Journal of Nursing Education

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Experiences in problem-solving for the baccalaureate student in nursing

Amelia J Barbus; Kathryn L Carbol

Abstract

The ability of the human being to identify his problems, approach them systematically, and make wise decisions has been basic to his survival. Although the concept of problem-solving is not new, greater emphasis has been placed on it recently, in academic circles, as a teaching process. The Department of Baccalaureate and Higher Degree Programs of the National League for Nursing recommends that the curriculum for baccalaureate programs include, among others, learning experiences that develop in students the following competencies:

. . . ability to analyze a nursing problem, to select and apply relevant knowledge, and to use appropriate methods with skill and understanding and suitable adaptation to the situation and the total nursing needs of the patient or family.1

A specific objective of the general and basic baccalaureate programs of the College of Nursing, Wayne State University, is the development of understanding and skills basic to self-direction and critical thinking. If we expect the professional nurse to assume a problem-solving approach to nursing situations and to initiate appropriate action, we must provide experiences vital to the development of these skills. Traditionally, many educational programs in nursing have not been successful in providing experiences that enable the student to acquire problem-solving skills. A recent study by the Institute of Research and Services in Nursing Education at Columbia University supports this statement.2 This study gives evidence that the professional nurse respondents demonstrated a pronounced deficit in the application of problem-solving skills.

What is problem-solving? The term is often used loosely and holds varied meanings for different people. We believe it is a process in which one assesses a situation, recognizes that a problem exists, defines the problem, considers relevant and pertinent facts, weighs the consequences of several choices of action, makes a judgment, and proceeds to test it. Evaluation of the results follows, and the conclusion serves as a basis for future application. According to Mills and Dean, certain conditions are required in the teaching of problem-solving. These conditions are:

1. The problem to be solved is adapted to the maturity and experience of the students.

2. The students have had analogous previous experience and must possess related information needed for the solution or they must know how to proceed to get this information.

3. The students are interested in solving the problem.3

The students in the basic program at Wayne State University are introduced to the problem-solving process in their first clinical experience. Throughout each subsequent experience they are guided in the further development of skill in problem-solving. The following example illustrates one student's approach to a nursing situation.

The student was involved in giving back care to an elderly patient who had had two thoracenteses on the right side and a drainage tube inserted on the left side. Through interview she learned that the patient was extremely weak, could not turn comfortably to either side, and could not assume the supine position because it interfered with her breathing. In addition, the pain involved in turning over eliminated the possibility of the prone position. One choice of action would be to have the patient sit up, but this would probably be tiring for the patient as well as for the nurse. In addition, care given in this way generally is inadequate. The student considered each of these approaches, relating the present experience to her knowledge of medicalsurgical nursing. She remembered that a patient who has had a thoracentesis is usually more comfortable when lying on the affected side since this position helps to splint the chest and lessen pain. Other factors considered by the student were the use of pillows for…

The ability of the human being to identify his problems, approach them systematically, and make wise decisions has been basic to his survival. Although the concept of problem-solving is not new, greater emphasis has been placed on it recently, in academic circles, as a teaching process. The Department of Baccalaureate and Higher Degree Programs of the National League for Nursing recommends that the curriculum for baccalaureate programs include, among others, learning experiences that develop in students the following competencies:

. . . ability to analyze a nursing problem, to select and apply relevant knowledge, and to use appropriate methods with skill and understanding and suitable adaptation to the situation and the total nursing needs of the patient or family.1

A specific objective of the general and basic baccalaureate programs of the College of Nursing, Wayne State University, is the development of understanding and skills basic to self-direction and critical thinking. If we expect the professional nurse to assume a problem-solving approach to nursing situations and to initiate appropriate action, we must provide experiences vital to the development of these skills. Traditionally, many educational programs in nursing have not been successful in providing experiences that enable the student to acquire problem-solving skills. A recent study by the Institute of Research and Services in Nursing Education at Columbia University supports this statement.2 This study gives evidence that the professional nurse respondents demonstrated a pronounced deficit in the application of problem-solving skills.

What is problem-solving? The term is often used loosely and holds varied meanings for different people. We believe it is a process in which one assesses a situation, recognizes that a problem exists, defines the problem, considers relevant and pertinent facts, weighs the consequences of several choices of action, makes a judgment, and proceeds to test it. Evaluation of the results follows, and the conclusion serves as a basis for future application. According to Mills and Dean, certain conditions are required in the teaching of problem-solving. These conditions are:

1. The problem to be solved is adapted to the maturity and experience of the students.

2. The students have had analogous previous experience and must possess related information needed for the solution or they must know how to proceed to get this information.

3. The students are interested in solving the problem.3

The students in the basic program at Wayne State University are introduced to the problem-solving process in their first clinical experience. Throughout each subsequent experience they are guided in the further development of skill in problem-solving. The following example illustrates one student's approach to a nursing situation.

The student was involved in giving back care to an elderly patient who had had two thoracenteses on the right side and a drainage tube inserted on the left side. Through interview she learned that the patient was extremely weak, could not turn comfortably to either side, and could not assume the supine position because it interfered with her breathing. In addition, the pain involved in turning over eliminated the possibility of the prone position. One choice of action would be to have the patient sit up, but this would probably be tiring for the patient as well as for the nurse. In addition, care given in this way generally is inadequate. The student considered each of these approaches, relating the present experience to her knowledge of medicalsurgical nursing. She remembered that a patient who has had a thoracentesis is usually more comfortable when lying on the affected side since this position helps to splint the chest and lessen pain. Other factors considered by the student were the use of pillows for added support, slight elevation of the head of the bed for greater lung expansion, and the use of correct body mechanics for herself.

The next step was to seek the cooperation of the patient and to carry out the nursing measure. Following this, the results of nursing care were evaluated and the student concluded that the patient had been given adequate care.

In the general nursing program the student is introduced to the process of problem-solving during class discussions of nursing situations. Since the general nursing student also has clinical experience in caring for individual patients, she has the opportunity to apply the process much the same as the basic student. Both groups of students acquire further experience in problem-solving in conferences and seminars in which a problem-solving approach is taken to patient situations.

Moving from the simple to the complex, the student is now ready to apply the problem-solving process at another level. It is, in effect, a building-on or developmental process. The steps remain the same, but the situation becomes more complex. Whereas the student previously had used the problem -solving approach in limited situations involving individual patients only, she now has the opportunity to apply her skills in situations involving a greater number of patients and/or personnel. This is the level of problem-solving with which this paper is primarily concerned and is offered as a senior clinical experience for both basic and general nursing students.

The process of problem-solving is discussed at a conference for the purpose of defining in general terms the advanced level of problem-solving and the purpose of this experience for the students. The greater portion of this assignment, however, is carried out in individual conferences. The student is expected to submit a rough draft of the statement of the problem, a working hypothesis or a question to be answered, and some idea of how she intends to investigate it. One of the difficulties that confront us is that students come to the initial conference with a statement which assumes the existence of the problem and the solution for it. They tend, generally, to place greater emphasis on recommendations than on the problem to be studied. For example, a student may feel there is a need for ward clerks before she has actually studied the situation or before the actual need for a ward clerk in that situation has been determined. It is at this point that students gain one of the most important values of this experience. It is often necessary for the instructor to assist the student in recognizing when a problem is too broad or too complex and in taking a related problem and limiting it sufficiently so that it can be studied. This, then, supports one of the required conditions for teaching problem-solving; the adaptation of the problem to be studied to the student's maturity and experience. In addition, the interest of the investigator in a particular problem is of primary importance. It is our belief, therefore, that the ultimate choice of the problem must rest with the student.

Another area in which students require considerable assistance is in the development of a tool for the collection of data. After considerable discussion of the problem, the student is asked to develop a tool, using her working hypothesis as a guide for limiting the study. Following approval by the instructor, the student proceeds to test the tool. Revisions may be necessary before data can be collected. All students require, in varying degrees, assistance in analyzing the data they have collected. Many students have difficulty in formulating relationships that stem direcdy from the major question to be answered. They seem to have a tendency to draw out and emphasize relationships that support preconceived recommendations. With assistance, then, students learn to make recommendations based on an analysis of the findings. The last two steps of problem-solving, namely, implementation and evaluation, are not carried out during this experience. Students are given the opportunity to share their findings in a conference with their classmates and agency personnel. Nursing service agencies have frequently used the recommendations made by students, and, although the students are not present when implementation takes places, we consider it important that they be informed of the agencies' use of previous studies by former students. Needless to say it is paramount that the instructor be enthusiastic about problem-solving for if she, herself, feels the excitement of discovery, this will be communicated to the students. Students have repeatedly stated that while the experience in problem-solving is extremely difficult, it is an experience they consider not only stimulating and rewarding but also essential to professional development.

A number of objectives are achieved through experience in problem-solving. Of particular concern to nurse educators is the need to provide students with a variety of experiences that guide the development of an inquiring mind - the avid desire to know the what, why, and how of nursing problems they encounter. A second purpose is to guide studente in improving their observational skills. Teachers in nursing are often disappointed when students are unable to recall in sufficient detail observations of certain situations. The expectation that students can perceive totally the details of any one situation does not take into consideration that the instructor's perception of the situation is comprehensive because she has made disciplined, purposeful observations before the student has been asked to do so. Observation, to be meaningful, must be purposeful.

Experience in problem-solving also advanced in students a certain objectivity in observation that is difficult to achieve through the usual academic experience. We are pleased when, occasionally, a study points up that the anticipated problem does not exist. Students are disappointed to some extent, but it gives them the opportunity to learn that, in many instances, what may initially appear to be a problem is not a problem when it is studied scientifically. They are cautioned that they are not doing research, which is the highest and most sophisticated level of problem-solving. They learn that their conclusions reflect only limited aspects of a specific situation.

If the upgrading of nursing practice is to be a continuing goal of its practitioners, we need to stimulate in students a dissatisfaction with the status quo. Resistance to change is no myth. The human individual is basically reluctant to change his environment, habits, or practices, or to alter his present comfortable and secure state, Man's resistance to change and his converse desire to improve himself is the core of considerable daily conflict. If we are to continue to make progress in improving patient care we must recognize the destructive and stagnant aspects of "job satisfaction" and contentment with the status quo.

Another value of this experience for students is the discovery that they have the intellectual capability to study a limited problem. They begin to realize that they are able to take an active part in initiating change based on sound observations. The student develops some beginning interest in the relationship between research and nursing practice. At the same time her ability to interpret the broader aspects of reported research improves.

We consider ourselves fortunate to have available for our use progressive nursing service agencies that are eager to improve their services to patients. These agencies have used the findings of studies by students to initiate changes in nursing care of patients, as a tool in the determination of program needs for in-service, in the determination of the value of a need for new equipment before purchasing them in quantity, procedure changes, etc. As a specific example: following a study designed to determine the extent of the knowledge of personnel regarding fire and safety procedures, a planned in-service program, based on deficiencies revealed by the study, was instituted. Further utilization of these studies may be in the area of evaluation. The same study could be repeated at the conclusion of the in-service program in an effort to determine the merit of such a program.

The following is a typical study by a senior baccalaureate student, and it illustrates the application of problem-solving skills in a more complex situation.

I. The Problem

A. Introduction

Complete bed rest is a term familiar to all nurses. It is frequently encountered in nursing and serves as a guide in planning patient care. Several authors of nursing textbooks define complete bed rest to mean that the patient is to remain in bed and is not permitted to exert himself to the slightest degree, for example, to change his position, to feed himself, or to reach for an article on the bedside stand.

This term is not always specifically defined, and various interpretations of complete bed rest are made by hospital personnel. When members of the health team hold divergent views regarding the interpretation of this term, it is obvious that the goal of continuity of care for individual patients cannot be achieved. This study was done to determine how personnel in one general hospital interpreted the order "complete bed rest."

B. Statement of problem

Do nursing and medical personnel have the same interpretation of the physician's order "complete bed rest?"

C. Limitations and scope

This study is concerned only with the physician's order "complete bed rest" and its interpretation by some members of the health team. It is not concerned with the application of the term in relation to specific patients nor with specific diseases. The study will include five members from each of the following groups: physicians, registered nurses, Wayne State University students from the General Nursing Program, licensed practical nurses, student practical nurses, and nurse aides.

D. De finition of terms

Nursing personnel - This term refers to registered nurses (RNs) Wayne State University students (WSUS), licensed practical nurses (LPNs), student practical nurses (SPNs), and nurse aides (NAs).

Physician's order - A written order on the patient's record, dated and signed by the physician.

Complete bed rest - A term which may also be defined as "absolute bed rest." Medical personnel - This term refers to staff physicians and resident physicians.

E. Method

1. Prepare an interview guide for eliciting responses to the following questions:

a. How do you interpret the physician's order "complete bed rest?"

b. How did you arrive at this interpretation?

2. Hold interviews with five members from each of the aforementioned groups.

F. Analysis and interpretation

The general response to the question regarding interpretation of the physician's order "complete bed rest" was that the patient was to remain in bed.

When questioned specifically in relation to permitting the patient to wash his face and hands:

7 of 30 would permit this

1 physician

3 WSU students

1 LPN

1 SPN

1 NA

14 of 30 would not permit this activity

2 physicians

2 RNs

1 WSU student

3 LPNs

4 SPNs

2 NAs

9 of 30 stated it would depend on the patient's condition

2 physicians

3 RNs

1 WSU student

1 LPN

2 NAs

In response to whether or not the patient should be given a complete bath by the nurse:

18 of 30 replied affirmatively

2 physicians

3 RNs

3 WSU students

3 LPNs

4 SPNs

3 NAs

2 of 30 replied negatively

1 physician

1 LPN

2 of 30 nurse aides stated they would ask the head nurse

8 of 30 stated it would depend on the patient's condition

2 physicians

2 WSU students

2 RNs

1 LPN

1 SPN

In response to whether or not the patient should be allowed to feed himself:

10 of 30 replied affirmatively

3 physicians

2 WSU students

2 LPNs

1 SPN

2 NAs

7 of 30 replied negatively

1 RN

1 WSU student

1 LPN

4 SPNs

13 of 30 stated it would depend on the patient's condition

2 physicians

4 RNs

2 WSU students

2 LPNs

3 NAs

In response to whether or not the patient should be allowed to turn himself:

15 of 30 stated they would permit this

4 physicians

2 WSU students

4 LPNs

2 SPNs

3 NAs

4 of 30 would not permit this activity

1 RN

1 WSU student

2 SPNs

11 of 30 stated it would depend on the patient's condition

1 physician

4 RNs

2 WSU students

1 LPN

1 SPN

2 NAs

In response to whether or not the patient should be permitted to reach for articles on the bedside table:

14 of 30 would permit this

3 physicians

2 WSU students 3 LPNs

3 SPNs

3 NAs

4 of 30 would not permit this activity

1 RN

1 WSU student

1 SPN

1 NA

12 of 30 stated it would depend on the patient's condition

2 physicians

4 RNs

2 WSU students

2 LPNs

1 SPN

1 NA

In response to the question, "How did you arrive at this interpretation?" four of the five physicians stated that they based their interpretations on their own judgment. One physician based his interpretation on information received from school, the literature, and on his own judgment. Within the group, four of the five physicians agreed that the patient would be permitted to turn himself. In all other aspects, however, responses varied. Two of the physicians stated they would specify limitations of activities on the order sheet in addition to writing the order "complete bed rest." Two of the physicians would not specifically define limitations, and one of the five physicians would verbally interpret specific limitations to the nurse.

All five registered nurses based their interpretations on their own judgment. Four of the five would consider the condition of the patient before deciding whether he would be permitted to feed himself or to reach for articles on the bedside table. Other responses varied. Two stated they would give the patient a complete bath, but activity in the other areas would be dependent on the patient's condition. One interpreted "complete bed rest" to mean that the patient should do nothing for himself.

All five of the WSU students based their interpretations on their own judgment, and one of the students included school as a source of information. There is a great deal of diversity within thé group. Perhaps one reason for this may be that they are basing their interpretations on information gained from experience in different hospitals.

Three of the five licensed practical nurses based their interpretations on information gained from school, one indicated school plus her own judgment, and one of the five stated she would ask the head nurse. Four of the five would permit the patient to turn himself. Responses to questions relating to other activities varied and were yes or no, with few references to "depending on the patient's condition."

Three of the five student practical nurses based their interpretations on information gained from school, one would use her own judgment, and one would ask the head nurse. Four of the five would give a complete bath, would not permit the patient to wash his face and hands, and would not permit the patient to feed himself. Responses to questions relating to other activities varied and were yes or no, with few references to "depending on the patient's condition."

Four of the five aides based their interpretations on their own judgment. One of the aides arrived at her interpretation from information gained in class. Three stated they would give a complete bath, and two would ask the head nurse before proceeding. Other responses varied and included "depending on the patient's condition" in the aspects relating to permitting him to feed himself, to turn, and to reach for articles on the bedside table. When asked what aspects of the patient's condition they would consider in making their decision, four of the five aides replied that it would depend upon the strength of the patient. He would be permitted to perform these functions if he were physically able to do so.

G. Conclusions and generalizations

The majority of nursing and medical personnel interviewed stateà they would not allow the patient to wash his face and hands.

The majority of nursing and medical personnel interviewed stated they would give the patient a complete bath.

The majority of the personnel interviewed stated that feeding the patient would depend upon his condition.

The majority of the nursing and medical personnel interviewed stated they would allow the patient to turn himself.

The majority of the personnel stated they would allow the patient to reach for articles on the bedside table.

Each physician had a different interpretation for the term complete bed rest. Since this is so, the interpretation that the individual nurse makes may or may not conform to what the physician intended. Nurses and physicians must communicate with each other in order that the approach to care be consistent.

According to Brown:

Messages transmitted in writing are viewed by students of communication as the least effective means of producing understanding. Only when the sender of the message has direct contact with the receiver can he hope to know what the latter hears and understands. Face-to-face interaction is regarded, therefore, as far superior to written communication. . . .4

It is vital that nurses initiate communication with physicians regarding the problems and needs of patients. The professional nurse further has the responsibility to communicate and interpret information to nonprofessional personnel.

A majority of the registered nurses interviewed based their interpretations on their own judgment, and this would be dependent upon the patient's condition. It is to be expected that the RN will have acquired the knowledge, understanding, appreciations, and skills that will enable her to make judgments relating to nursing care. This study did not include the extent to which the registered nurse based her judgment on scientific principles.

A majority of the aides also based their interpretations on their own judgment. According to the response in relation to criteria used in making these judgments, the aides interpreted the condition of the patient on the basis of his strength to manage a particular activity rather than on the acuity of the illness. The limited knowledge of the aide renders her unqualified to make such judgments. It is interesting to note that only two of the five aides would ask the head nurse if the patient should be given a complete bath, and in no other areas of activity would they seek her interpretation and guidance. It would seem that the aide is assuming responsibilities for which she is unprepared and the nurse, perhaps, is not assuming her responsibilities in makjng judgments and in interpreting nursing care for nonprofessional personnel. The total problem of interpretation should be left to either the physician and/or the professional nurse, not to the nonprofessional personnel.

H. Recommendations

It must be remembered that this study dealt with a minimum number of interviews. However, the data point up that a considerable proportion of nursing and medical personnel at one general hospital have various interpretations of the physician's order "complete bed rest." A follow-up pilot study might be done in which a check list of activities is designed and shown on all patient charts to determine the usefulness of the list in defining clearly the various limitations of activity that might be indicated. Such a list might include the various aspects involved in this study as well as bathroom privileges in general, bathroom privileges for bowel movements only, and brushing teeth. The physician would then check all activities permitted the patient. In our opinion it would seem that a check list is less desirable than actual nurse-doctor interaction on problems that affect patient care. Perhaps greater effort ought to be directed toward achieving this end.

Further study is indicated to determine the extent to which the professional nurse bases her judgment for care on scientific principles.

Personnel have indicated that they would consider the condition of the patient in determining nursing care. It would be interesting to learn how frequently personnel take time to evaluate the patient's condition in an effort to determine care.

Further study might also be done to determine specific problems existing in other areas where communication between physicians and nurses is not adequate.

10.3928/0148-4834-19630901-06

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