Problem-solving skills of senior student nurses: an exploratory study using simulation

International Journal of Nursing Studies 37 (2000) 135±143

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Problem-solving skills of senior student nurses: an exploratory study using simulation J.D. Roberts FINS, King's College London, Cornwall House, Waterloo Road, London, SE1 8WA, UK Received 7 January 1999; received in revised form 5 May 1999; accepted 3 August 1999

Abstract The Stages Model of problem-solving as evidenced in the use of the nursing process is the key vehicle for the operationalisation of problem-solving in current nursing practice. An expanded variant of the model formed the theoretical framework for this study which aimed to explore and compare the problem-solving skills of senior student nurses (n = 253) from three pre-registration nurse education programmes (RGN, diploma RN, integrated degree). Students' care planning skills were explored using a video-tape simulation exercise and data were subjected to statistical testing. Findings indicated a large range in the global care plan scores and while performance was similar in a number of areas independent of programme type, certain key di€erences also emerged. The ®ndings are discussed in the wider context of professional education and practice and the potential for further development of problem-solving skills in pre-registration nurse education is explored. # 2000 Elsevier Science Ltd. All rights reserved. Keywords: Problem-solving; Care planning; Pre-registration nurse education; Simulation

1. Introduction E€ective preparation for practice and ®tness for purpose have been recurring issues in the history of preregistration nurse education. The nature of clinical practice has altered in recent years and has been a€ected by a number of developments, not least by the introduction of the nursing process, a variant of the Stages Model of problem-solving (Green, 1966; Hill, 1979). The latter innovation highlighted the need for practitioners to demonstrate the e€ective application of problem-solving skills in practice. Pre-registration nurse education programmes are the chief vehicle for the acquisition and development of such skills in the novice practitioner. This paper describes an exploratory study of the care planning skills of senior student nurses from three

programmes of preparation (RGN, diploma RN, integrated degree). Simulation was the chosen method and the development and use of a video-tape simulation exercise is outlined. Key ®ndings are presented. The article concludes with a discussion of the implications of the ®ndings for nurse education and practice.

2. Review of the literature Higher order thinking, required when faced with challenging problems, arises out of complex mental processes and involves recall, evaluation of possessed knowledge, decision-making and further evaluation of outcomes (Hurst, 1985). In contemporary clinical practice such a process is central to the delivery of e€ective

0020-7489/00/$ - see front matter # 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 7 4 8 9 ( 9 9 ) 0 0 0 6 4 - 4

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nursing care. The role of internal and external factors in determining the performance of higher level cognitive skills is, however, equivocal (Duncan, 1959; Fennema and Carpenter, 1981; Mayer, 1989). Equally, the e€ect of di€erent teaching interventions upon problemsolving skills remains uncertain. Duncan (1959), comparing rote memorisation and process focused methods, suggested that there was little performance di€erence on simple tasks, while, with more complex tasks an understanding of the process of problem-solving proved advantageous. Interestingly, there has been a traditional emphasis in nurse education upon procedures without an understanding of underlying principles (Hollingsworth, 1986). Indeed, Chang and Gaskill (1991) have suggested that this trend may have led nurse teachers to focus on teaching problemsolving as a series of steps to be followed, with the underlying assumption being, that students will be able to apply the procedures to complex clinical problems. Despite variable results, the search for ways of enhancing clinical problem-solving ability has been a consistent feature of the medical and nursing literature in recent years. In contrast to medicine's early emphasis upon information-processing theory, the Stages Model of problem-solving has proved in¯uential in nurse education and practice. Indeed, the nursing process mirrors in its format the Stages Model of problem-solving (Green, 1966; Hill, 1979; Hurst et al., 1991). It consists of four key phases, namely: assessment; planning; implementation; and evaluation. Equally important to the successful implementation of the nursing process in practice are the twin concepts of holism and client participation in care. Empirical work examining the model's use in clinical practice remains, however, limited. The e€ectiveness of the nursing process in practice is in part dependent upon nurses' documentation skills yet de®ciencies in this area are a consistent feature of the literature (Walton, 1986; Coldwell and Page, 1996) and care planning skills in particular have been shown to be variable (Shea, 1986; Davis et al., 1994). The literature to date suggests that the clinical learning environment has a potentially signi®cant role to play in both nurses' perceptions and use of the nursing process (Bowman et al., 1983, 1986; Smith, 1988; Brown, 1989). Furthermore, the nursing process remains the main vehicle for teaching problem-solving in nurse education, despite suggestions that it may not in reality re¯ect the way individuals think (Benner et al., 1996). Equally, few empirical studies exist which seek to compare nurses' use of the Stages Model of problem-solving (Gover, 1971; Reid, 1981; While et al., 1995). The present study sought, therefore, to redress this imbalance.

3. Methodology 3.1. Purpose of the research The aim of the research was to explore and compare the problem-solving skills of senior students. A key objective was an exploration of the care-planning skills of students from three programmes of preparation. 3.2. Sample A purposeful sampling strategy was employed with the recruitment of three institutions providing each type of educational programme (integrated degree, RGN, diploma RN). The nine institutions were located in South East England. The selection of South East England was made on several grounds, these included: the evidence that one-third of all general nurse training for Part One of the Register (RGN) was located in South East England (ENB, 1993) and wider societal cultural di€erences would be minimised, although the researcher was unable to ®nd empirical evidence of locational cultural di€erences between nurse education institutions. The RGN programmes and integrated degree programmes were well established while the diploma RN programmes were in their infancy. The sample population for the research was students in the ®nal three months of their respective nursing programmes leading to Part 1 (RGN) and Part 12 (Adult Nursing) of the Register. The variety of educational attainment is noteworthy, ranging from the DC test to ®rst degree status. The gender distribution of the sample, 91% female (n = 231) and 9% (n = 22) male, re¯ects the female bias of the nursing profession, evidenced in recruitment pro®les irrespective of programme type (Davies, 1995). The total population (n = 410) of the nine programme centres was invited to participate in the study with a response rate of 62% (n = 253). 3.3. Ethical considerations and negotiation of access The RCN guidelines related to research in nursing acted as the framework when addressing ethical issues (RCN, 1997). Informed consent was facilitated by ensuring that all participants received information regarding certain key issues, namely: background to the study; the background of the researcher; the purpose, duration and anticipated bene®ts of the research; procedures in which participants would be involved and use of research ®ndings. Participants were given the option not to participate in the study and were free to withdraw at any time. Ethical clearance for the study was negotiated successfully with the relevant ethics committees. Access was gained through close

J.D. Roberts / International Journal of Nursing Studies 37 (2000) 135±143

liaison with the head of each educational institution followed by collaboration with course leaders. 3.4. Design The study adopted a two phase simulation design. The methods used included a written simulation exercise employed to explore senior students' data acquisition skills (the subject of a future paper), and a video-tape simulation exercise designed to explore senior students' care planning skills. It is the latter which is the focus of the present paper. Impact analysis may be used to assess the e€ect of a programme and other variables upon particular outcomes (Cook and Reichardt, 1979). Such an approach is typically quantitative and was adopted for use in this study.

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phase of simulation development. Production of the 12 min video took place in a skills laboratory over a 2 day period. Trained actors have been shown to simulate diseases/problems to an acceptable degree of realism (Whitehouse et al., 1984) and two actors were, therefore, recruited. Visual ®delity was enhanced by the use of props and background sound. Graphics, title sequences and music were produced separately and incorporated at a later stage. `Ecological' validity, the degree to which study participants found the exercise `realistic' was speci®cally addressed in the pilot study (n = 16). Feedback revealed the scenario to be closely aligned to the practice experience. Furthermore, the 30 minute time frame allocated for formulation of the care plan was acknowledged as realistic given the signi®cant time constraints encountered in practice.

3.5. Video-tape simulation

3.6. Data collection

Development of the video-tape simulation consisted of three di€erent phases: video production; formulation of a model care plan; and development of a scoring grid. The use of simulation does, however, raise a number of methodological challenges, speci®cally, issues associated with ®delity as well as validity and reliability. Fidelity refers to the degree to which a simulation resembles the real life experience (Thorndike, 1971; Norman, 1985). Equally signi®cant is clarity on the part of the researcher regarding research intent, selection of the most suitable simulation for the established goal and identi®cation of the constraints under which participants are to perform (Miller, 1987). Such issues are discussed in detail in an earlier paper (Roberts et al., 1995). An elderly client was chosen as the focus of the exercise to re¯ect demographic and in-patient trends in the United Kingdom (OPCS, 1989, 1994) and thereby enhance content representativeness and relevance (Anastasi, 1976; Messick, 1989). The scenario depicted an interaction between nurse and client in the form of an admission assessment interview. The client, a 77 year old woman was admitted with a history of dizzy episodes, falls, painful knees due to arthritis and constipation. She was anxious regarding her husband, who was an insulin dependent diabetic. The scenario needed to be of sucient complexity to demonstrate discriminatory potential but not disadvantage any one group. Furthermore, when directing the video production it was essential to ensure that cues (verbal and/or nonverbal) related to each of the problems, were accessible to the viewer. In line with earlier studies (McGuire and Babbott, 1967; Dincher and Stidger, 1976; Holzemer and McLaughlin, 1988), content validity was ensured by the use of a criterion group of experts (n = 7) at each

Each participant was given a set of paperwork prior to viewing the video-tape scenario. This consisted of: local nursing history forms for note taking; a blank sheet of A4 paper; and a blank nursing care plan. After viewing the video-tape, study participants were given thirty minutes in which to formulate a care plan. 3.7. Data analysis A two staged approach was adopted when developing the analytical tool, ®rstly, development of a model care plan and, secondly, construction of a scoring grid. The model care plan consisted of nine identi®ed problems each with ®ve subsections: problem identi®cation; aims/goals; nursing actions; rationale; and evaluation criteria. Using the criterion group of experts problems were prioritised and weighted accordingly. A three point weighting scale was devised. The weighting system ensured that the scoring method rewarded those who problem solved eciently and avoided the inclusion of irrelevant and incorrect data. Detailed scoring guidelines were devised to help clarify areas of potential ambiguity. In addition, to prevent rater drift, periodic meetings with an independent researcher were incorporated into the main data analysis period. Problems of interpretation were discussed and guidelines amended as appropriate. Data analysis commenced on completion of data collection using Minitab Statistical Software (Minitab Inc., 1991). The data generated were at the nominal level of measurement and were, therefore. subjected to non-parametric statistical tests, speci®cally, the Kruskal±Wallis and Mann±Whitney U tests and Spearman's rank correlation coecient test (one-sided). The

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conventional level of signi®cance (P < 0.05) was adopted (Siegel and Castellan, 1988; Cohen, 1992). 3.8. Validity and reliability of the video-tape simulation Evidence for the validity and reliability of clinical simulations is variable (McGuire and Babbott, 1967; Holzemer and McGlaughlin, 1988). In this study, issues related to concurrent validity and internal consistency were particularly signi®cant. 3.9. Concurrent validity A number of studies have found the relationship between simulation scores and clinical performance to be equivocal (Donnelly et al., 1974; Holzemer et al., 1986; Padrick, 1990). A positive correlation, however, has been found in other studies (Molidor et al., 1978; Holzemer et al., 1981). In this study, concurrent validity was examined by comparing the rank order of scores of a subset (n = 99) of participant performance on the video simulation exercise with performance as evaluated by non-participant observation in the ward setting utilising a ®fty-three item rating scale (While et al., 1995). The smaller subset were controlled for age (under 25 years), gender (female) and educational background (>1`A' levels). Statistical analysis was computed using Spearman's rank correlation coecient test. The results showed a correlation between the global score for the care plan and the total observation score (rs=0.185; P < 0.05). Using the Spearman's rank correlation coecient test a signi®cant association also emerged between a higher global score for the care plan and a higher observation score for use of the nursing process in planning care in the ward setting (rs=0.181; P < 0.05). 3.10. Internal consistency Estimating the reliability of a simulation exercise of this nature poses problems due to the di€erential weighting of items as well as their interdependent nature (Lewey and McGuire, 1966; McGuire and Babbott, 1967). The most widely used approach to estimating the reliability of such an exercise is the measurement of internal consistency (Frank-Stromberg, 1992). It is most frequently used for cognitive measures when concern lies with the consistency of performance of one group of individuals across items on a single measure. Tests of internal consistency measure the extent to which performance on any one item of an instrument is a good indicator of performance on any other item in the same instrument (Waltz et al., 1991). A tool is said to be internally consistent

Table 1 Cronbach's alpha coecients for subsections of care plan Alpha coecient

Care plan subsection

0.51 0.64 0.48 0.57 0.69

Problem identi®cation Aims and goals Nursing action Rationale Evaluation

or homogeneous, therefore, to the extent that all items measure the same trait. The Cronbach's coecient alpha is a widely used measure of internal consistency. The coecient alpha measures the extent to which any one item within the instrument indicates performance on any other item of that instrument. If an instrument has high internal consistency, items should have similar and relatively high correlations. The technique was used to explore the internal consistency of the simulation scoring system utilising the Statistical Package for the Social Sciences (SPSS, 1990). The simulation exercise yielded a modest total coecient alpha (r = 0.65) using the mean of the ®ve subsection scores. The coecient alphas for the ®ve subsections are set out in Table 1. Ventura et al.'s (1980) criteria of 0.75 was not reached. The results suggest low homogeneity of the subsections within the instrument. This result in turn re¯ects the inconsistency of performance by participants in the exercise. Inconsistency in performance both in subsection performance across problems as well as between subsections and potentially within subsections. Elstein et al. (1978) have referred to this phenomenon as the `content speci®city problem' which has been consistently found across formats (Page et al., 1990). This may be a re¯ection of the contextual nature of clinical problem solving (Benner, 1984; Holzemer et al., 1986). If this is indeed the case, then, as Holzemer et al. (1986) have suggested, existing tests for estimating reliability may not be the most appropriate. It is suggested, therefore. that isolating reliability tests suitable for simulations of this nature requires further consideration.

4. Findings The impact of ®ve key variables were explored, namely: programme of preparation; centre; highest educational quali®cation; excluding graduates from the diploma RN and RGN programmes; and gender. Key ®ndings related to programme are presented in this paper.

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Table 2 Programme of preparation by global care plan score Programme of preparation

Median global score

Minimum global score

Maximum global score

Integrated degree programme (n = 57) Diploma RN programme (n = 111) RGN programme (n = 85)

105.6 96.5 101.6

54.8 22.6 13.6

236.9 193.3 204.0

4.1. Programme of preparation There was a large range in the global care plan scores as indicated in Table 2. The scores ranged from 236.9 to 13.6 and the median global score ranged from 105.6 to 96.5. Integrated degree programme participants achieved the highest median global care plan score and diploma RN programme participants the lowest. This trend was re¯ected consistently throughout the data set with diploma RN participants achieving lower scores in most units of analysis. A number of participants scored zero for individual problems and no participant identi®ed all nine problems. The number of correct problems identi®ed ranged from 8 to 0 with a median of 4, and the highest scores were obtained for the physical rather than the psycho-social domain. The scores acquired for evidence of client participation in care ranged from 8 to 0 with a majority of participants (80%, n = 203) scoring zero. Similarly, the scores for evidence of a holistic approach to care ranged from 6 to 0 and a majority of participants (68%, n = 171) acquired a score of zero. A score for redundant data was acquired by just over half (51%, n = 131) of programme participants. The scores for cited rationale for nursing action ranged from 46.6 to 0 with a median range of 10.6 to 10, indicating a similar level of performance from senior students from the three programmes. Care plan

subsection scores indicated that the highest scores were gained for problem identi®cation as seen in Table 3. The scores ranged from 89.9 to 2 with a median range of 40.5 to 38.1. The highest median score was achieved by students of the integrated degree programme with the lowest median score achieved by the RGN programme students. There was a signi®cant di€erence between the scores of the three programmes of preparation according to the Kruskal±Wallis test (H = 7.63; 2 d.f.; P = 0.02). The Mann±Whitney U test was used to explore this further and revealed a signi®cant di€erence between the scores of the integrated degree and diploma RN programmes (W = 5581.0; P = 0.01) and the integrated degree and RGN programmes (W = 651.0; P = 0.02), with integrated degree participants achieving signi®cantly higher scores in this subsection. There was no signi®cant di€erence, however, between the diploma RN and RGN programme participants (W = 10843.5; P = 0.82). Closely associated with problem identi®cation is the establishment of appropriate aims and goals. As indicated in Table 4, the scores for aims and goals ranged from 33.6 to 0 with a median range of 15.1 to 10. The highest median score was achieved by the integrated degree programme students with the lowest median score being achieved by the diploma RN programme students. The Kruskal±Wallis test revealed a signi®cant di€erence between the scores of the three programmes

Table 3 Programme of preparation by scores gained for problem identi®cation Programme of preparation

Median score

Minimum score

Maximum score

Integrated degree programme (n = 57) Diploma RN programme (n = 111) RGN programme (n = 85)

40.5 39.1 38.1

19.0 2.0 5.9

89.9 75.8 65.8

Table 4 Programme of preparation by scores gained for aims and goals Programme of preparation

Median score

Minimum score

Maximum score

Integrated degree programme (n = 57) Diploma RN programme (n = 111) RGN programme (n = 85)

15.1 10.0 11.0

0 0 0

33.6 27.9 28.3

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Table 5 Programme of preparation by scores gained for evaluation Programme of preparation

Median score

Minimum score

Maximum score

Integrated degree programme (n = 57) Diploma RN programme (n = 111) RGN programme (n = 85)

7.3 8.0 8.0

0 0 0

38.0 37.3 66.0

of preparation (H = 6.51; 2 d.f.; P = 0.01). The Mann±Whitney U test was used to explore this di€erence further and a di€erence emerged between the scores for the integrated degree and the diploma RN programmes (W = 5518.5; P = 0.02) and between the integrated degree and RGN programmes (W = 4610.5; P = 0.03). Integrated degree programme participants achieved signi®cantly higher median scores for this subsection. There was no signi®cant di€erence between the diploma RN and the RGN programmes (W = 10835.0; P = 0.80). The lowest scores were obtained for the evaluation phase of the problem solving process as highlighted in Table 5. The scores ranged from 66 to 0 with a median range of 8 to 7.3. The highest median score was gained by the RGN and diploma RN programmes and the lowest by the integrated degree programme. There was no signi®cant di€erence, however, between the scores of the three programmes of preparation according to the Kruskal±Wallis test (H = 0.40; 2 d.f.; P = 0.82).

5. Discussion While the study ®ndings are of interest, they need to be examined in the context of the acknowledged methodological limitations of the study. The video-tape simulation exercise a€orded the opportunity to explore a situation commonly experienced by nurses in practice. The diculties encountered, however, when constructing and validating a test which seeks to measure nurses' care planning skills are well documented (Gover, 1971; Reid, 1981; Hurst et al., 1991; While et al., 1995). The promising Cronbach's alpha coecient (r = 0.65) for the video-tape simulation, using the mean of the ®ve subsection scores, suggests that further re®nement and testing have the potential to improve the validity of the instrument. The low subsection alpha coecients in particular indicate the need for future tool modi®cation. The diculties associated with the selection of suitable validity and reliability indicators have been a consistent theme in the simulation literature (McGuire and Babbott, 1967; Dincher and Stidger, 1976; Holzemer et al., 1986; Roberts et al., 1992). Further extensive research is required regarding the validity and reliability of simulations before the po-

tential of this research method can be fully exploited. The implications of the study ®ndings and any recommendations are, therefore, tentative in view of these acknowledged limitations. Senior students' care planning skills were variable with inconsistent performance across problems and between subsections. Overall performance was re¯ected in the global care plan scores and there was a large range in the scores obtained, including a number of students scoring zero for individual problems and subsections. The highest scores were gained for problem identi®cation and the lowest for evaluation. Such ®ndings echo those of Hurst et al. (1991) who explored the recognition and non-recognition of problem-solving stages in nursing practice and in which informants (n = 116) failed to discuss the evaluation phase of the process. The inclusion of a rationale section for nursing action within the analytical framework aimed to act as an additional discriminator by exploring senior students' ability to give a reasoned exposition for cited nursing actions. Professional education is concerned with the development within the neophyte of what Jarvis (1983, pp. 64±79) termed the ``knowledge how'' (i.e. the capacity to do) and ``knowledge why'' (i.e. knowledge regarding the underlying rationale). The low scores obtained for this subsection suggest that some senior student nurses had diculty in outlining the rationale underlying prescribed nursing actions, as highlighted in the earlier work of Baumann and Bourbonnais (1982). The performance of students regarding a holistic approach to care is of interest given its centrality in the nursing literature and professional legislation (UKCC, 1986, 1992; Kramer, 1990). This ®nding may re¯ect limited educational input regarding this aspect of patient care. Indeed, Sheehan (1991), in an examination of tutorial and clinical sta€s' (n = 40) understanding of the nursing process, found that a holistic approach was rarely mentioned. Furthermore, Smith (1988) highlighted the gap between rhetoric and practice regarding the operationalisation of a multi-focal approach to care. The development of a holistic approach to care may, however, be a skill which is developed in the light of experience and increased levels of expertise as suggested in the literature regard-

J.D. Roberts / International Journal of Nursing Studies 37 (2000) 135±143

ing expert practice (Benner et al., 1996). In view of this, the current study ®nding may be a re¯ection of the students' novice status. Associated with an individualised and holistic approach to care is the concept of client participation in care (Meyer, 1995; Cahill, 1996). The latter was seldom evident in the present data set. This ®nding is perhaps surprising given current legislation regarding patients' active involvement in care (DH, 1991). Furthermore, the active involvement of clients in all phases of the nursing process is emphasised in the literature (Yura and Walsh, 1978; Brooking, 1986; Meyer, 1995). The ®nding potentially re¯ects students' diculties in consistently and successfully translating theory into practice as ®rst highlighted by Bendall (1975). Equally, it may also indicate a delay in the translation of such recommendations into educational objectives on the part of nurse educationalists providing pre-registration programmes. In this data set, students representing integrated degree programmes achieved the highest median scores in a number of subsections, with statistical analysis revealing signi®cant di€erences in relation to two areas. Their performance was higher for problem identi®cation in comparison to their diploma RN programme (P = 0.01) and RGN programme (P = 0.02) counterparts. They also obtained higher scores for their documentation of aims and goals when compared with students from the diploma RN (P = 0.02) and RGN (P = 0.03) programmes. Interestingly, in a more controlled data subset, which excluded graduates from the RGN and diploma RN programmes, integrated degree programme students achieved signi®cantly higher global care plan scores than diploma RN students (P = 0.01). The study ®ndings potentially re¯ect the nature of undergraduate curricula. Cognitive learning is an essential goal of level 3 curricula (Jinks, 1994) and the HEQC (1996) discussion document clarifying the meaning of `graduateness' referred to ``core skills'' or generic qualities expected in graduates which include problem-solving (p. 6). In view of the aims of degree level curricula, namely, the development of the skills of investigating, questioning, defending and evaluating (Altschul, 1987; Salvage, 1988; Davis and Burnard, 1992; Jones, 1996), the performance of undergraduate students in this study was of interest. Senior students from the diploma RN programme obtained low scores in a number of subsections within the video-tape simulation exercise. The stated aims of the diploma RN programme (UKCC, 1986) include the development of analytical skills. A potential reason for this ®nding may be the more limited opportunity for diplomates to re®ne their care planning skills in the non-institutional setting. Furthermore, changes within the health service, in particular related to skill mix

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(Carr-Hill et al., 1992), mean that opportunities for students to learn by `doing' at the side of an experienced practitioner may be more limited. The RGN programme, in contrast, with its focus upon learning within the clinical setting and signi®cant service contribution (DHSS, 1972; Moores and Moult, 1979), means that participants from such programmes have potentially more opportunity to develop and re®ne their care planning skills than their counterparts on the diploma RN programme. Indeed, Alexander (1983) emphasised the potential for the integration of theory and practice in the use of the nursing process a€orded by the nature of the RGN course design. Furthermore, the focus upon institutional care within the RGN curricula, may also a€ord greater exposure to care planning in the acute sector. Moreover, the cohort size of the RGN programme groups, which did not exceed 35 students in the present study, is a potential strength of such programmes.

6. Conclusions The study ®ndings a€orded useful insights into the care planning skills of senior students from di€erent programmes of pre-registration nurse education. Traditionally nurse education curricula have adopted a content-focused approach, with an emphasis upon teaching facts, concepts and their relationship to particular subject domains (Frost, 1996; Jowett, 1995). Furthermore, course delivery has in the main been teacher-centred. The rapid pace of change, however, soon renders a substantial proportion of speci®c knowledge redundant. Equally, the changing nature of the nursing workforce witnessed in the increased use of support workers employed to deliver `basic' care has resulted in the need for the development of di€erent skills amongst quali®ed practitioners as they move away from direct care delivery towards a more managerial/ supervisory role, with an increased emphasis upon the e€ective planning of care (Ramprogus, 1995; Carlisle et al., 1996). However, ocial concern has been expressed that insucient attention is given to the planning of care on current pre-registration nurse education programmes (DH, 1991). To remedy this situation , an expanded range of learning experiences is required enabling studets to more fully develop generic thinking and problem solving skills. It is only through further empirical study that an enhanced understanding of the theoretical underpinnings of problem solving in nursing practice will emerge. The use of simulation in research of this nature has the potential to provide a standard against which performance may be judged (Spannaus, 1978) and allows for the control of extraneous variables pre-

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sent in the real life situation. While the need for further re®nement of method is acknowledged, it is suggested that the full potential of this research methodology has yet to be realised.

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