The Nursing Process: A Comprehensive Guide

Nursing Process

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.

ADPIE Nursing Process Infographic

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.

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

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Is the nursing process the same as “critical thinking”?

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Hi Joycelyn, Thank you so much for your kind words! It’s really rewarding to hear that it’s helping nursing students out there. We’re all about sharing knowledge and making things a bit easier. 😊 If there’s anything else you’d like to see or know, just let me know. And blessings right back at you!

Thank you so much…It’s a very comprehensive reference.

You’re very welcome, A.C! I’m glad you found the nursing process reference comprehensive and useful. Just out of curiosity, is there a particular step in the nursing process you’d like to explore more deeply, or do you have any specific areas where you’d like more detailed information?

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Hi Mawuli, I’m delighted to know that you’re finding our resources helpful! If you have any specific questions or if there’s a particular topic you’d like more information on, please feel free to ask. I’m here to assist you with any nursing-related inquiries you may have. Keep up the great work in your studies! 🩺📚🌟

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Hey Mokete, Thank you so much for the kind words! We’re thrilled to hear that you’re finding our nursing resources helpful. We’ll do our best to keep you updated with more valuable nursing PDFs and information. If there’s anything specific you’d like to see or if you have any questions, feel free to let us know. Keep up the great work in your nursing journey! 👩‍⚕️📚🌟

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You can download the articles by printing them as PDF :) You can use a service called printfriendly (google it) to make PDFs of our webpages.

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Thank you so much…It’s a very comprehensive reference. God bless you

Hello Theophilus, You’re very welcome, and thank you for the blessings! 😊 I’m glad you found the reference on the nursing process comprehensive. Just out of curiosity, is there a particular part of the nursing process you’re most interested in, or any aspect you’d like to explore more deeply?

God bless you too, and if you have any more questions, feel free to ask!

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  • Nurse Spotlight
  • Student Resources

The Value of Critical Thinking in Nursing

portrait of Gayle Morris, BSN, MSN

Gayle Morris

Contributing Writer

Learn about our editorial process .

Updated October 3, 2023

Male nurse checking on a patient

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

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

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

How Do Nurses Use Critical Thinking?

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

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

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

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

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

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

Featured Online MSN Programs

Top 5 ways nurses can improve critical thinking skills.

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

Case-Based Approach

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

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

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

Practice Self-Reflection

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

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

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

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

Develop a Questioning Mind

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

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

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

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

Practice Self-Awareness in the Moment

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

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

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

Use a Process

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

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

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

Common Critical Thinking Pitfalls in Nursing

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

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

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

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

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

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

An Essential Skill for All Nurses

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

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

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

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

How does nursing school develop critical thinking skills?

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

Do only nurse managers use critical thinking?

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

Meet Our Contributors

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

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

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

Portrait of Jenna Liphart Rhoads, Ph.D., RN

Jenna Liphart Rhoads, Ph.D., RN

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

Portrait of Nicholas McGowan, BSN, RN, CCRN

Nicholas McGowan, BSN, RN, CCRN

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

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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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Soleiman Ahmady

Virtual School of Medical Education and management, Shahid Beheshty University of Medical Sciences, Tehran, Iran

Sara Shahbazi

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

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

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

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

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BMC Nursing

ISSN: 1472-6955

nursing problem solving process

Clinical problem-solving in nursing: insights from the literature

Affiliation.

This paper reviews the literature surrounding the research on how individuals solve problems. The purpose of the review is to heighten awareness amongst nurses in general, and nurse academics in particular about the theories developed, approaches taken and conclusions reached on how clinicians problem-solve. The nursing process, which is heavily used and frequently described as a problem-solving approach to nursing care, requires a deductive reasoning process which is not the problem-solving process in use during care-giving activities. More knowledge is required on what process is in place as we develop as a profession. The literature highlights the complexities involved in attempting to uncover thinking processes. The main research approaches to discovering problem-solving strategies in the past three decades have been from a cognitive perspective, with two main theories, decision-theory and information processing-theory, underpinning the majority of studies conducted. None of the research approaches used to date has resulted in the identification of a general model of problem-solving that is consistent across tasks or disciplines. However, early hypothesis activation with subsequent testing of the hypothesis seems to be consistent in clinicians across disciplines.

Publication types

  • Clinical Competence*
  • Education, Nursing*
  • Nursing Process*
  • Problem Solving*

The 5 Nursing Process Steps – (Learn Each Step in Detail)

nursing problem solving process

One of the most important tools a nurse can use in practice is the nursing process. Although nursing schools teach first-year students about the nursing process, some nurses fail to grasp the impact its proper use can have on patient care. In this article, I will share information about the nursing process, its history, its purpose, its main characteristics, and the 5 steps involved in carrying out the nursing process. After reading this article, you will be able to answer the question, “what is the nursing process” and understand what is involved in each of the 5 steps of the nursing process. Additionally, throughout this article, after discussing a step of the nursing process, I will share an example of how the nurse would proceed with that step. For this article’s purposes, we will use information about the following patient: Mr. Collie, a fifty-four-year-old white male being admitted to the Medical-Surgical floor for acute congestive heart failure.

What Is The Nursing Process In Simple Words?

When was the nursing process developed, who developed the nursing process, what is the purpose of the nursing process, what are the 7 main characteristics of the nursing process, 1. within the legal scope of practice, 2. based on sound knowledge, 4. client-centered, 5. goal-directed, 6. prioritized, 7. dynamic and cyclical, how many steps are there in the nursing process, what are the 5 steps of the nursing process, step #1: assessment phase, step #2: diagnosis phase, step #3: planning phase, step #4: implementation phase, step #5: evaluation phase, useful resources to gain more information about the nursing process, blogs/websites, youtube videos, my final thoughts, frequently asked questions answered by our expert, 1. how is nursing process different from the scientific method, 2. do all nurses use the nursing process, 3. do doctors also use the nursing process, 4. what does adpie stand for, 5. is it always necessary for a nurse to follow all steps of the nursing process, 6. how does critical thinking impact the nursing process, 7. how does a health information system affect the nursing process, 8. how to use maslow hierarchy in the nursing process, 9. which nursing process step includes tasks that can be delegated, 10. which nursing process step includes tasks that cannot be delegated, 11. how does the nursing process apply to pharmacology.

nursing problem solving process

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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NURSE THEORY

ADPIE – The Five Stages of The Nursing Process

ADPIE is an acronym for assessment, diagnosis, planning, implementation, and evaluation.

The ADPIE process helps medical professionals remember the process and order of the steps they need to take to provide proper care for the individuals they are treating.

This process is essential as it provides a practical and thorough framework for patient care.

It also helps medical professionals develop critical thinking and problem-solving skills.

By following the ADPIE process, medical professionals can improve their work efficiency and promptly develop more accurate decisions.

Process Overview

The purpose of ADPIE is to help improve an individual’s mental, emotional, and physical health through analysis, diagnosis, and treatment.

The ADPIE process allows medical professionals to identify potential problems, develop solutions, and monitor the results individually.

Nurses must reevaluate, adjust and correct the process if it does not improve the patient’s condition.

Here is an explanation detailing each step of the process:

Assessment is the first step of the ADPIE process.

During the assessment phase, medical professionals will attempt to identify the problem and establish a database.

Interviewing the patient and family members, observing behavior, and performing examinations help with the assessment.

This step focuses heavily on collecting/recording data, validating information, and listing any abnormalities in the data.

Nurses collect assessment data in one of two ways, subjective or objective.

You cannot measure subjective data directly.

It includes verbal information like asking questions, obtaining verbal feedback, interviewing people, and collecting/gathering a patient’s health history data.

Subjective data is symptomatic because nurses cannot measure or observe it directly.

Objective data is measurable because nurses can see, hear, feel, or smell it.

It includes measuring a patient’s weight, blood pressure, heart rate, and body temperature.

Because objective data is measurable, nurses refer to it as signs.

Gathering as much data as possible during the assessment phase is essential.

While gathering data, Identify if the data is accurate, concise, consistent, and straightforward.

Once you’ve gathered enough accurate data, you can form a conclusion about the patient’s condition.

After that, move on to the next phase of the ADPIE process, diagnosis.

The process’s diagnosis phase is where the medical professional develops a theory or hypothesis about the individual’s situation based on the information collected while performing an assessment.

Although registered nurses cannot form a professional diagnosis, they can develop critical thinking and communicate their clinical judgments to their team members.

Nurses have a standardized language for communicating their clinical judgments, which comes from NANDA international .

That said, certified nurse practitioners can diagnose medical conditions and act as primary care providers for their patients.

Examples of Medical Language Nurse Use Include:

  • Activity intolerance
  • Constipation
  • Decreased cardiac output
  • Fluid volume deficit
  • Hypothermia
  • Sleep deficit

The diagnostic process allows medical professionals to decide on the individual they treat.

That determination determines whether the patient is dealing with a physiological, mental, or emotional condition.

And while nurses cannot give a professional diagnosis , they can identify actual or potential medical /health risks.

After performing a diagnosis, nurses must place risks that can cause complications or harm in order.

Organize the highest risks as the top priority (life-threatening).

Accordingly, nurses should label lower risks in descending order (non-life-threatening/minor/future well-being).

Nurses must identify, address and correct new problems that affect other priorities.

Therefore, nurses must perform assessments regularly to approach patient problems adequately.

After identifying and prioritizing the concerns, the next phase of the process is planning.

Planning involves developing a plan and establishing SMART goals to achieve the desired outcome.

For example, adequate planning helps reduce a patient’s pain or improve cardiovascular function.

SMART goals are specific, measurable, attainable, realistic/relevant, and time-restricted.

SMART goals provide the individual with focused activities designed to improve their condition.

They also provide medical professionals with a plan to measure and evaluate the individual’s improvements.

Goals may be short-term or long-term, singular in nature, and focus on the individual outcome.

Nurses must determine whether the SMART goals benefit the patient.

They must also make sure that the SMART goals are attainable.

In addition to SMART goals, nurses must develop and communicate a care plan and intervention strategies to the team.

It helps maximize the success of the goals.

The care plan involves the steps and strategies needed to achieve the desired goal.

Along with the care plan, developing intervention strategies keeps the individual on track.

Nurses communicate the care plan and intervention strategies to the patient and medical team as part of the treatment.

After nurses establish the care plan, interventions, and SMART goals, they must implement them into patient care.

Implementation

The implementation phase is the actionable part of the process.

It’s where the medical team implements the care plan, SMART goals, and interventions to achieve their goals.

Accordingly, nurses can evaluate and measure this process.

The implementation phase uses a combination of direct care and indirect care.

Direct care involves giving patients physical or verbal aid.

Direct care includes assisting the patient with mobility, performing physical maintenance, range of motion exercises, and assisting with daily living activities.

It may also include coaching, counseling, and providing feedback to the individual.

Indirect care involves actions performed while away from the patient.

Indirect care may include monitoring/supervising the medical staff, delegating responsibilities, and advocating on behalf of the patients.

While implementing the care plan, the nurse/team needs to use critical judgment.

They must also question care plan procedures to ensure it meets the demands/concerns of the people receiving the care.

Steps or procedures that appear inappropriate, non-actionable, or questionable should be questioned and reevaluated with the medical staff. 

Moreover, nurses must communicate with those receiving the care plan to ensure it is safe and aligns with the medical teams/individuals’ goals.

The last phase of the process is the evaluation phase.

It’s where the medical professionals assess and evaluate the success of the planning and implementation processes.

This phase ensures that the individual is making progress towards their goals and is achieving the desired outcome.

Healthcare professionals must evaluate if the process works and identify what brings the individual closer to their goals.

Nurses must reassess the problem if it isn’t working and determine whether it needs to be modified or eliminated.

Nurses must regularly perform evaluations during the ADPIE process to assess the plan and make adjustments.

By performing regular evaluations, medical professionals can determine the appropriate course of action, identify potential errors, and ensure that the process works as smoothly as possible.

ADPIE Recap

The ADPIE process assists medical professionals in identifying and addressing potential medical concerns.

By implementing the process, medical professionals can assess the patient’s condition and ensure they receive adequate care.

The assessment process begins through the collection of subjective and objective data.

This data allows medical to develop a diagnosis based on the collected information.

With the diagnosis, nurses can create a plan with interventions and SMART goals for the patient to follow.

The process is then implemented into action to achieve the plan’s goals.

Nurses must evaluate the process during and after implementation to ensure the individual achieves their goals.

ADPIE is an excellent way to improve critical thinking.

It helps nurses create, evaluate, and reevaluate procedures.

It also helps them implement and modify processes until they reach the desired outcome.

What Are The Five Stages of The Nursing Process?

The five stages of the nursing process are assessment, diagnosis, planning, implementation, and evaluation.

In other words, the five stages of the nursing process are ADPIE, which I explained earlier in this article.

Nurses follow these five stages to ensure proper patient care from the beginning of treatment until the end.

Consequently, It allows nurses to utilize a systematic approach to observing, analyzing, taking action, and reevaluating goals, strategies, and outcomes.

Overall this helps nurses perform their best and account for potential mistakes and errors throughout patient treatment.

The ADPIE nursing process is an essential component of clinical care.

It improves critical thinking and decision-making by breaking down processes into simplified and organized steps.

Each concurrent step builds upon the previous one throughout the process until nurses develop and implement a good approach.

With that said, numerous nurses lack experience applying the ADPIE nursing process.

It’s partially due to a shortage of information/resources and busy work schedules making it difficult to implement.

However, new processes are continually developing, allowing current/future nurses to incorporate these processes into their daily work.

Without processes like ADPIE and others, nurses would have more difficulty approaching complex patient care scenarios.

ADPIE isn’t well known among some nurses.

However, there are many well-known, and implemented processes nurses utilize.

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

Hyun hee jo.

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

Won Ju Hwang

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

Associated Data

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

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

1. Introduction

1.1. background.

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

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

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

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

1.2. Study Purpose

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

2. Methodology

2.1. study design.

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

2.2. Sampling Strategy

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

2.3. Ethical Considerations

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

2.4. Study Methods

  • (1) Demographics

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

  • (2) Self-leadership

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

  • (3) Goal commitment

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

  • (4) Critical thinking disposition

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

  • (5) Problem-solving abilities

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

2.5. Data Collection Method

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

2.6. Data Analysis

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

3.1. General Characteristics of Study Participants

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

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

M = Mean, SD = Standard Deviation

3.2. Problem-Solving Abilities According to General Characteristics

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

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

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

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

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

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

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

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

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

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

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

SE = Standard Error, VIF = Variance Inflation Factor.

4. Discussion

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

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

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

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

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

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

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

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

5. Conclusions

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

Funding Statement

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

Author Contributions

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

Institutional Review Board Statement

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

Informed Consent Statement

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

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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