- Email: [email protected]
Enhancing problem solving and nursing diagnosis in year III Bachelor of Nursing students
Nurse Education Today (2009) 29, 389–397
Nurse Education Today www.elsevier.com/nedt
Enhancing problem solving and nursing diagnosis in year III Bachelor of Nursing students Marilyn B. Lee
a,*
, Petra Brysiewicz
b
a
College of Nursing and Allied Health, University of North Alabama, One Harrison Plaza, Box 5124, Florence, AL 35632, United States b School of Nursing, University of KwaZulu-Natal, Durban, South Africa Accepted 18 October 2008
KEYWORDS
Summary
Problem solving; Nursing diagnosis; Triple jump; Nursing education
Background: The School of Nursing in which this research was conducted uses a problem based learning approach in clinical nursing courses. Although the skills required for problem solving, and those in nursing care planning, are similar and therefore, support each other in the learning environment, there is limited evidence of the effectiveness of this teaching strategy on problem solving and nursing care planning. Aim: The aim of this study was to implement a change in the clinical nursing course in the third year of the Bachelor of Nursing (BN) programme and determine if this change improved students’ problem solving and care planning. Method: A nine-step problem solving process to deal with problem scenarios was introduced. We hoped that consistent use of this systematic process would improve students’ problem solving and care planning skills in the classroom and the clinical area. In order to determine change in problem solving and care planning skills we compared (a) the previous third year student performance on semester I and II assessments with those of the study participants and (b) results at the end of semester I with end of semester II within the study cohort. Findings from these analyses are presented in this paper. c 2008 Elsevier Ltd. All rights reserved.
Background of the study
* Corresponding author. Tel.: +1 256 366 8259; fax: +1 256 765 5002. E-mail address: [email protected] (M.B. Lee).
In this paper, a study to explore the influence of an educational intervention expected to improve student problem solving and nursing diagnosis skills, is described and recommendations are made for future third year clinical courses.
0260-6917/$ - see front matter c 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2008.10.008
390
Problem solving and nursing diagnosis Teaching nursing students how to use the nursing problem solving process (nursing process) is critical to their ability to provide quality nursing care (Mu ¨ller-Staub et al., 2007c; Burkhart, 2006; Volpato, 2003; Mu ¨ller-Staub et al., 2007). Higuchi and Donald (2002) agree that nurses need complex thinking processes, as well as psychomotor and affective skills, in order to be expert clinical practitioners. An important component of the nursing process, which had not been emphasized in the teaching of the students involved in this research, is nursing diagnosis. A nursing diagnosis is a standardized statement about the health of a client (individual, family, or a community) in order to plan nursing care (Anderson, 1998; Perry and Potter, 2004). Nursing diagnoses are formulated based on the data discovered during nursing assessment (Doenges and Moorhouse, 2003). Formulating nursing diagnoses requires students to have a good grasp of nursing, social and human sciences as well as competencies such as health assessment, clinical reasoning and ability to integrate knowledge (Burkhart, 2006; Jaco, 2003). Although controversy exists on the usefulness (Hogston, 1997; Junttila ¨ et al., 2006; Olsson and Gardulf, 2006) and the reliability (Bonawit and Nolan, 1989) of nursing diagnosis in nursing practice; in the international nursing community, nursing diagnosis and other classification systems (NIC and NOC) are recognized as potentially valuable in the creation of an international nursing terminology system, as well as improving the quality of documentation (Erdemir et al., 2003; Levin, 2004; Mu ¨ller-Staub et al., 2007c). The International Council of Nurses has collaborated with nurses globally in an effort to develop an International Classification for Nursing Practice (ICNP, 2008) and thus use of nursing diagnoses in this setting might further this initiative. Problem solving in nursing is essential. Some authors have indicated that problem solving is enhanced when supported by a systematic approach, with clear expectations (Zerr, 1990; Newsome and Tillman, 1990; Clarke, 1986; Mu ¨ller-Staub et al., 2007). Smith and Roberts (2007) and others (Alexander et al., 2005; Benson et al., 2001) suggest that use of the problem based learning strategy in the classroom may enhance problem solving and critical thinking in applied sciences education. In order to measure problem solving abilities of students, staff at McMaster University, Canada developed a student assessment tool called the triple jump (Callin and Ciliska, 1983). In this assessment,
M.B. Lee, P. Brysiewicz students are presented with a problem scenario and expected to ask questions related to the scenario in order to assess, formulate nursing diagnoses and determine appropriate interventions. Students are then given time to perform independent study to help them understand the problem(s) better and to evaluate their nursing diagnoses and nursing interventions. Students return to the exam venue to finalize their nursing diagnoses as well as their nursing care plan. Because the BN nursing programme curriculum is problem based, the triple jump is used as one of the student assessment tools at the end of each semester in the third year clinical nursing course. Several studies have used the triple jump as the instrument to measure problem solving. Makhathini and Uys (1996) measured the problem solving ability of diplomats from a basic nursing programme. Uys et al. (2004) evaluated the outcomes of PBL programmes in nursing schools in South Africa in terms of the competence of graduates to solve problems in actual clinical settings, and compared this competence with that of graduates from non-PBL programmes. From our experience it seemed that students had difficulty systematically performing problem solving activities, this was particularly evident in assessment situations, such as with the triple jump. Because of this apparent gap in application of problem solving skills, we initiated a change in the manner in which PBL tutorials were conducted to see if adding more structure and specific content would improve student performance on assessment. In addition to the systematic process introduced (the nine-step process), the authors added content on nursing diagnosis and its relationship to other phases of the nursing process because students were not routinely taught to use this component of the nursing process. This omission resulted in students neglecting to incorporate this component of the nursing process into their nursing care planning as evidenced by tutorial performance and the end of semester triple jump assessments. Furthermore, students struggled with effectively planning nursing care for specific nursing diagnoses because they had minimal experience with linking diagnosis with the other phases of the nursing process.
Methods Problem statement Although students are taught to problem solve through PBL sessions, our students did not seem
Enhancing problem solving and nursing diagnosis in year III Bachelor of Nursing students to correlate the activities in the classroom with end of semester assessment. In addition, students did not formulate nursing diagnoses for their patients and thus had difficulty developing nursing care plans to address specific patient problems.
391
The authors designed this study to answer the following question: Is there a significant difference between the control and treatment group triple jump (problem solving) scores? The following null hypothesis was formulated: there will be no significant difference in the triple jump scores between the control and treatment group.
end in November thus June assessments are before November assessments in each academic year) received an intervention (treatment) and performance on the triple jump was measured. Triple jump scores from the 2005 year three academic year, that received no intervention (control), were then compared to those of the 2006 cohort. It was expected that if there were an improvement in problem solving skills this would be evidenced by higher scores on the triple jump between semesters I and II and the 2005 and 2006 cohorts. Qualitative data were collected on student satisfaction and perception of clinical application of problem solving and nursing diagnoses are reported elsewhere (Brysiewicz and Lee, submitted for publication).
Setting
Nine-step problem solving process
The setting for the study was a moderate size School of Nursing at a large university in South Africa using a problem based approach to nursing education. In South Africa, a number of schools of nursing have adopted PBL and the institution in which this study was conducted introduced PBL in 1994. The nursing programme is structured in such a way that first and second year focuses on healthy individuals, families and communities. The last part of second year exposes the students to primary health care settings. Third year in the programme is hospital-based acute care and fourth year is the year of specialisation in midwifery and mental health nursing. All students are allocated to a small group of around 12 students and usually there are no large group meetings except for orientation purposes. In each semester in year three, one of the primary means of assessment of students’ problem solving is the triple jump.
We designed a four hour teaching programme, taught in two–two hour sessions, to inform students of the systematic problem solving process that would be used in the 2006 PBL tutorials. The first two hours included an introduction to a ninestep process that was to be used in all tutorials for the year. The nine steps included were:
Research question
Population and sample All students in third year PBL tutorials were exposed to a nine-step problem solving process and were instructed on how to formulate nursing diagnoses as a part of their nursing process. Triple jump marks from third year in academic year 2005 (n = 39) were compared with the triple jump marks from third year academic year 2006 (n = 31).
Research design The design used for this study was a quasi experimental design. Students from the year three 2006 academic year (note: In the southern hemisphere, university academic years begin in February and
Step 1: Present a brief description of the patient. Step 2: Allow students in your group to pose hypotheses about what the possible problems are for this patient. Step 3: Allow students to ask you for data based on these hypotheses. Step 4: Facilitate formulation of a revised problem list. This may require you to tell students additional data that was not requested and sharing with them what hypotheses you had for this patient. Step 5: Allow students to ask more questions and to determine a final problem list. These should be in the form of nursing diagnoses, including possible diagnoses and risk diagnoses. Step 6: Determine if you need additional information, i.e., are you able to determine a list of diagnoses that you can support with data? Does the group have any idea of what interventions/nursing actions might be effective to reduce or eliminate the problems? What evidence do they have for this? This is an opportunity to get the group problem solving using information they have learned from a variety of disciplines. Step 7: Present your list of interventions and rationale for them. Students can then question you about these actions. You will be the clinical
392 expert. What evidence do you have that this nursing action decreases the problem you have identified in your nursing diagnosis? Step 8: Determine what data you would need to collect to see if the problem was reduced or eliminated? If the group is unable to assist with this you will provide this along with your rationale. How will you determine if the patient is ready for discharge? What can you do to ensure that the patient is ready for discharge? Step 9: In what other clinical situations might this information be useful? Identify related diagnoses and whether or not nursing actions identified would be useful in these cases.
M.B. Lee, P. Brysiewicz assessment items. Each of the items has a possible maximum score of five and a minimum of zero. The higher the score on each item, the better the performance on that item with regard to problem solving. A maximum total score of 80 would indicate excellent problem solving skills. The assessment corresponds to the nine-step process in the following way (numbers in brackets indicate the number of items on the triple jump that specifically relate to this problem solving component). Issue identification [1] – Steps 1 and 2. Data gathering [5] – Steps 3 and 4. Interim problem formulation [2] – Steps 2, 4, 5 and 6. Initial nursing interventions [1] – Steps 6 and 7. Self-assessment [1] – Step 6 Revised problem formulation [3] – Steps 2, 4, 5 and 6, Revised nursing interventions [3] – Steps 6 and 7.
Most of these nine steps correspond to the assessment areas of the triple jump (Callin and Ciliska, 1983), and it was expected that by following these nine steps problem solving would be improved and that this would be reflected by an increase in overall triple jump scores (Cholowski and Chan, 2004). During the second two hour session the authors included information on the formulation of nursing diagnosis and its relationship to care planning. In the previous years the students in third year had been following a medical model, thus our strategy was a move towards more emphasis on the use of the nursing process and encouraging the students to make use of specific nursing terminology, i.e., nursing diagnosis. It was expected that students who understood the use of nursing diagnosis would perform better on the three questions related to patient problem formulation in the triple jump assessment. It was also hoped that ability to set goals, plan interventions and evaluate their effectiveness would result in overall improvement in problem solving and care planning, reflected by improved overall triple jump scores, as other researchers have found (Pearce et al., 1990; Axelsson et al., 2006; Mu ¨ller-Staub et al., 2007a).
When considering the reliability of the triple jump assessment method, Callin and Ciliska (1983) demonstrated a strong inter-rater correlation (p = 0.91) between the initial tutor who scored the students compared with the scores obtained two to four weeks later by another tutor observing the videotape. The scores obtained at this time were strongly correlated (p = 0.77) (Callin and Ciliska, 1983). In this study a Cronbach’s alpha was calculated for each of the data sets (semesters I and II 2005 and semesters I and II 2006) as well as on the combined triple jump (all assessments in 2005 and 2006). The Cronbach’s alpha for the combined data sets was .864. For each of the individual data sets the Cronbach’s alpha ranged from .721 to .899 (June 2005 = .888; November 2005 = .721; June 2006 = .860 and November 2006 = .899).
Instrument – triple jump
Ethics
The triple jump assessment includes questions that measure students’ ability to identify issues (one question), gather data (five questions), formulate an interim patient problem list (two questions), identify preliminary nursing interventions (one question), perform self-assessment of learning needs (one question), formulate a revised patient problem list based on learning that occurred during independent study in the second step of the triple jump (three questions), identify revised nursing interventions (three questions); for a total of 16
Permission to conduct this research was sought from the Head of School, as well as the university ethics committee. All students willing to participate were provided with a participant information sheet and a written consent form, which students were asked to sign. The information sheet described the purpose of the research as well as the rights of the student to refuse to participate in the research and they were informed and that this would not jeopardize their marks or tutorial participation. The information sheet also contained the
Validity and reliability
Enhancing problem solving and nursing diagnosis in year III Bachelor of Nursing students authors’ contact details should the students require more details regarding the research.
0.5 or less. In addition, a chi square test was conducted to compare the proportion of positive change for the treatment and control groups associated with the total score and each triple jump item. Chi square tests were also conducted to compare the distributions of scores for June 2005 versus June 2006, and November 2005 versus November 2006 in order to assess whether or not control and treatment groups differed significantly in their responses on the triple jump.
Data analysis Data were de-identified and marks for each triple jump item for semesters I and II 2005 and 2006 (two cohorts and four measurements) were entered into Statistical Analysis System (SAS) v 9.1, while the original data were secured with the researchers. The statistical tests utilized in this paper were selected because a general linear model would not be appropriate, since the data are a Likert scale and neither continuous nor normally distributed. The chi square and sign tests are nonparametric procedures. Typically, non-parametric procedures tend to be ‘‘weak’’ procedures (meaning low in statistical power), however, low power tests are not objectionable as long as the test of hypothesis results in the rejection of the null hypothesis. Therefore, sign and chi square tests were used (Easton and McColl, 2007). Using a simple sign test a comparison of marks between semesters I and II of 2005 was performed to determine if there was a significant tendency for scores to change in a positive direction. A similar analysis was performed for the 2006 data. This analysis determines if in fact there is a tendency for positive change to occur, if there is this tendency then the proportion would tend to be greater than 0.5, otherwise, the true proportion would be
Table 1
Results Descriptive data A total of 140 triple jump scores [June 2005 (n = 39), November 2005 (n = 40), June 2006 (n = 31) and November 2006 (n = 30)] were compared both on total and individual item scores. The mean scores and standard deviation for each measurement are displayed in Table 1. Using a mean of >3.0 as the threshold, the items on which the control and treatment cohorts reached this value on all four measurements included: data gathering [1] and data gathering [5]. For the June 2005 cohort (control), students performed best on three items: data gathering [1], data gathering [3] and data gathering [5]. On the final assessment, November 2005 (control), ten items met threshold: issue identification, data gathering [1], data gathering [2], data gathering
Triple jump scores – descriptive statistics (n = 140).
Item
Issue identification Data gathering 1 Data gathering 2 Data gathering 3 Data gathering 4 Data gathering 5 Interim problem formulation 1 Interim problem formulation 2 Nursing intervention 1 Self-assessment Revised problem formulation 1 Revised problem formulation 2 Revised problem formulation 3 Revised nursing intervention 1 Revised nursing intervention 2 Revised nursing intervention 3 3.0.
393
June 2005 (n = 39)
November 2005 (n = 40)
June 2006 (n = 31)
November 2006 (n = 30)
l
SD
l
SD
l
SD
l
SD
2.62 3.18 2.95 3.05 2.13 3.28 2.79 2.56 2.77 2.74 2.67 2.51 2.51 2.41 2.31 2.44
.990 .683 .605 .793 1.42 .724 .732 .821 .931 1.093 .955 .997 .914 .818 .800 .882
3.45 3.03 3.06 3.10 2.19 3.10 3.16 3.00 3.10 3.13 3.39 3.06 2.77 2.94 2.77 2.81
.850 .657 .727 .870 1.64 .908 .820 .683 .700 .670 .844 .772 .920 .814 .845 .703
2.55 3.03 2.78 2.95 2.58 3.20 2.95 2.95 3.20 2.80 3.08 2.50 2.88 2.98 2.65 2.80
.904 .423 .620 .677 1.36 .723 .677 .677 .723 1.02 .656 1.24 .686 .800 .770 .966
3.30 3.13 3.07 3.20 1.93 3.30 3.17 3.60 3.33 3.23 3.20 3.17 2.90 3.13 2.90 3.13
.837 .819 .740 .714 1.62 .837 .834 .814 .711 .817 .761 .913 .995 .681 .662 .571
394
M.B. Lee, P. Brysiewicz
[3], data gathering [5], interim problem formulation [1], nursing intervention [1], self-assessment, revised problem formulation [1] and revised problem formulation [2]. Scores on the triple jump items for the June 2006 cohort (treatment), which occurred four months after the intervention, reached the threshold on four items: data gathering [1], data gathering [5] nursing intervention [1] and revised problem formulation [1]. At the final assessment (November 2006), after a full academic year of experience with the intervention, scores on 13 items reached threshold with only: data gathering [4], revised problem formulation [3] and revised nursing intervention [2] not reaching threshold.
Change in scores The simple sign tests conducted between June and November total and individual item scores between the control and treatment groups were not significant. Differences in change in total scores between the control and treatment group, calculated using the chi square statistic, were also not significant (p = .245). For individual items, change was signif-
Table 2
icant (p = .03) for revised problem formulation [1] with a tendency towards more positive change in the control group.
Test of significance Significant differences (a 6 0.05) in distribution of individual triple jump item scores between treatment and control groups in June and November were calculated using the chi square statistic. A chi square statistic is used to investigate whether distributions of categorical variables differ from one another. Because the number of observations in some categories was too low to justify use of the chi square analysis, pooling of scores was performed with one category including scores of 0, 1 and 2; the second category including the score of 3 and the third category including scores of 4 and 5. The chi square calculation determined that there were significant differences in distribution of scores between the control and treatment group in June on issue identification (p = .001), selfassessment (p = .03), revised problem formulation [1] (p = .02) and revised nursing interventions [1] (p = .05) (see Table 2). Revised nursing interventions [2] (p = .07), revised problem formulation
Significant differences (6.05) identified in chi square statistic.
Item Date
Frequencies 0, 1 and 2
Frequency 3
Frequencies 4 and 5
Total
p
Issue identification June 2005 June 2006
16 4
16 9
7 18
39 31
.0013
Self-assessment June 2005 June 2006
14 3
15 20
10 8
39 31
.0269
Revised problem formulation 1 June 2005 16 June 2006 4
15 14
8 13
39 31
.0223
Revised intervention 1 June 2005 June 2006
21 8
15 17
3 6
39 31
.0469
Issue identification November 2005 November 2006
16 5
19 13
4 13
39 31
.0043
Data gathering 1 November 2005 November 2006
3 6
32 17
4 8
39 31
.0476
24 12
6 17
39 31
.0015
Interim problem formulation 2 November 2005 9 November 2006 2
Enhancing problem solving and nursing diagnosis in year III Bachelor of Nursing students Table 3
395
Significant differences (.06–.10) identified in chi square statistic.
Item Date
Frequencies 0, 1 and 2
Frequency 3
Frequencies 4 and 5
n
p
Interim problem formulation 1 June 2005 15 June 2006 5
17 16
7 10
39 31
.0950
Interim problem formulation 2 June 2005 17 June 2006 7
18 16
4 8
39 31
.0923
Revised problem formulation 2 June 2005 18 June 2006 7
16 16
5 8
39 31
.0964
Revised intervention 2 June 2005 June 2006
23 11
14 14
2 6
39 31
.0675
Data gathering 4 November 2005 November 2006
14 19
13 5
12 7
39 31
.0918
[2] (p = .10), interim problem formulation [1] (p = .10) and interim problem formulation [2] (p = .09) approached significance at a 6 .10 (see Table 3). Significant differences between treatment and control groups in the November triple jump were found for issues identification (p = .004), data gathering [1] (p = .05) and interim problem formulation [2] (p = .002) (see Table 2). Only data gathering [4] approached significance at a 6 .10 (see Table 3).
Discussion Other studies have demonstrated improved problem solving skills using PBL (Makhathini and Uys, 1996; Uys et al., 2004; Tiwari et al., 2006). As mentioned earlier, studies indicate that the triple jump is valid in measuring student problem solving capabilities (Makhathini and Uys, 1996; Uys et al., 2004; Callin and Ciliska, 1983). Our study is different, however, because an intervention was introduced into the PBL curriculum to attempt to improve problem solving, as demonstrated by student triple jump scores at the end of each semester. No studies were found that specifically looked at individual elements of problem solving found in the triple jump and therefore it is difficult to compare the results in this study to other studies. Furthermore, the intervention in this study was specifically developed for this School of Nursing year three students and included both a change in process as well as content.
Descriptive data Since no scores reached threshold for data gathering [4] – ‘‘able to state knowledge which guides data collection’’, revised problem formulation [3] – ‘‘ranks patient problems in order of priority, supports ranking and recognizes the inter-relationship among problems’’, and revised nursing intervention [2] – ‘‘identifies interventions which resolve more than one patient problem’’; we conclude that there may be a validity problem with these measures. Upon examination, we discovered that revised problem formulation [3] – ‘‘ranks patient problems in order of priority, supports ranking and recognizes the inter-relationship among problems’’ was attempting to measure too many variables and therefore this item needed amendment to increase the validity and reliability. For the remaining items, we speculate that more emphasis needs to be added on these two processes (stating what guides the data collection and selecting interventions that address more than one patient problem) in the problem based learning tutorials. Although most of the significant differences in means were in the direction that the authors had hoped, this was not the case with item one: issues identification. For this item the 2005 cohort (control) scored significantly higher than the 2006 (treatment) cohort, although students in both cohorts did exceed threshold for this item in the November triple jump. It is possible that that issue identification was not emphasized as much as nursing diagnosis in the early steps of the nine-step
396 process. This speculation needs to be explored by analysing the scores on this component of the triple jump for the 2007 academic year cohort, after greater emphasis is made. Since the intervention included nursing diagnostic skills, it was expected that students’ ability to formulate both an interim and revised problem list using nursing diagnosis, would be significantly different between the control and treatment cohorts. The data seem to indicate that this was the case with the higher mean for the interim problem formulation [2] and revised problem formulation [1] and [2] for the 2006 cohort. These data seem to support the need for a special session such as our intervention, to help students recognize the need to perform nursing diagnosis. The data further supports this conclusion in that mean scores on revised nursing intervention [1]–[3] were higher in the treatment group for both June and November measurements. Based on the overall findings related to student performance on the triple jump, it appears there were generally better problem solving skills in students who had experienced the nine-step problem solving process, as the November 2006 cohort (treatment) reached threshold on 13 of the 16 items (81%) in the triple jump while the November 2005 (control) cohort reached threshold on only ten out of the 16 items (63%). The data suggest that students were better equipped to develop interim and revised patient problems (nursing diagnosis), an element that had been added to the problem solving process at the beginning of semester I in 2006. Furthermore, students appeared to be better able to formulate nursing interventions based on their nursing diagnoses.
Significant differences Although there were few significant differences (a = 0.05) in the distribution of scores between the treatment and control groups, examination of the individual item findings are of interest to us, especially for those items where mean scores were higher on the November triple jump for the treatment cohort. For example, item two: data gathering [1], where 90% of the scores on this item in the control group were three or less while 80% of the treatment group scores were three or above is encouraging. Furthermore, three of the five data gathering items all revealed similar percentage patterns. These findings, in combination with the five findings at 6.10 provide us with the necessary support for further research into the efficacy of these interventions.
M.B. Lee, P. Brysiewicz
Limitations of the study The limitation in this study discussed in this section of the paper. Although students demonstrated limited improvement in their ability to make nursing diagnoses and to intervene appropriately, there is no way to determine how significant the role of the nine-step method was in elevating these scores. The change may be due to something within the treatment cohort. A further limitation may be that two of the authors were facilitators in two of the treatment groups. Furthermore, there is limited training for facilitators who are marking the triple jump assessments. Variations in marking could be a result of inter-rater variability in marking; however, we attempt to overcome this by having multiple markers on the triple jump assessment.
Conclusion and recommendations This study was conducted primarily to determine if adding structure to the PBL process for the acute care clinical course in a third year clinical nursing course would improve student learning and ability to perform the nursing process. The findings indicate that this intervention was moderately effective. In addition, adding information on nursing diagnosis, an element in the nursing process, may have improved student performance on the November triple jump scores. However, one element of the triple jump assessment – issues identification – was problematic for students. This difficulty may have occurred because students were encouraged, not only to become more familiar with a revised problem solving process but also to identify issues using the language of nursing diagnosis. Based on these findings the facilitators in this course will continue to implement this strategy in academic year 2007 and research the effects. In relation to the three triple jump items in which students’ performance did not reach threshold, the authors will emphasize those areas (data gathering [4] and revised nursing interventions [2]) in the tutorial problem solving. With regard to problem formulation [3], this item will be examined and broken down into three separate elements that will be assessed in future triple jumps.
Acknowledgements The authors wish to acknowledge the skilled contribution of Mr. Innocent Myeni, the research assistant on this project. Mr. Myeni was responsible
Enhancing problem solving and nursing diagnosis in year III Bachelor of Nursing students for the data entry and preliminary analysis of the data.
References Alexander, J., McDaniel, G., Baldwin, M., 2005. If we teach then to fish: solving real clinical problems through problem based learning. Annual Review of Nursing Education 3, 109–123. Anderson, K.N. (Ed.), 1998. Appendix 19: Nursing Diagnoses. In Medical, Nursing, and Allied Health Dictionary, fifth ed. Mosby, Louis, Mo, pp. 1975–2035. Axelsson, L., Bjorvell, C., Mattiasson, A.C., Randers, I., 2006. Swedish registered nursing incentives to use nursing diagnoses in clinical practice. Journal of Clinical Nursing 15, 936– 945. Benson, G., Nosegaard, C., Drummond-Young, M., 2001. Facilitating small group learning in problem-based learning. In: Rideout, E. (Ed.), Transforming Nursing Education through Problem Based Learning. Jones & Bartlett, Sudbury, pp. 75–102. Bonawit, V., Nolan, A., 1989. Nursing diagnosis: educational workshops to promote skill and inter-rater reliability. Australian Journal of Advanced Nursing 6 (2), 29–34. Brysiewicz, P., Lee, M.B., submitted for publication. Nursing students’ evaluation of the introduction of nursing process/ nursing diagnosis focused tutorials in a South African university degree programme. Curationis (SA Nursing Journal). Burkhart, L., 2006. Integrating NNN into nursing education: a case study. International Journal of Nursing Terminologies and Classifications 17 (1), 22. Callin, M., Ciliska, D., 1983. Revitalizing problem solving with triple jump. Canadian Nurse 79, 41–44. Cholowski, K.M., Chan, L.K.S., 2004. Cognitive factors in student nurses’ clinical problem solving skills. Journal of Evaluation in Clinical Practice 10 (1), 85–95. Clarke, M., 1986. Action and reflective practice and theory in nursing. Journal of Advanced Nursing 11, 3–11. Doenges, M.E., Moorhouse, M.F., 2003. Application of Nursing Process and Nursing Diagnosis: An Interactive Text for Diagnostic Reasoning, fourth ed. F.A. Davis Company, Philadelphia.. Easton, V.J., McColl, J.H., 2007. Statistics Glossary V1.1. Accessed December 12, 2007. . Erdemir, F., Altun, E., Geckil, E., 2003. Nursing students’ selfassessments and opinions about using nursing diagnosis in clinical practice. International Journal of Nursing Terminologies and Classifications 14 (Suppl 4), 34. Higuchi, K.A.S., Donald, J.G., 2002. Thinking processes used by nurses in clinical decision making. Journal of Nursing Education 41 (4), 145–153. Hogston, R., 1997. Nursing diagnosis and classification systems: a position paper. Journal of Advanced Nursing 26, 496. International Council of Nurses, 2007. December 2007 ICNP Bulletin. Accessed July 1, 2008. . Jaco, M.K., 2003. Nursing rounds link nursing diagnoses to clinical practice. International Journal of Nursing Terminologies and Classifications, October–December. Accessed
397
07/17/07.. Tiwari, A., Lai, P., So, M., Yuen, K., 2006. A comparison of the effects of problem-based learning and lecturing on the development of students’ critical thinking. Medical Education 40, 547–554. Uys, L.R., van Rhyn, L.L., Gwele, N.S., McInerney, P., Tanga, T., 2004. Problem-solving competency of nursing graduates. Journal of Advanced Nursing 48 (5), 500–509. Volpato, M.P., 2003. Nursing diagnosis in medical–surgical patients. International Journal of Nursing Terminologies and Classifications, October–December. Accessed 07/17/07.
Available online at www.sciencedirect.com
Nurse Education Today www.elsevier.com/nedt
Enhancing problem solving and nursing diagnosis in year III Bachelor of Nursing students Marilyn B. Lee
a,*
, Petra Brysiewicz
b
a
College of Nursing and Allied Health, University of North Alabama, One Harrison Plaza, Box 5124, Florence, AL 35632, United States b School of Nursing, University of KwaZulu-Natal, Durban, South Africa Accepted 18 October 2008
KEYWORDS
Summary
Problem solving; Nursing diagnosis; Triple jump; Nursing education
Background: The School of Nursing in which this research was conducted uses a problem based learning approach in clinical nursing courses. Although the skills required for problem solving, and those in nursing care planning, are similar and therefore, support each other in the learning environment, there is limited evidence of the effectiveness of this teaching strategy on problem solving and nursing care planning. Aim: The aim of this study was to implement a change in the clinical nursing course in the third year of the Bachelor of Nursing (BN) programme and determine if this change improved students’ problem solving and care planning. Method: A nine-step problem solving process to deal with problem scenarios was introduced. We hoped that consistent use of this systematic process would improve students’ problem solving and care planning skills in the classroom and the clinical area. In order to determine change in problem solving and care planning skills we compared (a) the previous third year student performance on semester I and II assessments with those of the study participants and (b) results at the end of semester I with end of semester II within the study cohort. Findings from these analyses are presented in this paper. c 2008 Elsevier Ltd. All rights reserved.
Background of the study
* Corresponding author. Tel.: +1 256 366 8259; fax: +1 256 765 5002. E-mail address: [email protected] (M.B. Lee).
In this paper, a study to explore the influence of an educational intervention expected to improve student problem solving and nursing diagnosis skills, is described and recommendations are made for future third year clinical courses.
0260-6917/$ - see front matter c 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2008.10.008
390
Problem solving and nursing diagnosis Teaching nursing students how to use the nursing problem solving process (nursing process) is critical to their ability to provide quality nursing care (Mu ¨ller-Staub et al., 2007c; Burkhart, 2006; Volpato, 2003; Mu ¨ller-Staub et al., 2007). Higuchi and Donald (2002) agree that nurses need complex thinking processes, as well as psychomotor and affective skills, in order to be expert clinical practitioners. An important component of the nursing process, which had not been emphasized in the teaching of the students involved in this research, is nursing diagnosis. A nursing diagnosis is a standardized statement about the health of a client (individual, family, or a community) in order to plan nursing care (Anderson, 1998; Perry and Potter, 2004). Nursing diagnoses are formulated based on the data discovered during nursing assessment (Doenges and Moorhouse, 2003). Formulating nursing diagnoses requires students to have a good grasp of nursing, social and human sciences as well as competencies such as health assessment, clinical reasoning and ability to integrate knowledge (Burkhart, 2006; Jaco, 2003). Although controversy exists on the usefulness (Hogston, 1997; Junttila ¨ et al., 2006; Olsson and Gardulf, 2006) and the reliability (Bonawit and Nolan, 1989) of nursing diagnosis in nursing practice; in the international nursing community, nursing diagnosis and other classification systems (NIC and NOC) are recognized as potentially valuable in the creation of an international nursing terminology system, as well as improving the quality of documentation (Erdemir et al., 2003; Levin, 2004; Mu ¨ller-Staub et al., 2007c). The International Council of Nurses has collaborated with nurses globally in an effort to develop an International Classification for Nursing Practice (ICNP, 2008) and thus use of nursing diagnoses in this setting might further this initiative. Problem solving in nursing is essential. Some authors have indicated that problem solving is enhanced when supported by a systematic approach, with clear expectations (Zerr, 1990; Newsome and Tillman, 1990; Clarke, 1986; Mu ¨ller-Staub et al., 2007). Smith and Roberts (2007) and others (Alexander et al., 2005; Benson et al., 2001) suggest that use of the problem based learning strategy in the classroom may enhance problem solving and critical thinking in applied sciences education. In order to measure problem solving abilities of students, staff at McMaster University, Canada developed a student assessment tool called the triple jump (Callin and Ciliska, 1983). In this assessment,
M.B. Lee, P. Brysiewicz students are presented with a problem scenario and expected to ask questions related to the scenario in order to assess, formulate nursing diagnoses and determine appropriate interventions. Students are then given time to perform independent study to help them understand the problem(s) better and to evaluate their nursing diagnoses and nursing interventions. Students return to the exam venue to finalize their nursing diagnoses as well as their nursing care plan. Because the BN nursing programme curriculum is problem based, the triple jump is used as one of the student assessment tools at the end of each semester in the third year clinical nursing course. Several studies have used the triple jump as the instrument to measure problem solving. Makhathini and Uys (1996) measured the problem solving ability of diplomats from a basic nursing programme. Uys et al. (2004) evaluated the outcomes of PBL programmes in nursing schools in South Africa in terms of the competence of graduates to solve problems in actual clinical settings, and compared this competence with that of graduates from non-PBL programmes. From our experience it seemed that students had difficulty systematically performing problem solving activities, this was particularly evident in assessment situations, such as with the triple jump. Because of this apparent gap in application of problem solving skills, we initiated a change in the manner in which PBL tutorials were conducted to see if adding more structure and specific content would improve student performance on assessment. In addition to the systematic process introduced (the nine-step process), the authors added content on nursing diagnosis and its relationship to other phases of the nursing process because students were not routinely taught to use this component of the nursing process. This omission resulted in students neglecting to incorporate this component of the nursing process into their nursing care planning as evidenced by tutorial performance and the end of semester triple jump assessments. Furthermore, students struggled with effectively planning nursing care for specific nursing diagnoses because they had minimal experience with linking diagnosis with the other phases of the nursing process.
Methods Problem statement Although students are taught to problem solve through PBL sessions, our students did not seem
Enhancing problem solving and nursing diagnosis in year III Bachelor of Nursing students to correlate the activities in the classroom with end of semester assessment. In addition, students did not formulate nursing diagnoses for their patients and thus had difficulty developing nursing care plans to address specific patient problems.
391
The authors designed this study to answer the following question: Is there a significant difference between the control and treatment group triple jump (problem solving) scores? The following null hypothesis was formulated: there will be no significant difference in the triple jump scores between the control and treatment group.
end in November thus June assessments are before November assessments in each academic year) received an intervention (treatment) and performance on the triple jump was measured. Triple jump scores from the 2005 year three academic year, that received no intervention (control), were then compared to those of the 2006 cohort. It was expected that if there were an improvement in problem solving skills this would be evidenced by higher scores on the triple jump between semesters I and II and the 2005 and 2006 cohorts. Qualitative data were collected on student satisfaction and perception of clinical application of problem solving and nursing diagnoses are reported elsewhere (Brysiewicz and Lee, submitted for publication).
Setting
Nine-step problem solving process
The setting for the study was a moderate size School of Nursing at a large university in South Africa using a problem based approach to nursing education. In South Africa, a number of schools of nursing have adopted PBL and the institution in which this study was conducted introduced PBL in 1994. The nursing programme is structured in such a way that first and second year focuses on healthy individuals, families and communities. The last part of second year exposes the students to primary health care settings. Third year in the programme is hospital-based acute care and fourth year is the year of specialisation in midwifery and mental health nursing. All students are allocated to a small group of around 12 students and usually there are no large group meetings except for orientation purposes. In each semester in year three, one of the primary means of assessment of students’ problem solving is the triple jump.
We designed a four hour teaching programme, taught in two–two hour sessions, to inform students of the systematic problem solving process that would be used in the 2006 PBL tutorials. The first two hours included an introduction to a ninestep process that was to be used in all tutorials for the year. The nine steps included were:
Research question
Population and sample All students in third year PBL tutorials were exposed to a nine-step problem solving process and were instructed on how to formulate nursing diagnoses as a part of their nursing process. Triple jump marks from third year in academic year 2005 (n = 39) were compared with the triple jump marks from third year academic year 2006 (n = 31).
Research design The design used for this study was a quasi experimental design. Students from the year three 2006 academic year (note: In the southern hemisphere, university academic years begin in February and
Step 1: Present a brief description of the patient. Step 2: Allow students in your group to pose hypotheses about what the possible problems are for this patient. Step 3: Allow students to ask you for data based on these hypotheses. Step 4: Facilitate formulation of a revised problem list. This may require you to tell students additional data that was not requested and sharing with them what hypotheses you had for this patient. Step 5: Allow students to ask more questions and to determine a final problem list. These should be in the form of nursing diagnoses, including possible diagnoses and risk diagnoses. Step 6: Determine if you need additional information, i.e., are you able to determine a list of diagnoses that you can support with data? Does the group have any idea of what interventions/nursing actions might be effective to reduce or eliminate the problems? What evidence do they have for this? This is an opportunity to get the group problem solving using information they have learned from a variety of disciplines. Step 7: Present your list of interventions and rationale for them. Students can then question you about these actions. You will be the clinical
392 expert. What evidence do you have that this nursing action decreases the problem you have identified in your nursing diagnosis? Step 8: Determine what data you would need to collect to see if the problem was reduced or eliminated? If the group is unable to assist with this you will provide this along with your rationale. How will you determine if the patient is ready for discharge? What can you do to ensure that the patient is ready for discharge? Step 9: In what other clinical situations might this information be useful? Identify related diagnoses and whether or not nursing actions identified would be useful in these cases.
M.B. Lee, P. Brysiewicz assessment items. Each of the items has a possible maximum score of five and a minimum of zero. The higher the score on each item, the better the performance on that item with regard to problem solving. A maximum total score of 80 would indicate excellent problem solving skills. The assessment corresponds to the nine-step process in the following way (numbers in brackets indicate the number of items on the triple jump that specifically relate to this problem solving component). Issue identification [1] – Steps 1 and 2. Data gathering [5] – Steps 3 and 4. Interim problem formulation [2] – Steps 2, 4, 5 and 6. Initial nursing interventions [1] – Steps 6 and 7. Self-assessment [1] – Step 6 Revised problem formulation [3] – Steps 2, 4, 5 and 6, Revised nursing interventions [3] – Steps 6 and 7.
Most of these nine steps correspond to the assessment areas of the triple jump (Callin and Ciliska, 1983), and it was expected that by following these nine steps problem solving would be improved and that this would be reflected by an increase in overall triple jump scores (Cholowski and Chan, 2004). During the second two hour session the authors included information on the formulation of nursing diagnosis and its relationship to care planning. In the previous years the students in third year had been following a medical model, thus our strategy was a move towards more emphasis on the use of the nursing process and encouraging the students to make use of specific nursing terminology, i.e., nursing diagnosis. It was expected that students who understood the use of nursing diagnosis would perform better on the three questions related to patient problem formulation in the triple jump assessment. It was also hoped that ability to set goals, plan interventions and evaluate their effectiveness would result in overall improvement in problem solving and care planning, reflected by improved overall triple jump scores, as other researchers have found (Pearce et al., 1990; Axelsson et al., 2006; Mu ¨ller-Staub et al., 2007a).
When considering the reliability of the triple jump assessment method, Callin and Ciliska (1983) demonstrated a strong inter-rater correlation (p = 0.91) between the initial tutor who scored the students compared with the scores obtained two to four weeks later by another tutor observing the videotape. The scores obtained at this time were strongly correlated (p = 0.77) (Callin and Ciliska, 1983). In this study a Cronbach’s alpha was calculated for each of the data sets (semesters I and II 2005 and semesters I and II 2006) as well as on the combined triple jump (all assessments in 2005 and 2006). The Cronbach’s alpha for the combined data sets was .864. For each of the individual data sets the Cronbach’s alpha ranged from .721 to .899 (June 2005 = .888; November 2005 = .721; June 2006 = .860 and November 2006 = .899).
Instrument – triple jump
Ethics
The triple jump assessment includes questions that measure students’ ability to identify issues (one question), gather data (five questions), formulate an interim patient problem list (two questions), identify preliminary nursing interventions (one question), perform self-assessment of learning needs (one question), formulate a revised patient problem list based on learning that occurred during independent study in the second step of the triple jump (three questions), identify revised nursing interventions (three questions); for a total of 16
Permission to conduct this research was sought from the Head of School, as well as the university ethics committee. All students willing to participate were provided with a participant information sheet and a written consent form, which students were asked to sign. The information sheet described the purpose of the research as well as the rights of the student to refuse to participate in the research and they were informed and that this would not jeopardize their marks or tutorial participation. The information sheet also contained the
Validity and reliability
Enhancing problem solving and nursing diagnosis in year III Bachelor of Nursing students authors’ contact details should the students require more details regarding the research.
0.5 or less. In addition, a chi square test was conducted to compare the proportion of positive change for the treatment and control groups associated with the total score and each triple jump item. Chi square tests were also conducted to compare the distributions of scores for June 2005 versus June 2006, and November 2005 versus November 2006 in order to assess whether or not control and treatment groups differed significantly in their responses on the triple jump.
Data analysis Data were de-identified and marks for each triple jump item for semesters I and II 2005 and 2006 (two cohorts and four measurements) were entered into Statistical Analysis System (SAS) v 9.1, while the original data were secured with the researchers. The statistical tests utilized in this paper were selected because a general linear model would not be appropriate, since the data are a Likert scale and neither continuous nor normally distributed. The chi square and sign tests are nonparametric procedures. Typically, non-parametric procedures tend to be ‘‘weak’’ procedures (meaning low in statistical power), however, low power tests are not objectionable as long as the test of hypothesis results in the rejection of the null hypothesis. Therefore, sign and chi square tests were used (Easton and McColl, 2007). Using a simple sign test a comparison of marks between semesters I and II of 2005 was performed to determine if there was a significant tendency for scores to change in a positive direction. A similar analysis was performed for the 2006 data. This analysis determines if in fact there is a tendency for positive change to occur, if there is this tendency then the proportion would tend to be greater than 0.5, otherwise, the true proportion would be
Table 1
Results Descriptive data A total of 140 triple jump scores [June 2005 (n = 39), November 2005 (n = 40), June 2006 (n = 31) and November 2006 (n = 30)] were compared both on total and individual item scores. The mean scores and standard deviation for each measurement are displayed in Table 1. Using a mean of >3.0 as the threshold, the items on which the control and treatment cohorts reached this value on all four measurements included: data gathering [1] and data gathering [5]. For the June 2005 cohort (control), students performed best on three items: data gathering [1], data gathering [3] and data gathering [5]. On the final assessment, November 2005 (control), ten items met threshold: issue identification, data gathering [1], data gathering [2], data gathering
Triple jump scores – descriptive statistics (n = 140).
Item
Issue identification Data gathering 1 Data gathering 2 Data gathering 3 Data gathering 4 Data gathering 5 Interim problem formulation 1 Interim problem formulation 2 Nursing intervention 1 Self-assessment Revised problem formulation 1 Revised problem formulation 2 Revised problem formulation 3 Revised nursing intervention 1 Revised nursing intervention 2 Revised nursing intervention 3 3.0.
393
June 2005 (n = 39)
November 2005 (n = 40)
June 2006 (n = 31)
November 2006 (n = 30)
l
SD
l
SD
l
SD
l
SD
2.62 3.18 2.95 3.05 2.13 3.28 2.79 2.56 2.77 2.74 2.67 2.51 2.51 2.41 2.31 2.44
.990 .683 .605 .793 1.42 .724 .732 .821 .931 1.093 .955 .997 .914 .818 .800 .882
3.45 3.03 3.06 3.10 2.19 3.10 3.16 3.00 3.10 3.13 3.39 3.06 2.77 2.94 2.77 2.81
.850 .657 .727 .870 1.64 .908 .820 .683 .700 .670 .844 .772 .920 .814 .845 .703
2.55 3.03 2.78 2.95 2.58 3.20 2.95 2.95 3.20 2.80 3.08 2.50 2.88 2.98 2.65 2.80
.904 .423 .620 .677 1.36 .723 .677 .677 .723 1.02 .656 1.24 .686 .800 .770 .966
3.30 3.13 3.07 3.20 1.93 3.30 3.17 3.60 3.33 3.23 3.20 3.17 2.90 3.13 2.90 3.13
.837 .819 .740 .714 1.62 .837 .834 .814 .711 .817 .761 .913 .995 .681 .662 .571
394
M.B. Lee, P. Brysiewicz
[3], data gathering [5], interim problem formulation [1], nursing intervention [1], self-assessment, revised problem formulation [1] and revised problem formulation [2]. Scores on the triple jump items for the June 2006 cohort (treatment), which occurred four months after the intervention, reached the threshold on four items: data gathering [1], data gathering [5] nursing intervention [1] and revised problem formulation [1]. At the final assessment (November 2006), after a full academic year of experience with the intervention, scores on 13 items reached threshold with only: data gathering [4], revised problem formulation [3] and revised nursing intervention [2] not reaching threshold.
Change in scores The simple sign tests conducted between June and November total and individual item scores between the control and treatment groups were not significant. Differences in change in total scores between the control and treatment group, calculated using the chi square statistic, were also not significant (p = .245). For individual items, change was signif-
Table 2
icant (p = .03) for revised problem formulation [1] with a tendency towards more positive change in the control group.
Test of significance Significant differences (a 6 0.05) in distribution of individual triple jump item scores between treatment and control groups in June and November were calculated using the chi square statistic. A chi square statistic is used to investigate whether distributions of categorical variables differ from one another. Because the number of observations in some categories was too low to justify use of the chi square analysis, pooling of scores was performed with one category including scores of 0, 1 and 2; the second category including the score of 3 and the third category including scores of 4 and 5. The chi square calculation determined that there were significant differences in distribution of scores between the control and treatment group in June on issue identification (p = .001), selfassessment (p = .03), revised problem formulation [1] (p = .02) and revised nursing interventions [1] (p = .05) (see Table 2). Revised nursing interventions [2] (p = .07), revised problem formulation
Significant differences (6.05) identified in chi square statistic.
Item Date
Frequencies 0, 1 and 2
Frequency 3
Frequencies 4 and 5
Total
p
Issue identification June 2005 June 2006
16 4
16 9
7 18
39 31
.0013
Self-assessment June 2005 June 2006
14 3
15 20
10 8
39 31
.0269
Revised problem formulation 1 June 2005 16 June 2006 4
15 14
8 13
39 31
.0223
Revised intervention 1 June 2005 June 2006
21 8
15 17
3 6
39 31
.0469
Issue identification November 2005 November 2006
16 5
19 13
4 13
39 31
.0043
Data gathering 1 November 2005 November 2006
3 6
32 17
4 8
39 31
.0476
24 12
6 17
39 31
.0015
Interim problem formulation 2 November 2005 9 November 2006 2
Enhancing problem solving and nursing diagnosis in year III Bachelor of Nursing students Table 3
395
Significant differences (.06–.10) identified in chi square statistic.
Item Date
Frequencies 0, 1 and 2
Frequency 3
Frequencies 4 and 5
n
p
Interim problem formulation 1 June 2005 15 June 2006 5
17 16
7 10
39 31
.0950
Interim problem formulation 2 June 2005 17 June 2006 7
18 16
4 8
39 31
.0923
Revised problem formulation 2 June 2005 18 June 2006 7
16 16
5 8
39 31
.0964
Revised intervention 2 June 2005 June 2006
23 11
14 14
2 6
39 31
.0675
Data gathering 4 November 2005 November 2006
14 19
13 5
12 7
39 31
.0918
[2] (p = .10), interim problem formulation [1] (p = .10) and interim problem formulation [2] (p = .09) approached significance at a 6 .10 (see Table 3). Significant differences between treatment and control groups in the November triple jump were found for issues identification (p = .004), data gathering [1] (p = .05) and interim problem formulation [2] (p = .002) (see Table 2). Only data gathering [4] approached significance at a 6 .10 (see Table 3).
Discussion Other studies have demonstrated improved problem solving skills using PBL (Makhathini and Uys, 1996; Uys et al., 2004; Tiwari et al., 2006). As mentioned earlier, studies indicate that the triple jump is valid in measuring student problem solving capabilities (Makhathini and Uys, 1996; Uys et al., 2004; Callin and Ciliska, 1983). Our study is different, however, because an intervention was introduced into the PBL curriculum to attempt to improve problem solving, as demonstrated by student triple jump scores at the end of each semester. No studies were found that specifically looked at individual elements of problem solving found in the triple jump and therefore it is difficult to compare the results in this study to other studies. Furthermore, the intervention in this study was specifically developed for this School of Nursing year three students and included both a change in process as well as content.
Descriptive data Since no scores reached threshold for data gathering [4] – ‘‘able to state knowledge which guides data collection’’, revised problem formulation [3] – ‘‘ranks patient problems in order of priority, supports ranking and recognizes the inter-relationship among problems’’, and revised nursing intervention [2] – ‘‘identifies interventions which resolve more than one patient problem’’; we conclude that there may be a validity problem with these measures. Upon examination, we discovered that revised problem formulation [3] – ‘‘ranks patient problems in order of priority, supports ranking and recognizes the inter-relationship among problems’’ was attempting to measure too many variables and therefore this item needed amendment to increase the validity and reliability. For the remaining items, we speculate that more emphasis needs to be added on these two processes (stating what guides the data collection and selecting interventions that address more than one patient problem) in the problem based learning tutorials. Although most of the significant differences in means were in the direction that the authors had hoped, this was not the case with item one: issues identification. For this item the 2005 cohort (control) scored significantly higher than the 2006 (treatment) cohort, although students in both cohorts did exceed threshold for this item in the November triple jump. It is possible that that issue identification was not emphasized as much as nursing diagnosis in the early steps of the nine-step
396 process. This speculation needs to be explored by analysing the scores on this component of the triple jump for the 2007 academic year cohort, after greater emphasis is made. Since the intervention included nursing diagnostic skills, it was expected that students’ ability to formulate both an interim and revised problem list using nursing diagnosis, would be significantly different between the control and treatment cohorts. The data seem to indicate that this was the case with the higher mean for the interim problem formulation [2] and revised problem formulation [1] and [2] for the 2006 cohort. These data seem to support the need for a special session such as our intervention, to help students recognize the need to perform nursing diagnosis. The data further supports this conclusion in that mean scores on revised nursing intervention [1]–[3] were higher in the treatment group for both June and November measurements. Based on the overall findings related to student performance on the triple jump, it appears there were generally better problem solving skills in students who had experienced the nine-step problem solving process, as the November 2006 cohort (treatment) reached threshold on 13 of the 16 items (81%) in the triple jump while the November 2005 (control) cohort reached threshold on only ten out of the 16 items (63%). The data suggest that students were better equipped to develop interim and revised patient problems (nursing diagnosis), an element that had been added to the problem solving process at the beginning of semester I in 2006. Furthermore, students appeared to be better able to formulate nursing interventions based on their nursing diagnoses.
Significant differences Although there were few significant differences (a = 0.05) in the distribution of scores between the treatment and control groups, examination of the individual item findings are of interest to us, especially for those items where mean scores were higher on the November triple jump for the treatment cohort. For example, item two: data gathering [1], where 90% of the scores on this item in the control group were three or less while 80% of the treatment group scores were three or above is encouraging. Furthermore, three of the five data gathering items all revealed similar percentage patterns. These findings, in combination with the five findings at 6.10 provide us with the necessary support for further research into the efficacy of these interventions.
M.B. Lee, P. Brysiewicz
Limitations of the study The limitation in this study discussed in this section of the paper. Although students demonstrated limited improvement in their ability to make nursing diagnoses and to intervene appropriately, there is no way to determine how significant the role of the nine-step method was in elevating these scores. The change may be due to something within the treatment cohort. A further limitation may be that two of the authors were facilitators in two of the treatment groups. Furthermore, there is limited training for facilitators who are marking the triple jump assessments. Variations in marking could be a result of inter-rater variability in marking; however, we attempt to overcome this by having multiple markers on the triple jump assessment.
Conclusion and recommendations This study was conducted primarily to determine if adding structure to the PBL process for the acute care clinical course in a third year clinical nursing course would improve student learning and ability to perform the nursing process. The findings indicate that this intervention was moderately effective. In addition, adding information on nursing diagnosis, an element in the nursing process, may have improved student performance on the November triple jump scores. However, one element of the triple jump assessment – issues identification – was problematic for students. This difficulty may have occurred because students were encouraged, not only to become more familiar with a revised problem solving process but also to identify issues using the language of nursing diagnosis. Based on these findings the facilitators in this course will continue to implement this strategy in academic year 2007 and research the effects. In relation to the three triple jump items in which students’ performance did not reach threshold, the authors will emphasize those areas (data gathering [4] and revised nursing interventions [2]) in the tutorial problem solving. With regard to problem formulation [3], this item will be examined and broken down into three separate elements that will be assessed in future triple jumps.
Acknowledgements The authors wish to acknowledge the skilled contribution of Mr. Innocent Myeni, the research assistant on this project. Mr. Myeni was responsible
Enhancing problem solving and nursing diagnosis in year III Bachelor of Nursing students for the data entry and preliminary analysis of the data.
References Alexander, J., McDaniel, G., Baldwin, M., 2005. If we teach then to fish: solving real clinical problems through problem based learning. Annual Review of Nursing Education 3, 109–123. Anderson, K.N. (Ed.), 1998. Appendix 19: Nursing Diagnoses. In Medical, Nursing, and Allied Health Dictionary, fifth ed. Mosby, Louis, Mo, pp. 1975–2035. Axelsson, L., Bjorvell, C., Mattiasson, A.C., Randers, I., 2006. Swedish registered nursing incentives to use nursing diagnoses in clinical practice. Journal of Clinical Nursing 15, 936– 945. Benson, G., Nosegaard, C., Drummond-Young, M., 2001. Facilitating small group learning in problem-based learning. In: Rideout, E. (Ed.), Transforming Nursing Education through Problem Based Learning. Jones & Bartlett, Sudbury, pp. 75–102. Bonawit, V., Nolan, A., 1989. Nursing diagnosis: educational workshops to promote skill and inter-rater reliability. Australian Journal of Advanced Nursing 6 (2), 29–34. Brysiewicz, P., Lee, M.B., submitted for publication. Nursing students’ evaluation of the introduction of nursing process/ nursing diagnosis focused tutorials in a South African university degree programme. Curationis (SA Nursing Journal). Burkhart, L., 2006. Integrating NNN into nursing education: a case study. International Journal of Nursing Terminologies and Classifications 17 (1), 22. Callin, M., Ciliska, D., 1983. Revitalizing problem solving with triple jump. Canadian Nurse 79, 41–44. Cholowski, K.M., Chan, L.K.S., 2004. Cognitive factors in student nurses’ clinical problem solving skills. Journal of Evaluation in Clinical Practice 10 (1), 85–95. Clarke, M., 1986. Action and reflective practice and theory in nursing. Journal of Advanced Nursing 11, 3–11. Doenges, M.E., Moorhouse, M.F., 2003. Application of Nursing Process and Nursing Diagnosis: An Interactive Text for Diagnostic Reasoning, fourth ed. F.A. Davis Company, Philadelphia.
397
07/17/07.
Available online at www.sciencedirect.com