statement

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

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Tuesday, November 18, 2014

Problem solving and nursing process.

•  Indepenent e.g. initiating intake and output recording.
•  Interdependent e.g. educating client about the therapeutic nutrition in consultation with the dietitian.
•  Dependent e.g. maintains intravenous therapy. That is carrying out doctors order on medication.
•  Cognitive or mental abilities e.g. applying knowledge, thinking critically, analyzing,judgement and decision making.
•  Affective e.g. attitudes, values, acceptance and respect for self and clients, inter-actional activities.
•  Psychomotor e.g. technical skills such as administering medicines, dressing and bathing.
•  Comprehensive knowledge base
•  Experience and skills in the field
•  Professional commitment (such as belief, ethical base accurately).

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