problem solving in nursing administration

What is Problem-Solving in Nursing? (With Examples, Importance, & Tips to Improve)

Whether you have been a nurse for many years or you are just beginning your nursing career, chances are, you know that problem-solving skills are essential to your success. With all the skills you are expected to develop and hone as a nurse, you may wonder, “Exactly what is problem solving in nursing?” or “Why is it so important?” In this article, I will share some insight into problem-solving in nursing from my experience as a nurse. I will also tell you why I believe problem-solving skills are important and share some tips on how to improve your problem-solving skills.

What Exactly is Problem-Solving in Nursing?

5 reasons why problem-solving is important in nursing, reason #1: good problem-solving skills reflect effective clinical judgement and critical thinking skills, reason #2: improved patient outcomes, reason #3: problem-solving skills are essential for interdisciplinary collaboration, reason #4: problem-solving skills help promote preventative care measures, reason #5: fosters opportunities for improvement, 5 steps to effective problem-solving in nursing, step #1: gather information (assessment), step #2: identify the problem (diagnosis), step #3: collaborate with your team (planning), step #4: putting your plan into action (implementation), step #5: decide if your plan was effective (evaluation), what are the most common examples of problem-solving in nursing, example #1: what to do when a medication error occurs, how to solve:, example #2: delegating tasks when shifts are short-staffed, example #3: resolving conflicts between team members, example #4: dealing with communication barriers/lack of communication, example #5: lack of essential supplies, example #6: prioritizing care to facilitate time management, example #7: preventing ethical dilemmas from hindering patient care, example #8: finding ways to reduce risks to patient safety, bonus 7 tips to improve your problem-solving skills in nursing, tip #1: enhance your clinical knowledge by becoming a lifelong learner, tip #2: practice effective communication, tip #3: encourage creative thinking and team participation, tip #4: be open-minded, tip #5: utilize your critical thinking skills, tip #6: use evidence-based practices to guide decision-making, tip #7: set a good example for other nurses to follow, my final thoughts, list of sources used for this article.

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Nurse leaders as problem-solvers

Addressing lateral and horizontal violence.

Anthony, Michelle R. PhD, RN; Brett, Anne Liners PhD, RN

Michelle R. Anthony is a program coordinator at Columbia (S.C.) VA Health Care System. Anne Liners Brett is doctoral faculty at the University of Phoenix in Tempe, Ariz.

Acknowledgment: The authors acknowledge the support of the University of Phoenix Center for Educational and Instructional Technology Research.

The contents of this article do not represent the views of the US Department of Veterans Affairs or the United States Government.

The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

For more than 126 additional continuing-education articles related to management topics, go to NursingCenter.com/CE .

Earn CE credit online: Go to http://nursing.ceconnection.com and receive a certificate within minutes .

Read about a qualitative, grounded theory study that looked to gain a deeper understanding of nurse leaders' perceptions of their role in addressing lateral and horizontal violence, and the substantive theory developed from the results.

The issue of lateral and horizontal violence (LHV) has plagued the nursing profession for more than 3 decades, yet solutions remain elusive. The significance of LHV isn't lost on nurse leaders because it creates an unhealthy work environment. Research literature worldwide has continued to report the prevalence of disruptive behaviors experienced by nursing students, novice nurses, and seasoned nurses in the workforce. The World Health Organization, International Council of Nurses, and Public Services International have recognized this issue as a major global public health priority. 1

LHV, also called nurse-on-nurse aggression, disruptive behavior, or incivility, undermines a culture of safety and negatively impacts patient care. 2,3 This experience, known to nurses as “eating their young,” isn't only intimidating and disruptive, it's also costly and demoralizing to the nursing profession and healthcare organizations. 4,5 Although the impact of LHV can be dreadful for both the institution and its staff, little is known about the reasons for these behaviors among nursing professionals. 2

LHV encompasses all acts of meanness, hostility, disruption, discourtesy, backbiting, divisiveness, criticism, lack of unison, verbal or mental abuse, and scapegoating. 6 The sole intent of bullying behaviors is to purposefully humiliate and demean victims. Bullying behaviors also taint healthcare organizations; cause irreparable harm to workplace culture; breakdown team communication; and severely impact the quality of the care provided, thereby jeopardizing patient safety. 7,8 Researchers have reported that acts of LHV are used to demonstrate power, domination, or aggression; for retribution; to control others; and to enhance self-image. 9-12

Previous studies have shown that the frequency of LHV in healthcare organizations is quite severe, with about 90% of new nurses surveyed reporting acts of incivility by their coworkers. 13 Sixty-five percent of nurses in one survey reported witnessing incidents of despicable acts, whereas another 46% of coworkers in the same survey reported the issue as “very serious” and “somewhat serious.” 13

LHV poses a significant challenge for nurse leaders who are legally and morally responsible for providing a safe working environment. 2,6 The purpose of this qualitative, grounded theory study was to gain a deeper understanding of nurse leaders' perceptions of their role in addressing LHV and develop a substantive theory from the results.

Literature review

A paucity of evidence exists in the literature regarding how nurse leaders perceive their role in addressing LHV. 14 Studies have shown that this phenomenon is attributed to heavy workloads, a stressful work environment, and lack of workgroup cohesiveness, as well as organizational factors such as misuse of authority and the lack of organizational policies and procedures for addressing LHV behaviors. 15

In one study, one-third of the nurses reported that they had observed emotional abuse during several of their work shifts. 16 Another study indicated that 30% of survey respondents (n = 2,100) stated LHV occurs weekly. 17 A third study revealed that 25% of participants noted LHV happened monthly, and a fourth study of ED nurses reported that about 27.3% of the nurses had experienced LHV perpetrated by nursing leadership (managers, supervisors, charge nurses, and directors), physicians, or peers in the last 6 months. 18

In a survey completed by members of the Washington State Emergency Nurses Association, 27% of respondents experienced acts of bullying in the past 6 months. 19 Another study reported that 27% to 85% of nurse respondents had experienced some form of uncivil behavior. 20 Other data have shown that those more vulnerable to violent, disruptive, and intimidating behaviors are newly licensed nurses beginning their careers. 21

Although nurse leaders can be perpetrators of LHV, they play an essential role in addressing LHV behaviors and creating a safe work environment. 22 The literature suggests that, in many cases, a lack of awareness and response by nurse leaders adds to the prevalence of LHV. 23 This may be due, in part, to nurse leaders being aligned with the perpetrators who are creating the toxic work environment. 6 The literature suggests that an environment where staff members feel safe to practice results in a culture that decreases burnout and promotes nurse retention and quality outcomes. 24,25

This qualitative, grounded theory study focused on nurse leaders' perception of their role in breaking the cycle of LHV for staff members whom they supervise. Two research questions guided the study: 1. How do nurse leaders perceive their role in addressing LHV among nursing staff members under their supervision? 2. What substantive theory may emerge from the data collected during interviews with nurse leaders?

A grounded theory methodology was used to explore the nurse leader's role in addressing LHV with the intent of developing a substantive theory through the meaningful organization of data themes to provide a framework to address the phenomenon of LHV. Purposive sampling was used to recruit a total of 14 participants for this study from a large healthcare system in the Southeastern US. The participants were chosen because of their experience with LHV and their ability to discuss and reflect on those experiences. Informed consent was obtained before the start of the study, which included explaining the reason for the study and what to expect. In addition, permission was obtained from the Institutional Review Board.

Data collection and analysis

Demographic data collected to describe the sample included gender, age range, number of years holding a management position, supervisory responsibility, and highest degree obtained. (See Table 1 .)

Semistructured, in-depth interviews were the primary mode of data collection. The recorded interviews were conducted face-to-face and lasted about 60 minutes. Data collection continued until saturation was achieved. Data saturation occurred when no new descriptive codes, categories, or themes were emerging from the analyzed data. The interviews were transcribed verbatim and verified through a member check process.

During the data analysis process, themes and patterns were identified. Data from each participant's interview were examined to determine if the responses were aligned with the identified themes. Analysis of the data included coding at increasingly abstract levels and constant comparison. Qualitative software assisted in coding the information and uncovering subtle trends.

Four themes emerged from core categories developed during the qualitative data coding process.

Theme 1: Understanding/addressing LHV . In question one, participants were asked to describe their understanding of LHV. Five subthemes emerged from the data collected with this question. (See Table 2 .)

Theme 2: Experience addressing LHV . In the second question, participants were asked about their experience with addressing incidents of LHV. Six subthemes were identified. (See Table 3 .)

Theme 3: Role perception in addressing LHV . In the third question, participants were asked what they perceive their role to be in addressing LHV. Six subthemes resulted from this question. (See Table 4 .)

Theme 4: Organizational impediment to addressing LHV . In question four, participants were asked to describe the factors within the organization that influence or impede their role in addressing LHV. This question yielded nine subthemes. (See Table 5 .)

Substantive theory

As a result of the themes that emerged from the data, a substantive theory was developed. This is especially important for the nursing profession to develop as a scientifically based practice. Theories help guide research and provide the expansion, generation, and validation of the science of nursing knowledge. 26 The substantive theory will help nurse leaders become more cognizant of the role that effective leadership plays in preventing or intervening in incidents of LHV in the workplace. The analysis revealed that nurse leaders are aware that the quality of patient care and staff well-being can be adversely affected by the impact of LHV.

Data themes were used to formulate the following theory: Nurse leaders address LHV affecting their staff members by solving problems, creating a safe work environment, and reducing institutional barriers that impede addressing LHV in a timely fashion. Nurse leaders perceive their role as a problem-solver, which is a necessary step in advocacy. 27 Problem-solving is a process that contains the elements of decision-making and critical thinking. 28

The theory that emerged from the core categories explicitly focused on the central phenomenon of LHV in the nursing work environment. Figure 1 shows the interrelatedness of the themes to the resultant substantive theory.

Discussion and implications

The study results have several implications for both the nursing profession and nurse leaders. The nursing profession requires decisive and robust leadership, and the role of the nurse leader is to be a combination of nurturer, investigator, and judge to examine incidents of LHV. 26,29-32 Nurse leaders are responsible for setting the tone and expectations for a safe work environment. This includes modeling the expected ethical behaviors; for example, doing the right things for the right reasons, being collegial toward each other, and being respectful of other's differences. One participant remarked, “This is a different world based on how I was raised. I was raised to be respectful to people.”

In addition, nurse leaders are responsible for enforcing policies created to address disruptive behaviors and working with the administration as soon as an incident occurs. Past research indicates that a healthy and collaborative work environment fosters nurse engagement and patient safety. 25,30 Staff members and patients need a leader to protect them when necessary; thus, the nurse leader needs to “walk the walk” in providing a safe environment for all. Nurse leaders engaged in these kinds of behaviors are providing strong leadership and practicing strong decision-making, thus ensuring the continued robustness of their organizations.

Recommendations and limitations

Future research could replicate this study in a different geographic region to explore the causes of LHV by soliciting the views of nursing students, new graduate nurses, and nurse educators from unionized and nonunionized hospital systems and comparing the results to further understand this phenomenon. Additionally, developing a tool to test the substantive theory could substantiate the nurse leader's role as a problem-solver to address incidence of LHV in the workplace.

The decision to conduct this study in one type of healthcare organization limits the ability to compare the interviewed nurse leaders' experiences with nurse leaders in other healthcare organizations. The experiences of nurses in other healthcare organizations may be different; thus, overall generalizability of the study may be limited.

Say “no” to the status quo

The results of this study support the findings of previous researchers. 23,31,33,34 Accepting the status quo is unacceptable and can cause irreparable harm to organizational well-being if LHV isn't addressed. Collaboration between nurse leaders and administrators is essential to successfully reduce institutional obstacles that prevent the timely handling of LHV incidents. The role of the nurse leader as a problem-solver should be clear, defined, and well supported to seek resolutions to toxic behaviors that are hurting the work environment. But we must remember that creating a policy doesn't equal change. Every employee from the lowest level in the organization to the highest ranks of administration must model civil behaviors.

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International Journal of Nursing Science

p-ISSN: 2167-7441    e-ISSN: 2167-745X

2018;  8(4): 73-76

doi:10.5923/j.nursing.20180804.03

Critical Thinking and Decision Making in Nursing Administration: A Philosophical Analysis

Lilian G. Tumapang

College of Advanced Education, Ifugao State University, Nayon, Lamut, Ifugao, Philippines

Copyright © 2018 The Author(s). Published by Scientific & Academic Publishing.

Nurse administrators are compelled to manage the dynamic health care system and advance excellence at every level of the organization. A challenge that besets nursing management points at developing the capacity of nurse executives to apply critical thinking in making decisions and establishing priorities in the clinical setting. To this direction, the theory titled “Critical thinking and decision making in nursing administration” aims to elucidate the association of critical thinking to the decision-making process in the context of nursing management. As for the philosophical standpoint, the author advocates for the “no-one-philosophical view-fits-all” approach or perspective. The key point of analysis would lie in the employment of the concepts, ideas, beliefs, and notions derived a given phenomenon.

Keywords: Critical thinking, Decision-making, Nursing administration, Philosophical perspective

Cite this paper: Lilian G. Tumapang, Critical Thinking and Decision Making in Nursing Administration: A Philosophical Analysis, International Journal of Nursing Science , Vol. 8 No. 4, 2018, pp. 73-76. doi: 10.5923/j.nursing.20180804.03.

Article Outline

1. introduction, 2. philosophical underpinnings, 3. the theory of critical thinking and decision-making in nursing administration.

3.1. Theoretical Assumptions

3.2. propositions, 3.3. key concepts, 3.4. metaparadigm of nursing according to the author’s constructivist perspective, 3.5. application to nursing, 4. testing of the theory, 5. conclusions, acknowledgements.

The Value of Critical Thinking in Nursing

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

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

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

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

How Do Nurses Use Critical Thinking?

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

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

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

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

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

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

Top 5 Ways Nurses Can Improve Critical Thinking Skills

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

Case-Based Approach

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

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

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

Practice Self-Reflection

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

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

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

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

Develop a Questioning Mind

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

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

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

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

Practice Self-Awareness in the Moment

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

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

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

Use a Process

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

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

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

Common Critical Thinking Pitfalls in Nursing

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

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

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

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

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

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

An Essential Skill for All Nurses

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

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

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

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

How does nursing school develop critical thinking skills?

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

Do only nurse managers use critical thinking?

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

Meet Our Contributors

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

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

Jenna Liphart Rhoads, Ph.D., RN

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

Nicholas McGowan, BSN, RN, CCRN

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

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Common Issues in Nursing: How Nurse Managers Can Help

4 min read • September, 18 2023

The nursing profession comes with many rewards and accompanying challenges. To support your nursing staff so they can focus on providing quality care, proactively address these common issues for nurses — and implement positive changes to help your team overcome daily hurdles.

Nursing Issue #1: Inadequate Staff

Focusing on value-based and holistic patient-centered care requires a larger, more diverse, and highly educated nursing workforce. But maintaining adequate staffing remains an ongoing issue. Insufficient staffing can contribute to other nursing issues affecting job satisfaction, such as burnout , high staff turnover, scheduling dissatisfaction, less time to provide quality patient care, and a poor work-life balance.

Tips to Tackle Staffing Issues

Nurse leaders constantly deal with the hiring and retention of nursing staff . There isn't a quick fix for the nursing shortage, but you can take steps to alleviate the issue.

• Review your onboarding program to ensure it continues past the initial orientation. A better grasp of your organization's values and mission may encourage nurses to stay and prompt them to recommend working there.
• Ensure your wage and benefit package is competitive. Evaluate comparable positions in similar organizations in your area and advocate for wage or benefit changes as necessary.
• Seek staff feedback on what's working well and what needs improvement. Facilitate open lines of communication through regular team meetings and opportunities to meet individually.
• Implement a staff survey to uncover underlying nursing practice issues. Communicating with nursing staff — and making internal improvements based on their input — can improve trust and nurture a more positive outlook for your nursing team.
• Offer flexible work schedules and hire part-time and per diem staff.

Nursing Issue #2: Mental Health Concerns

Nurses experience daily on-the-job stress, often with little time to process the events. A shortage of nurses has placed greater demands on individuals, making the need for increased mental health awareness imperative.

Tips to Tackle Mental Well-Being

Your team counts on you to advocate for their mental health and well-being. Be proactive in addressing their concerns.

• Raise awareness by normalizing conversations about mental health, encouraging nurses to express their concerns, and listening and learning from their feedback.
• Examine the workplace culture to determine if it provides support, encourages meaningful dialogue, and builds positive relationships.
• Plan a routine debriefing after an incident to allow time to address concerns and identify issues.
• Provide internal resources by offering employee assistance programs and educational programs. The Well-Being Initiative provides various resources to help nurses prioritize their mental health care.
• Promote self-care by encouraging communication around stress management . If necessary, assist staff in prioritizing tasks and encourage delegation as appropriate.
• Help your staff identify early signs of burnout or other mental health issues in themselves and their co-workers and encourage intervention.

Nursing Issue #3: Lack of Advancement Opportunities

Nurses may leave an organization if they don't see opportunities for advancement or feel their contributions aren't valued. Committing to nurturing career growth by offering chances for internal development, educational improvement, and succession planning may prompt nurses to stay.

Tips to Tackle Career Growth

Use your leadership skills to foster an environment where your staff is knowledgeable about current healthcare trends.

• Promote education by advocating for time off for conferences, providing information on continuing education courses , and encouraging the pursuit of nursing certification or advanced degrees.
• Implement cross-training so nurses can become energized with additional roles that help prevent career stagnation.
• Develop a mentoring program by pairing nurses with peers or someone from a different unit or organization. These one-on-one relationships could grow over the years and assist with career development.
• Show transparency with succession planning by developing competencies to assess readiness for advancement. These plans may include annual reviews, adherence to the company's mission statement, commitment to positive organizational culture, and desire for further development.

Nursing Issue #4: Fear of Workplace Violence

An unsafe work environment can result in decreased job satisfaction, loss of work due to injury, and an inability to provide quality patient care. Acts of nursing workplace violence often go unreported . Nurses may be at an increased risk of physical or verbal abuse from patients, family members, or co-workers.

Tips to Tackle Workplace Violence

As a leader, it's your responsibility to ensure a safe, secure environment for your staff and patients. Implement strategies to make workplace safety a priority.

• Nurture a healthy and positive work environment by promoting a culture that holds people accountable for negative behaviors such as incivility or bullying. Model the desired behavior by making yourself approachable and practicing peaceful communication.
• Note times when there's a higher risk of violence. These periods may include when patients get transferred, wake from anesthesia, or get diagnosed with cognitive impairment, substance abuse, or acute psychiatric needs.
• Identify and address how to safely provide care when physically close to a patient or while performing uncomfortable procedures. Encourage nurses to assess verbal and nonverbal behaviors displayed in body language to help identify signs of escalation.
• Train all staff in de-escalation techniques and workplace violence prevention.
• Develop a zero-tolerance policy regarding appropriate conduct for patients and staff and support a comprehensive workplace violence prevention program .
• These examples serve as a starting point for addressing common problems in nursing practice. Prioritize your focus on the nursing issues most relevant to your team so your staff can continue to provide quality patient care and feel satisfied in their careers.

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5 Whys: Finding the Root Cause

When a problem presents itself, ask "Why?" five times until you reach the root cause.

• 5 Whys tool instructions, example, and template

The key to solving a problem is to first truly understand it. Often, our focus shifts too quickly from the problem to the solution, and we try to solve a problem before comprehending its root cause. What we think is the cause, however, is sometimes just another symptom.

One way to identify the root cause of a problem is to ask “Why?” five times. When a problem presents itself, ask “Why did this happen?” Then, don’t stop at the answer to this first question. Ask “Why?” again and again until you reach the root cause.

This technique is attributed to Taiichi Ohno, father of the Toyota Production System, which revolutionized automobile manufacturing with methods now known as Lean. It’s important to note that there may be multiple root causes of a problem, and that different people who see different parts of the system may answer the questions differently. For a more comprehensive tool, please see RCA 2 : Improving Root Cause Analyses and Actions to Prevent Harm .

*NOTE: Before filling out the templates, first save the PDF files to your computer. Then open and use that version of the tool. Otherwise, your changes will not be saved.

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‘Past public health lessons must be learnt’

STEVE FORD, EDITOR

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Thinking your way to successful problem-solving

13 September, 2001 By NT Contributor

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

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

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

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

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

Types of problems

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

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

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

Diagnosing problems

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

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

Initial analysis

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

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

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

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

Generating solutions

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

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

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

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

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

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

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

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

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

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

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

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

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

Making a decision

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

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

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

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

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

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

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

Implementing the solution

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

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

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

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Factors Influencing Problem-Solving Competence of Nursing Students: A Cross-Sectional Study

Eunhee choi.

1 Department of Nursing, Korean Bible University, 32 Dongil-ro(st) 214-gil, Nowon-gu, Seoul 01757, Korea; moc.revan@1029iohci

Jaehee Jeon

2 Department of Nursing, Gangneung-Wonju National University, Gangneung-si 26403, Korea

Associated Data

Not applicable.

Problem-solving ability is an important competency for nursing students to enable them to solve various problems that occur in dynamic clinical settings. The purpose of this cross-sectional study was to identify the factors that affect the problem-solving ability of nursing students. The subjects of this study were 192 nursing college students in their second year or beyond. The research tool consisted of an online questionnaire, with a total of 91 items regarding general characteristics, metacognition, and communication competence. Data collection was conducted from 10 to 30 March 2022. An online survey link was uploaded to the student group of a social network service from two nursing colleges that permitted data collection. Subjects who agreed to participate directly accessed and responded to the online survey. The collected data were analyzed using descriptive statistics, and the factors associated with the problem-solving ability of nursing students were examined using hierarchical multiple regression analysis. The subjects’ mean problem-solving ability score was 3.63 out of 5. Factors affecting problem-solving ability were age, communication competence, and metacognition, among which metacognition had the greatest influence. These variables explained 51.2% of the problem-solving ability of nursing students. Thus, it is necessary to provide guidance to improve metacognition and to develop educational methods to improve communication competence in curricular and non-curricular courses to improve the problem-solving ability of nursing students.

1. Introduction

Nurses must have the ability to develop individual problem-solving methods to satisfy their patients’ diverse and high-level health needs [ 1 ]. However, the medical field is characterized by uncertainty, instability, and unpredictability; thus, it is not easy for nurses to apply or utilize the knowledge learned within controlled situations in schools, and therefore, it is often difficult for nurses to address the health needs of patients [ 2 ]. The problem-solving ability required in such situations is an essential skill that college students majoring in nursing must have in order to effectively perform their assigned nursing tasks after graduation, while successfully adapting in order to practice in a rapidly changing medical field [ 3 ]. Therefore, strategies to improve the problem-solving ability of nursing students should be applied in their education.

This study aimed to examine the relationship between metacognition, communication competency, and the problem-solving ability of nursing students, and to identify factors that affect nursing students’ problem-solving ability. The results represent basic data that could help inform the development of educational strategies to improve the communication skills of nursing students.

Problem solving involves recognizing the difference between the problem solver’s current state and the goal state to be reached, and resolving the obstacles that prevent them from achieving the goal [ 4 ]. Acquiring problem-solving ability based on judgment and critical thinking is an important element of nursing education [ 5 ]. Furthermore, the use of effective problem-solving strategies based on professional knowledge is a competency that a professional nurse should possess [ 3 ].

Recently, metacognition has been recognized in psychology and pedagogy as a central element of the understanding, self-learning, communication, and problem-solving processes. Metacognition is the ability to think about one’s own thinking [ 6 ], as expressed by the individual knowing and controlling their thought processes and applying previously acquired knowledge, skills, and experiences using appropriate strategies [ 7 ]. In particular, metacognition is an important variable for learning and problem-solving. It is the knowledge related to the selection of an appropriate strategy for the task; the establishment, selection, and application of problem-solving measures; evaluation of the effectiveness of the applied measures; and checking and adjusting the performance process [ 6 , 7 ]. Accordingly, interest in metacognition is increasing in the field of nursing, with emphasis on the problem-solving ability of nursing students [ 8 ].

Metacognition affects problem solving by cultivating the learner’s active attitude, linking existing knowledge with new knowledge, and fostering the development of practical cognitive strategies that can be used for problem solving [ 7 ]. Previous studies on learners’ metacognition have observed that a higher level of metacognition leads to an improvement in the problem-solving process, as metacognition has a significant effect on goal setting and problem-solving performance [ 9 ]. Thus, metacognition and problem-solving ability are closely related; furthermore, metacognition is a key strategic aspect in the problem-solving process [ 10 ]. Although metacognition is a powerful predictor of learning outcomes and problem-solving success, it is not clear how metacognition works regarding cognitive strategies and learning outcomes [ 11 ]. A study of adolescent metacognition-related cognition (learning strategies and problem-solving strategies) and how metacognition affects various types of learning performance confirmed that problem solving is the only mediator between general metacognition and learning performance [ 11 ]. Metacognition plays a major role in improving learning and work ability, and the appropriate use of metacognition when performing nursing tasks can improve the personal lives of nurses [ 12 ]. Therefore, it is necessary to assess the influence of metacognition and problem-solving ability on nursing education.

Communication competence is a major factor that affects problem-solving ability [ 13 ]. It is essential for smoothly maintaining professional relationships with medical personnel, patients, and guardians in diverse and complex medical environments [ 14 ]. Since communication competence is an important aspect of problem solving, it can affect the quality of nursing and the satisfaction of the patient [ 15 ]. There is an urgent need to improve communication competence, as various issues that arise during the clinical process can be solved through communication between medical staff and patients, and nurses are responsible for much of the continuous communication with patients and their guardians [ 16 ]. However, a lack of communication competence among nurses may lead to miscommunication, and thereby, poor outcomes, even if nurses possess good problem-solving methods [ 13 ].

While previous studies have revealed the relationship between communication competence and the problem-solving ability of nursing students [ 13 , 17 ], there is a lack of research regarding the relationship between metacognition, communication competence, and problem-solving ability. Through this research, we confirmed the relationship between the metacognition and problem-solving ability of nursing college students, the relationship between communication ability and problem-solving ability, and finally, examined the factors that affect variables associated with problem-solving ability, including metacognition.

2. Materials and Methods

2.1. design.

This study used quantitative methods to investigate the relationship between the metacognition, communication ability, and problem-solving ability of nursing students and to identify factors that affect problem-solving ability.

2.2. Participants and Procedures

The subjects of this study were nursing students enrolled in two nursing colleges in the same city and region. Since data collection was conducted in March, second-year, third-year, and fourth-year students, with college life experience, were targeted. The required number of study subjects was calculated using the G-Power 3.1.9.7 program, which determined a significance level of 0.05, an effect size of 0.15, a power of 0.90, and 11 predictors, for multiple regression analysis. The minimum sample size was 152. In consideration of the dropout rate, 170 was set as the target number of subjects.

Data collection was conducted from 10 to 30 March 2022. The survey was conducted online. Consent for participation in the study was obtained by the individual reading the explanation of the purpose of the study and checking a consent box, which was displayed on the first screen of the online survey. The study subjects were redirected to the questionnaire completion page after providing their consent. It required approximately 10 min to complete the questionnaire. A total of 200 participants accessed and completed the questionnaire; 192 questionnaires were used for analysis after excluding 8 questionnaires that were determined to have been completedinccurately.

2.3. Instruments

The tools of this study consisted of a total of 91 items, including 9 items regarding general characteristics, 20 metacognition items, 15 items dealing with communication competencies, and 45 regarding problem-solving skills.

The items regarding the general characteristics of the subjects included age, sex, academic level, interpersonal relationships, satisfaction with major, problem based learning (PBL) experience, number of related experiences, clinical practice experience (yes or no), and number of weeks of clinical practice experience.

Metacognition was assessed using the state metacognitive inventory developed by O’Neil Jr et al. [ 18 ], as modified and supplemented by Joo [ 19 ]. It consists of a total of 20 items that assess the four sub-factors of metacognition: cognition, cognitive strategy, plan, and monitoring, using a 5-point Likert scale ranging from 1 point, for ‘not at all’, to 5 points, for ‘strongly agree’. The Cronbach’s α measure of the reliability of the tool was 0.86 at the time of development and 0.89 in the study of Joo [ 19 ]. The value in the current study was 0.91.

Communication competence was measured using a comprehensive interpersonal communication competence scale developed by Rubin [ 20 ], as modified and supplemented by Hur [ 21 ] to fit Korean culture. This tool consists of 15 items related to communication, such as self-exposure, cross-exposure, social tension relief, assertiveness, and concentration. Each item is assessed on a 5-point Likert scale ranging from 1 point, for ‘not at all’, to 5 points, for ‘strongly agree’. The Cronbach’ α reliability measure at the time of development was 0.72, and the value in this study was 0.84.

Problem-solving ability was assessed via a life-skills measurement tool developed by the Korea Educational Development Institute [ 22 ]. This tool considers 5 problem factors (clarification, cause analysis, alternative development, plan and implementation, and performance evaluation) and 9 sub-factors (problem recognition, information collection, analysis ability, divergent thinking, decision making, planning ability, execution and risk taking, evaluation, and feedback), and thus consists of 45 items in total. Each item is assessed on a 5-point Likert scale ranging from 1 point, for ‘very rarely’, to 5 points, for ‘very often’, with higher scores indicating better problem-solving skills. The reliability at the time of tool development was indicated by a Cronbach’s α value of 0.95, whereas in this study, the Cronbach’s α value was 0.90.

2.4. Statistical Analysis

Statistical analyses were performed using SPSS (ver. 25) statistical software (IBM). The subjects’ general characteristics, metacognition, communication competence, and problem-solving ability were analyzed by number and percentage, as well as mean and standard deviation. To test the normality of all variables, skewness and kurtosis were assessed. In general, when the absolute value of skewness is less than 2 or the absolute value of kurtosis is less than 7, there are no problems associated with deviations in the variable distributions from normality [ 23 ]. In this study, skewness ranged between −0.002 and 0.435, with absolute values less than 2, and kurtosis ranged between −0.204 to 1.580, with absolute values less than 7, thus indicating that the variables satisfied the assumption of univariate normality. Differences in metacognition, communication competence, and problem-solving ability according to the general characteristics of the subjects were analyzed by mean, standard deviation, independent t-test, and one-way ANOVA, followed by Scheffé’s post hoc analysis. The correlation between metacognition, communication competence, and problem-solving ability of the participants was analyzed using Pearson’s correlation coefficient. Factors affecting the subject’s problem-solving ability were analyzed using hierarchical multiple regression.

2.5. Ethical Considerations

Before the study was conducted, the research proposal and questionnaire were approved by the Institutional Review Board of Gangneung–Wonju National University (No: GWNUIRB-2022-1). The tools used in the study were used after obtaining the consent of the original author. When explaining the purpose of the study, it was emphasized that the participants had the right to withdraw from the study at any time, that the anonymity and confidentiality of the survey results were guaranteed, and that the study results would not be used for other purposes. Participants were provided with a small gift to motivate participation.

3.1. General Characteristics

Table 1 illustrates that the participants’ mean age was 21.56 ± 1.99. Most participants were women (81.3%).

General Characteristics of Participants (N = 192).

† SD, standard deviation; ‡ PBL, problem-based learning.

3.2. Scores for Metacognition, Communication Competence, and Problem-Solving Ability

Table 2 illustrates that the average score of the subjects’ metacognition was 3.86 ± 0.47 (out of 5). Among the sub-domains, cognitive strategy showed the highest score of 4.03 ± 0.45, followed by monitoring, with 3.90 ± 0.59. The average for communication competence was 3.92 ± 0.42 points (out of 5 points). The average for problem-solving ability was 3.63 ± 0.35 (out of 5), and among the sub-domains, problem clarification was the highest at 3.83 ± 0.52, and cause analysis was the lowest at 3.28 ± 0.36.

Scores for metacognition, communication competence, and problem-solving ability. (N = 192).

3.3. Differences in Problem-Solving Ability According to General Characteristics

The problem-solving ability according to the general characteristics of the subjects was as follows ( Table 3 ): age (F = 4.32, p = 0.015), academic level (F = 10.17, p < 0.001), interpersonal relationships (F = 9.47, p < 0.001), satisfaction with major (F = 3.73, p = 0.012), PBL experience (F = 3.73, p = 0.012), number of PBL experiences (F = 3.20, p = 0.025), and practical experience (F = 2.74, p = 0.007). There was a significant difference in problem-solving ability accorfing to the number of training weeks (F = 4.46, p = 0.013). Scheffé’s post hoc analysis indicated that participants older than 23 years old and younger than 20 years old, as well as fourth-year students, were more dissatisfied than were second-year students. In other cases, interpersonal relationships were very good. Additionally, satisfaction with the major was more than satisfactory. Problem-solving ability was statistically significantly higher for those with more than 7 weeks of practice, and there was no case of not having more than 7 weeks of practice.

Differences in metacognition, communication competence, and problem-solving ability according to nursing students’ general characteristics (N = 192).

† Scheffé test; ‡ PBL, problem based learning.

3.4. Relationship beetween Metacognition, Communication Competence, and Problem-Solving Ability

There was a strong, significantly positive correlation between metacognition and problem-solving ability (r = 0.672, p < 0.001), and communication competence and problem-solving ability (r = 0.542, p < 0.001). There was also a strong, significantly positive correlation between metacognition and communication competence (r = 0.557, p < 0.001; Table 4 ).

Relationships between metacognition, communication competence, and problem-solving ability (N = 192).

3.5. Factors Influencing Problem-Solving Ability

Among general characteristics, variables were converted into dummy variables as needed to confirm their effect on the problem-solving ability of nursing students (e.g., age, 23 years or older = 1; academic level, third year = 1; interpersonal relationships, very good = 1; satisfaction with major, more than satisfied = 1; the number of PBL experiences, 3–6 times = 1; and the number of training weeks, 7 weeks or more = 1). A hierarchical stepwise multiple regression analysis was then performed, inputting communication ability followed by metacognition, which were significantly correlated.

The Durbin–Watson value was 1.96 (close to 2), which confirmed that there was no autocorrelation between the independent variables. The variance inflation factor was 1.013 to 4.999; as all value were less than 10, there were no problems with multicollinearity between independent variables.

General characteristics that showed a significant difference with problem-solving ability in univariate analyses were first input to Model 1, namely age, academic level, interpersonal relationships, and satisfaction with major. This model explained 8.1% of the variance in problem-solving ability. When PBL experience and frequency, clinical practice, and number of weeks were added to Model 1 (Model 2), the variance explained was 12.5%, namely an increased of 4.4% compared to Model 1. When communication competence and metacognition were additionally added to Model 2 (Model 3), the variance explained was 51.2%, which is an increase of 38.7% compared to Model 2. Finally, age (β = 0.11, p = 0.048), communication competence (β = 0.24, p = 0.001), and metacognition (β = 0.52, p = 0.023) were significantly related to problem-solving ability. These variables exhibited an explanatory power of 51.2% (F = 21.01, p < 0.001) regarding job satisfaction; the most influential variable was metacognition ( Table 5 ).

Factors influencing problem-solving ability (N = 192).

† Dummy variables; ‡ Reference; ¶ PBL, problem-based learning; * p < 0.05.

4. Discussion

In this study, the mean problem-solving ability score of nursing students was 3.63 out of 5, which is similar to the 3.56 points reported in a study targeting third- and fourth- year students in the department of nursing [ 24 ]. However, the current value is higher than the 3.44 points reported in a study targeting first- and second-year students [ 13 ]. Participants in these studies were nursing students in the second, third, and fourth years of study in this paper, in the third and fourth years in the study done by Kim et al. [ 24 ]; and in the first and second grades in the study by Ji et al. [ 13 ]. Problem-solving ability can be developed under the influence of various factors; those identified in previous studies include communication ability [ 13 ], critical thinking ability [ 12 , 25 ], metacognition [ 11 ], and self-directed learning [ 2 ]. These factors are continuously improved through various interpersonal relationships formed while learning and studying liberal arts and other major subjects, rather than existing as innate abilities [ 26 ]. Therefore, the degree of problem-solving ability was rather high in the study targeting the upper grades. Problem-solving ability in various unexpected situations is essential for working as a nurse [ 27 ]. In the current study, the problem-solving ability score of nursing students approximated the 72.6 percentile of the full 100-point scale. Although this score is relatively high, it is nevertheless necessary to improve problem-solving ability; given the nature of the nurse’s job, this ability represents a very important competency. Therefore, it is necessary to improve the problem-solving ability level of nursing students in Korea. The results of this study showed that factors affecting nursing students’ problem-solving ability were metacognition, communication competence, and age. It is necessary to establish a strategy that considers these factors to improve the problem-solving ability of nursing students.

The participants’ average metacognitive score was 3.86 out of 5, which was slightly higher than the 3.61 observed in a study conducted using the same tools for second-year nursing students [ 12 ]. While direct comparison using other tools is difficult, the metacognitive level of 72.3 obtained by Kim [ 28 ] for all grades in the nursing department was lower than the 77.2 points (out of 100 points) obtained in this study. According to Sternberg and Sternberg [ 29 ], the problem-solving phase includes problem identification, problem expression, strategy formulation, information construction, resource allocation, supervision, and evaluation. For health science students, metacognitive instruction has been shown to have a positive effect on students’ problem-solving ability and in improving academic achievement [ 30 ]. That is, metacognition is a key factor in predicting learning outcomes in the problem-solving domain [ 31 ]. These results were replicated in this study, which showed that a higher metacognitive level of nursing students indicated a significantly higher problem-solving ability. The subjects of this study were second-, third-, and fourth-year nursing students, and it is thought that their metacognitive level was improved compared to students in earlier phases of education, as a result of the curriculum of the nursing department. Educational programs and strategies to improve metacognition will be needed to improve the problem-solving ability of nursing students. The components of metacognition are thinking deeply in the planning stage, establishing possible strategies, undertaking regulating and monitoring activities to carry out the strategy, and revising and regulating to ensure that the solution is progressing in an appropriate direction to achieve the goal [ 32 ]. Therefore, a professor who instructs and checks nursing students is necessary to enable them to set their own goals in the curricular and non-curricular programs as they advance through the course, plan and implement strategies to achieve their goals through deep thinking, and conduct their own monitoring and control processes.

The average communication competence score of the subjects was 3.92 out of 5. Previous studies targeting students in various years of the course at the department of nursing found that the communication competence of nursing students also improved as they progressed through the course, with values reported of 3.58 points [ 33 ] and 3.56 points [ 34 ].

In previous studies, communication competence was a factor affecting nursing students’ problem-solving ability [ 13 ]. However, the current study is valuable because it additionally revealed that the level of problem-solving ability significantly increased according to the level of communication competence. Case-based education is suggested as a strategy to simultaneously improve communication competence and problem-solving skills in nursing student education [ 17 ]. This is because it is difficult to solve problems through integrative thinking and effective communication in a clinical environment, such as a hospital, with only theoretical knowledge of nursing subjects. Thus, the PBL method is applied to theoretical education in nursing colleges [ 35 , 36 ]. The results of this study showed that the presence or absence of PBL education had a significant effect on the problem-solving ability of nursing students; this ability improved when the PBL factor was added to Model 2. Therefore, it is necessary for nursing professors to practice and improve the communication competence of their students through case-based education in various subjects beginning in the first year to improve the problem-solving abilities of the students.

Additionally, the age of the subjects was also a factor influencing the problem-solving ability. Stewart, Cooper, and Moulding [ 37 ] reported that metacognitive levels increase with age. The study revealed that the communication competence of nursing students improved through various experiences [ 38 ]. Age may have had a similar influence.

Previous studies identified critical thinking disposition, empathy, nursing professional intuition, self-leadership [ 24 ], learning motivation [ 17 ], and communication competence [ 13 ] as examples of factors that affect nursing students’ problem-solving ability. However, this study demonstrated that metacognition also significantly affects the problem-solving ability of nursing students. In particular, metacognition and communication competence are considered key concepts, as they explained 51.2% of nursing students’ problem-solving ability. Therefore, it is necessary to consider and continuously apply educational strategies to improve metacognition and communication competence in the education of nursing students in the future.

This study is limited by the small number of nursing colleges that were included in the sampling, as this hinders the generalizability of the results.

5. Conclusions

This was a descriptive research study that identified the degree of and correlations between metacognition, communication competence, and problem-solving ability of nursing students, and identified factors that affect problem-solving ability. The results demonstrated that age, communication competence, and metacognition were the factors that most significantly affected the problem-solving ability of nursing students. Among these factors, metacognition had the greatest influence. Therefore, to improve the problem-solving ability of nursing students, an educational strategy is needed to improve communication competence through case-based learning in the curriculum, and development and application of activities such as PBL. In addition, the guidance of professors is needed to enable nursing students to improve their metacognition.

Since this study revealed that metacognition is a factor that influences the problem-solving ability of nursing students, we recommend conducting a study to check whether it affects actual problem-solving by developing and applying a metacognitive improvement curriculum in the future.

Acknowledgments

We would like to thank the nursing students who participated in the study.

Funding Statement

This study was supported by the research fund of Korean Bible University in 2021.

Author Contributions

Conceptualization, E.C. and J.J.; methodology, E.C. and J.J.; validation, E.C.; formal analysis, E.C.; investigation, E.C. and J.J.; resources, E.C. and J.J.; data curation, E.C.; writing—original draft preparation, E.C.; writing—review and editing, J.J.; supervision, E.C.; project administration, E.C. and J.J.; funding acquisition, E.C. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board (or Ethics Committee) of Gangneung–Wonju National University (No. GWNUIRB-2022-1).

Informed Consent Statement

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

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

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Nurse managers' decisions: fast and favoring remediation

Affiliation.

• 1 The University of Arizona College of Nursing, Tucson, AZ 85721-0203, USA. [email protected]
• PMID: 20305465
• PMCID: PMC2880498
• DOI: 10.1097/NNA.0b013e3181d40f7c

How do nurse managers make decisions about quality issues on their units? We asked 10 nurse managers in 3 Arizona hospitals to describe how they resolved a recent quality issue. The managers tended to use a linear, but cognitively expensive strategy, often jumping from problem to solution without a clear goal and selecting solutions biased toward remedial education. Decision support tools should help managers think more systemically and efficiently, while encouraging consideration of more alternatives to reach targeted goals.

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The Decision Ladder (adapted from Vicente, 1999)

A heparin overdose. The decision…

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