Problem-solving tests in nurse education

NURSE EDUCATION TODAY, 1985, 5, 56-62 Longman Group 1985

Problem-solving tests in nurse education Keith Hurst

The nursing process is playing an increasing role in nursing practice, management, research and education. Evidence is put forward to support the view that the success of the nursing process is dependent upon the user's problem-solving ability. The article approaches problem-solving with a theory appropriate to nursing, and deals in particular with the development and use of problem-solving tests. The relevant literature is reviewed, to learn whether the recently introduced patientcentred, problem-oriented, statutory nursing examinations have the ability to measure a nurse's clinical problem-solving skills. Such tests could form part of a nurse teacher's battery of valid and reliable tests of clinical problem-solving. The article goes on to discuss some of the implications for nurse educationists, including 'cognitive styles' and the phenomena of 'market variability'.

INTRODUCTION Nurse education can be divided into two broad categories, namely traditional and progressive education (Hurst 1983). Traditional nurse education is characterised by its teacher centredness and a subject content which is diseaseorientated (Darcy 1980, Darwin 1980, Boylan 1982). Naturally, traditional nursing examinations reflect this disease orientation with the emphasis upon lower-order cognitive skills, for example, knowledge and comprehension, demanded of the examinee for a successful examination outcome. An analysis of all statutory nursing examinations, for the general part of the register, set between the years 1968 to 1978, revealed that most questions were related to one or more diseases which tested the candidate's lower-order thinking skills. K Hurst SRN DN RCNT RNT Cert Ed, Senior Nurse (Research), Central Nottinghamshire Health Authority, Mansfield, Notts

56

Within the last 10 years, nurse educationists have shared an interest in and use of a more learner-orientated teactfing strategy which utilises a patient-centred rather than a diseaseorientated approach (Hollingworth 1979, Cooper 1981, Goble 1981).lOne of the main assumptions of this progressive style of nurse education is that it helps to prepare the learner for the problem-solving demands of the 'nursing process' - which is a systematic method of organising an individual patient's nursing care (Yura & Walsh 1978). Moreover, the success of the 'nursing process' depends upon the nurse's problem-solving ability, since each patient's nursing requirements present to the nursing staff as nursing problems which have to be solved. The various national boards, through their" training syllabuses, circulars and education officers, have not been slow to encourage the development of progressive nurse education. Similarly, these statutory bodies have changed the focus of their examination from the tra-

NURSE EDUCATION TODAY 57

ditional (disease-oriented) type of questioning to a patient-centred, problem-solving slant, in an effort to develop nurse examination which more effectively reflects modern nursing theory and practice. However, it is not yet safe to assume tlmt 'new-style' nurse examinations are a valid indicator of a student nurse's problemsolving ability. Clearly, there is a need for problem-solving tests in nursing. But what are the implications for nurse educators? Can nursing examinations be confirmative tests of problem-solving? If not, what do constitute tests of problem-solving? How are they constructed? How are they marked, evaluated and validated? Such questions can only be answered by appropriate empirical research. On the other hand, many helpful clues can be found within the literature on problem-solving. Some of the evidence is presented here for consideration by the reader.

T o summarise, nursing care organised in the sequence of the 'nursing process' demands that nurses use analytical thinking, make decisions and evaluate nursing interventions based upon observation, biological measurement of and inquiry into their patients' cases. This process approximates the scientific method of solving problems.

Table 1 The problem-solving approach of the "nursing process' compared with the scientific method

An overview of the human problemsolving theory

THE THEORY OF HUMAN PROBLEM-SOLVING

Now that problem-solving has been placed in a nursing context, what remains to be done is to select an appropriate theoretical backcloth t o the notion of problem-solving tests in nursing. Newell & Simon's (1972) theory of human problem-solving is an appropriate framework upon which to build the remainder of this discussion. This theory offers explanations and propositions concerning the relationships between the process of problem-solving and the RELATIONSHIP BETWEEN teaching and evaluation of this process. PROBLEM-SOLVING AND NURSING However, while this article is primarily conBefore the main discussion of problem-solving cerned with evaluating problem-solving, the tests, it may be profitable to expand upon the teaching and learning of problem-solving in role of problem-solving in nursing. Problem- relation to the nursing process is not ignored solving is a form of higher-order thinking but is implicit rather than explicit within the where problem solutions arise out of complex discussion. Similarly, Newell & Simon's theory mental processes involving recall, evaluation of of human problem-solving is not the only emrecalled knowledge, decision-making and fur- pirically based explanation of problem-solving, ther evaluation of outcomes. Waher et al but shortage of time and space limits the (1976) took this definition further by compar- ensuing discussion to their work. The reader ing the problem-solving approach of the 'nurs- who wishes to study this aspect more exing process' with the scientific method of solv- tensively should consult the reference list at the ing problems (Table 1). end of this article.

Stages in the 'nursing process"

Stages in the scientific method

A Assessment and problem definition B Planning and setting objectives C Implementation of nursing care D Evaluating outcome

A Systematic recording B Hypothesis development C Testing D Measuring

A short explanation of Newell & Simon's theory cannot do justice to the authors' original book, which is almost 1000 pages in length. However, the theory's key concepts will be highlighted. Newell & Simon's work is underpinned by what its developers refer to as 'information processing'. Basic~illy this involves cognitive processes such as searching for, retrieving, analysing, deciding about and

58 NURSE EDUCATION TODAY evaluating information. The way these concepts are used to explain human problemsolving behaviour is both interesting and stimulating. Furthermore, in practical terms many nurses would admit that there is more than a hint of similarity between the theoretical concepts described and the dynamics of the nursing process itself. Another interesting feature of Newell and Simon's work is that it fits elegantly into a hierarchical structure of cognitive behaviour. Successful problem-solving is dependent upon lower-order cognitive skills such as knowledge and comprehension (Bloom et al 1956), whereas creativity, the highest form of thinking, relies upon successful problem-solving (Gagn~ 1970). In summary, the theory of human problemsolving, based upon the concept of information processing, provides explanations whether the problems are simple or complex. More specifically, the theory itself is a useful one to explain the 'nursing process' in terms of the process, teaching of and evaluating nursing problemsolving. The main points described here, along with the next section, will contribute greatly to the section on problem-solving tests.

THE PROCESS OF PROBLEM-SOLVING Many workers discuss the process of problemsolving in fairly well-defined stages (Thomson 1959, Newell & Simon 1972, Yura & Walsh 1978), four being a manageable number: 9 Identification of problem 9 Definition of problem and ranking of subproblems 9 Strategies for problem-solving 9 Evaluation and verification of problem solutions. Each of the stages will be discussed briefly. The initial act is to 'fix' the problem (Thomson 1959), that is to focus attention on the problem, and then to identify the problem area, which Newell & Simon refer to as the 'problem space' that has well-defined boundaries (also described as the 'internal task environment'). It is within this 'problem space' that the problem-

solver wiU apply his or her cognitive skills to achieve problem solution. The next phase is an exploration of the field within which the problem exists (Thomson 1959). This 'search' of the problem space enables the worker to analyse the problem and the subproblems and to set up the tentative hypotheses which are to be tested. At this juncture the solver implements one or more problem-solving strategies, for example, simple recall enables the worker to bring back to memory old problem solutions appropriate to the current problem (Yura & Walsh 1978). Alternatively, other cognitive skills may be brought into play. Newell & Simon (1972) asserted that analysis of subgoals, identified within the 'problem space', helps tile solver to generate new information and perspectives which may lead to problem solution. These authors extended this notion of subgoal analysis and placed it into a cyclical or looping process which can best be summariscd as: 1. selection ofsubgoal; 2. application of strategies, for example, recall of previous problem solutions; 3. evaluation of outcome; 4. application of a new strategy, if the outcome is unsuccessful; 5. selection of another subgoal, if the outcome is satisfactory. This cyclical activity is seen to be crucial for successful problem-solving (Gagn6 1966). Other problem-solving strategies which may be employed include trial-and-error and working backwards and forwards through established pathways. Newell & Simon (1972) believe that the more difficult the problem, tile more trial-and-error will be used. Clearly, different strategies involve different time scales an important point when evaluating tests of problem-solving. Similarly, efticicnt problemsolving is more likely when the individual is knowledgeable, intelligent, well motivated and emotionally stable (Gagn6 1966, Raiffa 1970, Newell & Simon 1972). Huckabay (1980) added that the successful problem-solver is one who can define the problem and link the relevant information, points which have implications too for the construction of problemsolving tests.

NURSE EDUCATION TODAY 59 The 'cyclical looping' of problem-solving strategies is continued until the final solution is achieved or, alternatively, the problem is abandoned. In tile event of a successful outcome, the process goes further than just problem resolution. Gagn6 (1966) explained how it is that successful outcomes are highly resistant to forgetfulness. Furthermore, solutions become easily transferable; Newell & Simon (1972) suggested that successful outcomes are open to extension, refinement and embellishment. In summary, the problem-solving process can be conveniently described in four stages, although the dividing line between some of the stages is blurred. The key processes in problemsolving are 'fixation' and 'identification' of the problems; 'boundaries' which confine the 'problem space'; tlle solver identifies 'problems', 'subproblems', 'goals' and 'subgoals' to which problem-solving 'strategies', for example 'looping', are applied. Once a solution to the problem is achieved, the outcome is evaluated and often remembered and may be recalled for application in similar circumstances, a process called 'transferring'. It is plain that much can be learned from tile process of problem-solving and, what is more important, applied to all aspects of-the nursing process.

EVALUATING PROBLEM-SOLVING Tile preceding discussion, although sometimes detailed and lengthy, is crucial to what is the

main subject of this article - the development of problem-solving tests appropriate to nursing. Within the nursing curriculum tile nurse teacher generally has a free hand in selecting the teaching method to put over nursing theory, but on the matter of evaluating nursing attainment she or he is constrained (for the next few years at least) by the statutory nursing examinations supervised by the various national boards. Using Bloom's taxonomy to represent the cognitive skills measured in nursing, Table 2 shows how nursing examinations attempt to determine a student nurse's abilities. Several points can be drawn from this table. First, it emphasises the hierarchical nature of Bloom's taxonomy. Secondly, it indicates the extent to which 'new style' (patient-centred and problem-orientated) examinations involve all six levels of Bloom's taxonomy when the questions are compared with the semantic stipulations for each category as set out by Bloom et al (1956). More specifically, 'knowledge' (of facts, principles, categories and structures) is measured by all three types of tests. 'Comprehension' (an understanding of what is being communicated) too has to be demonstrated by the candidate in all three tests. Thirdly, 'application' (of rules, principles and methods) is necessary for success in all three tests. The next category, 'analysis' (the breakdown of communications into their constituent elements), is required for success in 'new style' examinations and, to a lesser extent, in traditional nursing examinations and in multiple choice

Table 2 The relationship b e t w e e n Bloom's t a x o n o m y and nursing examinations Statutory nursing examinations

Bloom's taxonomy 1 2 3 4 5 6

Knowledge Comprehension Application Analysis Synthesis Evaluation

Key:

Traditional examinations

"New style' examinations

Multiple choice questions

+++ +++ +++ + +

+++ +++ +++ +++ +++ +++

+++ +++ +++ ++ + +

+Features superficially; ++Features occasionally; +++Features consistently.

60

NURSE EDUCATION TODAY

questions. 'Synthesis' (building new information from parts) is only minimally involved in 'traditional' tests and is necessary in only a few multiple choice questions (typically those based upon a patient profile), while much synthesis of information is necessary in 'new style' examinations. Finally, 'evaluation' (judging criteria) is barely a requirement for multiple choice questions, whereas there is a heavy demand for evaluation skills in 'new style' examinations. Clearly, 'new style' examinations are comprehensive in terms of Bloom's taxonomy and would seem to have the potential to provide a valid, academic criterion of potential problemsolving in the clinical situation. However, there is as yet little evidence of their validity, reliability, sensitivity and usability to hand. What other, evidence is available to help construct tests of problem-solving? Newell & Simon (1972) suggested that problem-solving can be assessed by one or more of the .following methods: 1. analysing the success (or failure) of the outcome; 2. measuring the length of time taken to solve the problem or subproblems; 3. assessing the quality of solutions; 4. analysing the problem-solving strategies; 5. assessing the number and type of subproblems analysed, that is, the amount by which the 'problem space' has been reduced. An inspection of 'new style' examinations shows that one or more of the above methods is/are included in the fabric of the questions and additionally in the marking and grading of answers to this type of question. Moreover, Huckabay (1980) insisted that tests which purport to measure problem-solving skills must utilise the concepts described in the theory of human problem-solving, that is presentation of main problems and subproblems, provision of opportunities for lower-order thinking (in terms of Bloom's taxonomy) for transfer of learning and for furnishing of appropriate cues, stimuli and guidance. Thomson (1959) added that the test problem should be well defined. These points too are evident in the 'new style'

examinations, which further strengthens the belief that such questions test problem-solving ability. Finally, there is plenty of evidence in the literature covering problem-solving to justify the choice of the nursing examination boards for patient-centred, problem-orientated questions to measure the finalist student nurse's problem-solving ability appropriate to modern nursing. However, two more variables warrant discussion before this article is completed and these are taken up in the next section.

PERSONALITY FACTORS AND PROBLEM-SOLVING Hilgard et al (1971) identified five broad components of personality: iX Morphological and physiological aspects B Intellectual and other abilities C Motivational disposition and needs D Expressive and stylistic traits E Interests, values and social attitudes. Clearly, the discussion so far has concentrated upon (B) in the above list. However, although Newell & Simon (1972) asserted that all human problem-solvers have basic organisational features, that is identical memory parameters and other common characteristics, they are still capable of arbitrary problem-solving behaviour. Faced with the same task, solvers may show: (a) similar problem-solving strategies and achievement of solutions; (b) similar strategies with only some solvers achieving solutions; (c) dissimilar strategies with or without arriving at a solution. Tile authors cited above suggested that the reason for these differences is partly genetic and partly environmental. Other workers discuss these differences in problem-solving ability in terms of (D) in Hilgard's list, which are known collectively as cognitive styles (Hilgard 1971). Partridge (1983) defined cognitive styles as individual perceptions of and responses to the environment. From a review of the literature, the writer identified a total of 15 cognitive styles. However, Basset (1978) narrowed the

NURSE EDUCATION TODAY 61 list down to six categories: 1. 2. 3. 4. 5. 6.

Mode of responsiveness Sensory orientation Thinking patterns Field dependence/independence Mode ofcategorisation Thought structure.

On the other hand,.Gagn6 (1970) discussed these individual differences of thinking styles directly in relation to problem-solving. His classification highlights categories in which individuals show differences in: a) storing rules - involving aspects of long and short term memory; b) ease of recall - recalling appropriate information rapidly; c) distinctiveness of concept - ability to define problems; d) fluency of hypothesis - ability to form testable propositions relevant to the problem; e) matching of specific instances to a general class. Clearly, Gagn6's classification is both more manageable and more appropriate in terms of problem-solving. It becomes obvious that because of these differences learners will perform differently in tests of problem-solving. This raises some questions. Are problem-solving tests measuring more than intellectual abilities? Furthermore, is it possible to predict which nurses will become effective problem-solvers once their preferred learning styles have been identified? The area is open for further study.

THE CHOICE BETWEEN RECOGNITION TESTS AND SUPPLY TESTS From the evidence provided earlier it appears that 'new style' tests have the potential to measure a student nurse's problem-solving ability. However, when supply tests are used, they attract several criticisms and one of the most crushing of these is the criticism of the subjectivity which creeps into the marking system.

More specifically, the range of marks awarded to the same answer by different markers can vary considerably (Husband 1976, Gronlund 1981). Clearly, the objective of the test is to measure problem-solving ability, but its validity is in question for the wrong reasons. However, there are methods which help to overcome these worries and they include markers' guides and assessing a known group of markers using intermarking reliability. A more extreme solution would be to abandon supply tests in favour of recognition tests, for example, using multiple choice questions particularly seqdenced MCQs. The use of MCQs to measure higher-order thinking has many supporters (De Tornyay 1968, Bligh 1971, Gronlund 1981). On the other hand, such tests attract criticism too. The discussion of multiple choice questions will end at this point, since the subject forms a separate topic in this series of evaluation in nurse education. In summary, then, evaluating problemsolving introduces variables other than aspects of test validity and reliability. These variables fall on either side of the dividing line between the examiner and examinee. In the case of tile latter, individual differences in thinking styles decree how individuals tackle and perform on such tests; the person constructing these tests should be aware of this point. Finally, individual differences in the assessor's ability in marking and grading of answers to tests of problem-solving can make a mockery of test validity.

CONCLUSION This review of some of the literature relating to human problem-solving has approached problem-solving with a theory appropriate to nursing practice and management, and particularly to nurse education. It should suggest some clues as to why tests of problem-solving are important in nursing education and how such tests might be constructed and evaluated. This aspect of nursing is under-researched and is crying out for further examination and investigation.

62 NURSE EDUCATION TODAY

Acknowledgements The author would like to thank the following people for their assistance: Mr D J Brotherhood, ,Mrs C Bowler, Mrs A Dean, *lr H I Day, Miss C P ,McCalman, Dr V Reed, M r J Sheehan.

References Basset G W" 1978 Individual differences; guidelines for educational practice. Allen & Unwin, London Bligh D A 1971 What's the use of lectures? University Teaching Methods Unit, London Bloom B, Englehart M, Furst E, Hill W, Krathwol D 1956 Taxonomy of educational objectives. Handbook 1: Cognitive domain. Longman, London Boylan A 1982 The nursing process and the role of tile registered nurse. Nursing Times 78(34): 1443-1444 Cooper S S.1981 Methods of teaching revisited - case study method. Journal of Continuing Education in Nursing 12(5): 32-36 Darcy P T 1980 The nursing process - a base for all developments. Nursing Times 76(20): 497-500 Dare,fin J 1980 Obedience is not enough. Nursing Mirror 151(14): 32-34 De Tornyay R 1968 Measuring problem-solving skills by means of the simulated clinical nursing problem-solving test. Journal of Nursing Education 7(3): 3-38 Gagn6 R 1966 Human problem-solving. In: Kleinmuntz B (ed) Problem-solving research methods and theories. Wiley, New York

Gagn6 R 1970 The conditions of learning, 3rd edn. Holt Rhinehart & Winston, New York Goble I W J 1981 Educating the professional nurse of tomorrow ... today. Nursing Times 77(17): 746-748 Gronlund N E 1981 Measurement and evaluation in teaching. Collier-Macmillan, London Hilgard E R, Atkinson R C, Atkinson R L 1971 Introduction to psychology, 5th edn. Harcourt Brace Jovanovich, New York Hollingsworth S 1979 Teaching the nursing process, a challenge for nurse teachers. Nursing Times 75(30): 1263 Huckabay L M 1980 Conditions of learning and instruction; modutarised. Mosby, St Louis Hurst K 1983 An experimental method of comparing traditional and progressive teaching strategies in student nurse education. Unpublished dissertation, Sheffield City Polytechnic Husbands C T 1976 Ideological bias it) the marking of examinations: a method of testing for its presence and its implications. Research in Education 15:17-38 Newell A, Simon H 1972 Human problem-solving. Prentice-Hall, Englewood Cliffs, NJ Partridge R 1983 Learning styles: A re~icw of selected models. Journal of Nursing Education 22(6): 243-248 Raiffa H 1970 Decision analysis. Addison-Wesley, Cambridge, Mass Thomson R 1959 Psychology of thinking. Penguin, Harmondsworth Walte~-J B, Pardee G P, Melbo D M 1976 The dynamics of problem-orientated approaches. Lippincott, Philadelphia Yura H, Walsh M 1978 The nursing process. Prentice Hall, London