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Problem Solving in Nursing: Strategies for Your Staff

4 min read • September, 15 2023

Problem solving is in a nurse manager’s DNA. As leaders, nurse managers solve problems every day on an individual level and with their teams. Effective leaders find innovative solutions to problems and encourage their staff to nurture their own critical thinking skills and see problems as opportunities rather than obstacles.

Health care constantly evolves, so problem solving and ingenuity are skills often used out of necessity. Tackling a problem requires considering multiple options to develop a solution. Problem solving in nursing requires a solid strategy.

Nurse problem solving

Nurse managers face challenges ranging from patient care matters to maintaining staff satisfaction. Encourage your staff to develop problem-solving nursing skills to cultivate new methods of improving patient care and to promote  nurse-led innovation .

Critical thinking skills are fostered throughout a nurse’s education, training, and career. These skills help nurses make informed decisions based on facts, data, and evidence to determine the best solution to a problem.

Problem-Solving Examples in Nursing

To solve a problem, begin by identifying it. Then analyze the problem, formulate possible solutions, and determine the best course of action. Remind staff that nurses have been solving problems since Florence Nightingale invented the nurse call system.

Nurses can implement the  original nursing process  to guide patient care for problem solving in nursing. These steps include:

• Assessment . Use critical thinking skills to brainstorm and gather information.
• Diagnosis . Identify the problem and any triggers or obstacles.
• Planning . Collaborate to formulate the desired outcome based on proven methods and resources.
• Implementation . Carry out the actions identified to resolve the problem.
• Evaluation . Reflect on the results and determine if the issue was resolved.

How to Develop Problem-Solving Strategies

Staff look to nurse managers to solve a problem, even when there’s not always an obvious solution. Leaders focused on problem solving encourage their team to work collaboratively to find an answer. Core leadership skills are a good way to nurture a health care environment that supports sharing concerns and  innovation .

Here are some essentials for building a culture of innovation that encourages problem solving:

• Present problems as opportunities instead of obstacles.
• Strive to be a positive role model. Support creative thinking and staff collaboration.
• Encourage feedback and embrace new ideas.
• Respect staff knowledge and abilities.
• Match competencies with specific needs and inspire effective decision-making.
• Offer opportunities for  continual learning and career growth.
• Promote research and analysis opportunities.
• Provide support and necessary resources.
• Recognize contributions and reward efforts .

Embrace Innovation to Find Solutions

Try this exercise:

Consider an ongoing departmental issue and encourage everyone to participate in brainstorming a solution. The team will:

• Define the problem, including triggers or obstacles.
• Determine methods that worked in the past to resolve similar issues.
• Explore innovative solutions.
• Develop a plan to implement a solution and monitor and evaluate results.

Problems arise unexpectedly in the fast-paced health care environment. Nurses must be able to react using critical thinking and quick decision-making skills to implement practical solutions. By employing problem-solving strategies, nurse leaders and their staff can  improve patient outcomes  and refine their nursing skills.

Images sourced from Getty Images

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What is Critical Thinking in Nursing? (With Examples, Importance, & How to Improve)

Successful nursing requires learning several skills used to communicate with patients, families, and healthcare teams. One of the most essential skills nurses must develop is the ability to demonstrate critical thinking. If you are a nurse, perhaps you have asked if there is a way to know how to improve critical thinking in nursing? As you read this article, you will learn what critical thinking in nursing is and why it is important. You will also find 18 simple tips to improve critical thinking in nursing and sample scenarios about how to apply critical thinking in your nursing career.

What is Critical Thinking in Nursing?

4 reasons why critical thinking is so important in nursing, 1. critical thinking skills will help you anticipate and understand changes in your patient’s condition., 2. with strong critical thinking skills, you can make decisions about patient care that is most favorable for the patient and intended outcomes., 3. strong critical thinking skills in nursing can contribute to innovative improvements and professional development., 4. critical thinking skills in nursing contribute to rational decision-making, which improves patient outcomes., what are the 8 important attributes of excellent critical thinking in nursing, 1. the ability to interpret information:, 2. independent thought:, 3. impartiality:, 4. intuition:, 5. problem solving:, 6. flexibility:, 7. perseverance:, 8. integrity:, examples of poor critical thinking vs excellent critical thinking in nursing, 1. scenario: patient/caregiver interactions, poor critical thinking:, excellent critical thinking:, 2. scenario: improving patient care quality, 3. scenario: interdisciplinary collaboration, 4. scenario: precepting nursing students and other nurses, how to improve critical thinking in nursing, 1. demonstrate open-mindedness., 2. practice self-awareness., 3. avoid judgment., 4. eliminate personal biases., 5. do not be afraid to ask questions., 6. find an experienced mentor., 7. join professional nursing organizations., 8. establish a routine of self-reflection., 9. utilize the chain of command., 10. determine the significance of data and decide if it is sufficient for decision-making., 11. volunteer for leadership positions or opportunities., 12. use previous facts and experiences to help develop stronger critical thinking skills in nursing., 13. establish priorities., 14. trust your knowledge and be confident in your abilities., 15. be curious about everything., 16. practice fair-mindedness., 17. learn the value of intellectual humility., 18. never stop learning., 4 consequences of poor critical thinking in nursing, 1. the most significant risk associated with poor critical thinking in nursing is inadequate patient care., 2. failure to recognize changes in patient status:, 3. lack of effective critical thinking in nursing can impact the cost of healthcare., 4. lack of critical thinking skills in nursing can cause a breakdown in communication within the interdisciplinary team., useful resources to improve critical thinking in nursing, youtube videos, my final thoughts, frequently asked questions answered by our expert, 1. will lack of critical thinking impact my nursing career, 2. usually, how long does it take for a nurse to improve their critical thinking skills, 3. do all types of nurses require excellent critical thinking skills, 4. how can i assess my critical thinking skills in nursing.

• Ask relevant questions • Justify opinions • Address and evaluate multiple points of view • Explain assumptions and reasons related to your choice of patient care options

5. Can I Be a Nurse If I Cannot Think Critically?

How To Improve Critical Thinking Skills In Nursing? 24 Strategies With Examples

Last updated on August 19th, 2023

Nurses play a critical role in making critical decisions that directly impact patient outcomes in the dynamic field of healthcare. Developing strong critical thinking skills is essential for success in this role.

In this article, we present a comprehensive list of 23 nursing-specific strategies aimed at improving critical thinking and improve the quality of patient care.

24 Strategies to improve critical thinking skills in nursing

You may also want to check out: 15 Attitudes of Critical Thinking in Nursing (Explained W/ Examples)

1. Reflective Journaling: Delving into Deeper Understanding

Reflective journaling is a potent tool for nurses to explore their experiences, actions, and decisions.

By regularly pondering over situations and analyzing their thought processes, nurses can identify strengths and areas for improvement.

This practice encourages the conscious development of critical thinking by comparing past experiences with current knowledge and exploring alternative solutions.

After a particularly challenging case, a nurse reflects on their decision-making process, exploring what worked well and what could have been done differently.

2. Meeting with Colleagues: Collaborative Learning for Critical Thinking

Regular interactions with colleagues foster a collaborative learning environment. Sharing experiences, discussing diverse viewpoints, and providing constructive feedback enhance critical thinking skills .

Colleagues’ insights can challenge assumptions and broaden perspectives, ultimately leading to more well-rounded clinical judgments.

A nursing team gathers to discuss a recent complex case, sharing their perspectives, insights, and lessons learned to collectively improve patient care strategies.

3. Concept Mapping: Visualizing Complexity

Concept mapping is an excellent technique to synthesize intricate patient information. By creating visual representations of patient problems and interventions, nurses can identify relationships and patterns that might not be apparent otherwise.

This strategy aids in comprehensive care planning and encourages nurses to think holistically about patient care.

Creating a concept map to connect patient symptoms, diagnostics, and interventions reveals patterns that help the nurse formulate a comprehensive care plan.

4. Socratic Questioning: Digging Deeper into Situations

The art of Socratic questioning involves asking probing questions that lead to deeper understanding.

Applying this technique allows nurses to uncover assumptions, examine inconsistencies, and explore multiple viewpoints.

This approach is especially valuable when reviewing patient history, discussing conditions, and planning care strategies.

When assessing a patient’s deteriorating condition, a nurse asks probing questions to uncover potential underlying causes and prioritize appropriate interventions.

5. Inductive and Deductive Reasoning: From Specifics to Generalizations

Developing skills in both inductive and deductive reasoning equips nurses to analyze situations from different angles.

Inductive reasoning involves drawing conclusions from specific observations, while deductive reasoning starts with general premises to arrive at specific conclusions.

Proficient use of these methods enhances nurses’ ability to make accurate clinical judgments.

When encountering a series of patients with similar symptoms, a nurse uses inductive reasoning to identify a common pattern and deduce potential causes.

6. Distinguishing Statements: Fact, Inference, Judgment, and Opinion

Clear thinking demands the ability to differentiate between statements of fact, inference, judgment, and opinion.

Nurses must critically evaluate information sources, ensuring they rely on evidence-based practice.

This skill safeguards against misinformation and supports informed decision-making.

While reviewing a patient’s history, a nurse differentiates factual medical information from inferences and subjective judgments made by different healthcare professionals.

7. Clarifying Assumptions: Promoting Effective Communication

Recognizing assumptions and clarifying their underlying principles is vital for effective communication. Nurses often hold differing assumptions, which can impact patient care.

By acknowledging these assumptions and encouraging open discussions, nursing teams can collaboratively create care plans that align with patients’ best interests.

Before suggesting a treatment plan, a nurse engages in a conversation with a patient to understand their cultural beliefs and preferences, ensuring assumptions are not made.

8. Clinical Simulations: Learning through Virtual Scenarios

Clinical simulations provide nurses with a risk-free environment to practice decision-making and problem-solving skills.

These virtual scenarios mimic real-life patient situations and allow nurses to test different approaches, assess outcomes, and reflect on their choices.

By engaging in simulations, nurses can refine their critical thinking abilities, learn from mistakes, and gain confidence in their clinical judgment.

Engaging in a simulated scenario where a patient’s condition rapidly changes challenges a nurse’s decision-making skills in a controlled environment.

9. Case Studies and Grand Rounds: Analyzing Complex Cases

Engaging in case studies and participating in grand rounds exposes nurses to complex patient cases that require in-depth analysis.

Working through these scenarios encourages nurses to consider various factors, potential interventions, and their rationale.

Discussing these cases with colleagues and experts fosters collaborative critical thinking and widens the spectrum of possible solutions.

Nurses participate in grand rounds, discussing a challenging case involving multiple medical specialties, encouraging a holistic approach to patient care.

10. Continuing Education and Lifelong Learning: Expanding Knowledge

Staying up-to-date with the latest advancements in nursing and healthcare is crucial for effective critical thinking.

Pursuing continuing education opportunities, attending conferences, and engaging in self-directed learning keeps nurses informed about new research, technologies, and best practices.

This continuous learning enriches their knowledge base, enabling them to approach patient care with a well-rounded perspective.

Attending a nursing conference on the latest advancements in wound care equips a nurse with evidence-based techniques to improve patient outcomes.

11. Debates and Discussions: Encouraging Thoughtful Dialogue

Organizing debates or participating in structured discussions on healthcare topics stimulates critical thinking.

Engaging in debates requires researching and presenting evidence-based arguments, promoting the evaluation of different perspectives.

Nurses can exchange insights, challenge assumptions, and refine their ability to defend their viewpoints logically.

Engaging in a debate on the pros and cons of a new treatment method encourages nurses to critically analyze different viewpoints and strengthen their own understanding.

12. Multidisciplinary Collaboration: Gaining Insights from Various Disciplines

Collaborating with professionals from diverse healthcare disciplines enriches nurses’ critical thinking.

Interacting with doctors, pharmacists, therapists, and other experts allows nurses to benefit from different viewpoints and approaches.

This cross-disciplinary collaboration broadens their understanding and encourages innovative problem-solving.

Collaborating with physical therapists, nutritionists, and pharmacists helps a nurse develop a holistic care plan that addresses all aspects of a patient’s recovery.

13. Ethical Dilemma Analysis: Balancing Patient Autonomy and Best Practice

Ethical dilemmas are common in nursing practice. Analyzing these situations requires nurses to weigh the principles of beneficence, non-maleficence, autonomy, and justice.

By critically examining ethical scenarios, nurses develop the capacity to navigate morally complex situations, prioritize patient welfare, and make ethically sound decisions.

When faced with a patient’s refusal of treatment due to religious beliefs, a nurse evaluates the ethical considerations, respects autonomy, and seeks alternatives.

14. Root Cause Analysis: Investigating Adverse Events

When adverse events occur, performing a root cause analysis helps identify the underlying causes and contributing factors.

Nurses engage in a systematic process of analyzing events, exploring the “5 Whys” technique , and developing strategies to prevent similar occurrences in the future.

This approach cultivates a thorough and analytical approach to problem-solving.

After a medication error, a nurse leads a root cause analysis to identify system failures and implement preventive measures to enhance patient safety.

15. Creative Thinking Exercises: Expanding Solution Repertoire

Encouraging creative thinking through brainstorming sessions or scenario-based exercises widens the range of possible solutions nurses consider.

By thinking outside the box and exploring innovative approaches, nurses develop adaptable problem-solving skills that can be applied to complex patient care challenges.

Brainstorming creative approaches to comfort a distressed pediatric patient empowers a nurse to find innovative methods beyond routine interventions.

16. Journal Clubs: Fostering Evidence-Based Discussion

Participating in journal clubs involves healthcare professionals coming together to dissect recent research articles.

This practice ignites critical thinking by allowing nurses to evaluate study methodologies, scrutinize findings, and consider the implications for their practice.

Engaging in evidence-based discussions not only cultivates a culture of critical inquiry but also reinforces continuous learning.

At the monthly journal club meeting, Nurse Mark engages in a discussion on a recent research article focusing on pain management strategies for post-operative patients.

The group analyzes the study design, scrutinizes the findings, and considers the potential implications for their practice.

During the discussion, Mark raises thought-provoking questions about the study’s methodology and suggests potential applications in their hospital’s patient care protocols.

This active participation in journal clubs not only refines Mark’s critical thinking but also instills evidence-based practices into his nursing approach.

17. Critical Reflection Groups: Collaborative Learning and Analysis

Similarly, establishing critical reflection groups, where nurses meet regularly to discuss experiences, cases, and challenges, fosters collective learning.

These sessions encourage the exchange of diverse perspectives, enriching the analysis process and ultimately enhancing patient care strategies.

Through shared insights and discussions, nurses can refine their clinical reasoning and broaden their problem-solving capabilities.

Nurse Emma actively participates in critical reflection groups in order to broaden her clinical knowledge. During a recent meeting, the group tackled a difficult patient case with complicated symptomatology.

Emma suggests alternative diagnostic pathways based on her own experiences. Emma’s critical thinking skills are honed as a result of the group’s dynamic interaction, which also emphasizes the importance of collaborative decision-making in complex scenarios.

18. Mindfulness and Reflection Practices: Enhancing Self-Awareness

Mindfulness techniques, such as meditation and deep breathing, encourage self-awareness and a clear mind.

Engaging in these practices helps nurses become more attuned to their thoughts and emotions, leading to better self-regulation and improved decision-making during high-pressure situations.

Engaging in mindfulness exercises before a demanding shift helps a nurse maintain focus, manage stress, and make clear-headed decisions.

19. Problem-Based Learning: Applying Knowledge in Real Scenarios

Problem-based learning involves presenting nurses with real-world patient cases and encouraging them to collaboratively solve the problems.

This approach bridges the gap between theoretical knowledge and practical application, fostering critical thinking through active problem-solving.

Working through a simulated patient case challenges nurses to apply theoretical knowledge to practical situations, refining their clinical reasoning.

20. Self-Assessment and Feedback: Evaluating Decision-Making Skills

Regularly assessing one’s own decision-making process and seeking feedback from peers and mentors is essential for improvement.

Reflecting on past decisions, considering alternative approaches, and understanding the rationale behind them contribute to the refinement of critical thinking skills.

A nurse evaluates their performance after a patient’s unexpected complication, seeking feedback from peers and mentors to identify areas for improvement.

21. Cultural Competence Training: Navigating Diverse Perspectives

Cultural competence training enhances critical thinking by enabling nurses to understand the diverse cultural beliefs and practices of patients.

This knowledge is vital for providing patient-centered care, as it encourages nurses to think critically about the unique needs of each individual.

A nurse attends cultural competence training to understand the dietary preferences of a diverse patient population, ensuring respectful and patient-centered care.

22. Active Listening and Empathetic Communication: Gathering Insights

Active listening and empathetic communication with patients and their families enable nurses to gather comprehensive information about their conditions, concerns, and preferences.

This data forms the basis for critical analysis and informed decision-making in patient care.

Through attentive listening, a nurse uncovers a patient’s underlying concerns, leading to an informed care plan that addresses both medical needs and emotional well-being.

23. Mentorship and Preceptorship: Learning from Experienced Professionals

Having a mentor or preceptor provides novice nurses with the opportunity to learn from experienced professionals.

Mentors guide critical thinking by sharing their insights, challenging assumptions, and offering guidance in complex situations. This relationship fosters growth and expertise development.

A novice nurse gains valuable insight from a mentor, who guides them through complex cases, offering real-world wisdom and refining critical thinking skills.

24. Self-Assessment and Feedback: Evaluating Decision-Making Skills

Reflecting on past decisions, considering alternative approaches, and understanding the rationale behind them contribute to the refinement of critical thinking skills .

Nurse Sarah regularly takes time to assess her decision-making skills by reviewing past patient cases. After a challenging case involving conflicting symptoms, she reflects on her initial approach, the outcomes, and what she could have done differently.

She seeks feedback from her senior colleague, who provides insights on alternative diagnostic paths. Sarah’s self-assessment and feedback-seeking process enable her to identify areas for improvement and refine her critical thinking in similar situations.

• Clinical Reasoning In Nursing (Explained W/ Example)
• 8 Stages Of The Clinical Reasoning Cycle
• What is Critical Thinking in Nursing? (Explained W/ Examples)

Enhancing critical thinking skills is an ongoing journey that transforms nursing practice.

Reflective journaling, collaborative learning, concept mapping, Socratic questioning , reasoning techniques, distinguishing statements, and clarifying assumptions all play integral roles in nurturing these skills.

By incorporating these strategies into their daily routines, nurses can improve their critical thinking skills.

Additionally, this will help nurses in navigating the complexities of the healthcare field with confidence, expertise, and the ability to make well-informed decisions that improve patient outcomes.

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Effectiveness of Problem-Based Learning on Development of Nursing Students’ Critical Thinking Skills

A systematic review and meta-analysis.

Wei, Baojian MD; Wang, Haoyu BS; Li, Feng MSc; Long, Yan MSc; Zhang, Qi MSc; Liu, Hang MSc; Tang, Xiujun MSc; Rao, Mingjun MD

Author Affiliations: Adjunct Professor (Dr Wei), School of Nursing, Shandong First Medical University & Shandong Academy of Medical Sciences, Taian, Shandong, China; and Instructor (Messrs Wang, Li, Zhang, Liu, and Tang and Ms Long), Professor (Mr Tang), and Adjunct Professor (Dr Rao), Department of Plastic Surgery, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China.

Correspondence: Dr Rao ( [email protected] ) and Mr Tang ( [email protected] ) , Department of Plastic Surgery, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China.

This work was supported by the Research Program of Taishan Medical College Education and Teaching Research Project (No. XY2018051).

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website ( www.nurseeducatoronline.com ).

Accepted for publication: September 17, 2023

Early Access: November 16, 2023

Cite this article as: Wei B, Wang H, Li F, Long Y, Zhang Q, Liu H, Tang X, Rao M. Effectiveness of problem-based learning on development of nursing students’ critical thinking skills: a systematic review and meta-analysis. Nurse Educ . 2024;49(3):E115-E119. doi:10.1097/NNE.0000000000001548

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Background: 

Problem-based learning (PBL) is a student-centered approach to teaching that has been applied in medical and nursing education. The effectiveness of PBL in promoting critical thinking in nursing students has been studied extensively with mixed results.

Purpose: 

The meta-analysis aimed to investigate the impact of PBL interventions on critical thinking skills of nursing students.

Methods: 

PubMed, Embase, Cochrane, and CINAHL databases were electronically searched. Methodological quality was examined using the Newcastle-Ottawa Scale and version 2 of the Cochrane risk-of-bias tool. Data were analyzed with 95% confidence intervals based on random-effect models.

Results: 

Nineteen studies involving 1996 nursing students were included in the analysis. The results of the analysis demonstrated greater improvement in critical thinking skills compared with the control group (overall critical thinking scores: standardized mean difference [SMD] = 0.47, 95% CI = 0.33-0.61, P < .01).

Conclusions: 

The meta-analysis indicates that PBL can help nursing students to improve their critical thinking.

Nursing occupies a critical role in health care. The profession entails a myriad of responsibilities, including recognizing patients’ symptoms, taking measures to administer medications, providing other measures to help relieve symptoms, and collaborating with other health care workers to optimize patients’ comfort and families’ understanding and adaptation. 1 To effectively fulfill these responsibilities, nurses require professional knowledge across various aspects of health care. 2 , 3 Critical thinking, an essential cognitive capacity, plays a pivotal role in enabling nurses to make informed decisions and fulfill their diverse roles. 4 It involves a combination of cognitive skills and affective dispositions, as defined by the American Philosophical Association, and positively influences clinical practice, patient health, student education, and the growth of nursing science. 5 , 6

Problem-based learning (PBL) is an innovative teaching method that has gained widespread application among institutions worldwide, particularly in the fields of medical and nursing education. 6 , 7 As described by Zakaria et al, 8 PBL is a student-centered, outcome-based approach that has been proven to enhance the quality of learning across various disciplines and academic levels. PBL is described as a process-focused teaching strategy that employs small groups centered on solving well-integrated clinical problems. Unlike traditional instruction, which relies heavily on lectures and limited self-directed learning, PBL encourages active problem-solving and collaboration among students. 9 PBL has been hailed as the “most significant innovation in education for professions in many years,” a testament to its transformative impact on the field of education. 10-12 Indeed, PBL has emerged as a game-changer in medical education, and its effects on nursing education have also been studied extensively. 13

Numerous studies have shown that PBL significantly enhances critical thinking skills (CT skills) among medical students. 14 As Hajrezayi et al note, critical thinking involves purposeful, self-regulatory judgment that results in interpretation, analysis, evaluation, and inference, skills that are invaluable in the clinical setting. 15 PBL, as a teaching strategy, focuses on engaging students in group discussions to address complex and ambiguous clinical problems. This process involves analyzing problems, setting objectives, gathering information, summarizing ideas, and reflecting on problem-solving experiences. 16 Research has demonstrated that this teaching strategy effectively develops critical thinking abilities in medical students. 17

However, the efficacy of PBL as a teaching method for enhancing critical thinking in nursing students remains a topic of debate among researchers. Previous systematic reviews evaluating critical thinking in PBL have produced mixed results, with some studies supporting a positive relationship between PBL and critical thinking and others disputing it. 18-20

To address these inconsistencies and provide a more comprehensive understanding of the effectiveness of PBL in promoting critical thinking in nursing students, we synthesized the data of previous studies published and conducted a more comprehensive meta-analysis.

Methodology for Meta-analysis

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure a systematic and transparent process. The PRISMA statement comprises a 27-item checklist and a 4-phase flow diagram, which guide the analysis. 21 We carefully applied each item on the checklist to guarantee transparent reporting of our systematic review, while the flow diagram helped us visualize and track the different stages of our analysis. The review protocol was registered on PROSPERO (PROSPERO ID: CRD42023406592).

Search Strategy

We conducted a comprehensive search of the literature using electronic databases (PubMed via National Library of Medicine, Embase via Elsevier, Cochrane via Cochrane library, and CINAHL via EBSCO) from inception to September 9, 2023, supplemented by a manual search of reference lists of relevant articles. There was no limit to search date, language, and publication period. We used a combination of keywords and MeSH terms related to the topic to optimize the search results, detailed in the supplementary material (see Supplemental Digital Content 1, available at: https://links.lww.com/NE/B450 ).

Study Selection

Two reviewers (R.M. and W.B.) independently screened the titles and abstracts for eligibility. Articles that did not meet the inclusion criteria were excluded. The same 2 reviewers then independently reviewed full texts of remaining articles for inclusion in the meta-analysis. Discrepancies were resolved through discussion and consensus with a third reviewer (T.X.).

Included studies satisfied the following criteria: (1) participants were nursing students including graduate and undergraduate nursing students, (2) the intervention group used PBL, (3) the control group used traditional lectures, (4) trials evaluated critical thinking, (5) reported sample size, mean difference, and standard deviation of critical thinking scores. Excluded studies included nonnursing subjects, interventions other than PBL, no critical thinking evaluation, and incomplete/duplicate articles. Both randomized and nonrandomized controlled trials were included.

Data Extraction

Two reviewers independently extracted data from the included studies using a standardized data extraction form. The data extracted included study characteristics (author, year of publication, and country), participant characteristics (sample size and grade), description of PBL, teaching methods combined with PBL, research of design, and critical thinking tools (the mean difference from baseline to post-test, as well as standard deviation). Any discrepancies were resolved through discussion and consensus with a third reviewer.

Quality Assessment

Two reviewers independently assessed the quality of the included studies using a Newcastle-Ottawa Scale (NOS) for cohort studies, and version 2 of the Cochrane risk-of-bias tool for randomized trials. A study was considered as high quality if the NOS score was 7 or more, moderate quality if the NOS score between 4 and 7, and low quality if the NOS score less than 4. As for version 2 of the Cochrane risk-of-bias tool, when there are “some concerns” (or high risk of bias ratings) in some domains, the overall risk of bias is rated as “some concerns” (or high), respectively. Any discrepancies were resolved through discussion and consensus with a third expert.

Data Analysis

We used a random-effects model to pool the effect sizes across studies. To determine the significance of our findings, we set a threshold of a 2-sided P value less than .05 for all analyses. We assessed heterogeneity using the I 2 statistic and P value of Cochran's Q statistic, P value < .10 and I 2 > 50% were considered as heterogeneity. The I 2 statistic, which indicates the percentage of variation attributed to heterogeneity, was an easily interpretable way to assess the degree of heterogeneity. We considered an I 2 statistic of 25% to 50% to indicate low heterogeneity, 50% to 75% to indicate moderate heterogeneity, and more than 75% to indicate high heterogeneity. If there is heterogeneity, we explored potential sources of heterogeneity using subgroup analyses based on the duration of PBL intervention (hours or weeks), the grade of nursing students, and the assessment tools of CT skills. We conducted sensitivity analyses to examine the robustness of the findings and assessed publication bias using funnel plots and Egger's test. All analyses are conducted using R software.

Ethics Approval

As this study is a meta-analysis of previously published studies, no ethical approval was required.

We conducted a thorough review of available literature on PBL interventions for nursing students and ultimately obtained 19 studies (see Supplemental Digital Content 2, available at: https://links.lww.com/NE/B451 ).

Study Characteristics

All included studies were published between 2004 and 2021 and involved 1996 nursing students from Iran (n = 3), South Korea (n = 8), China (n = 6), the United States (n = 1), and Turkey (n = 1). The participants included first-year, second-year, third-year, fourth-year, and graduates with a work experience ranging from 1 to 21 years; 1876 participants were undergraduate nursing students while 120 participants were graduate nursing students with a work experience ranging from 1 to 21 years. The length of the PBL intervention period varied, with 7 articles lasting less than 12 weeks and 9 articles lasting 12 weeks or more. PBL interventions were integrated with various teaching methods, including simulation, case-based learning, teamwork, concept mapping, clinical practice, internet, and tutors as guides (tutors help clarify concepts and answer questions).

To assess the critical thinking, 18 included studies adopted different assessment tools including the California Critical Thinking Skills Test (CCTST, n = 6), California Critical Thinking Dispositions Inventory (CCTDI, n = 5), Assessment Technologies Institute Critical Thinking Test (n = 1), Watson-Glaser Critical Thinking Scale (n = 1), and critical thinking tools developed by Yoon (n = 2), Kwon (n = 2), Park (n = 1), McMaster University (n = 1). Among these assessment tools, the CCTST and CCTDI stand out as the primary tools utilized in the studies. The detailed characteristics were presented in Supplemental Digital Content 3, available at: https://links.lww.com/NE/B452 .

Risk of Bias

Nine of the 12 cohort studies had a low risk of bias (see Supplemental Digital Content 4, available at https://links.lww.com/NE/B453 ). However, all 7 randomized controlled studies had a high risk of bias (see Supplemental Digital Content 5, available at: https://links.lww.com/NE/B454 ). None of the randomized controlled studies specified whether the allocation sequence was concealed until participants were enrolled and assigned to interventions, nor were they able to conceal their allocation from the participants, the teachers, and the outcome assessors during the trial.

Meta-analysis Results

Nineteen studies involving 1996 participants (PBL group = 941, lecture group = 1055) reported overall critical thinking scores. The pooled effect size showed significant difference (standardized mean difference [SMD] = 0.47, 95% CI = 0.33-0.61, P < .001) in favor of PBL, compared with traditional lectures (see Supplemental Digital Content 6, available at: https://links.lww.com/NE/B455 ). There was moderate heterogeneity ( I 2 = 52%, P < .01).

Subgroup Analysis and Publication Bias

We conducted further subgroup analyses to explore the underlying sources of heterogeneity. Regarding nursing students of different grades, compared with second-year students, the critical thinking scores of the first- and third-year improved more, but there was no clear pattern of higher or lower critical thinking scores among higher grades (see Supplemental Digital Content 7, available at: https://links.lww.com/NE/B456 ). Additionally, we conducted subgroup analysis based on the different assessment tools used in the studies and discovered that nursing students who took the CCTST had higher scores compared with the CCTDI. Furthermore, the subgroup analysis based on intervention time showed that an intervention duration with fewer weeks and more hours had a greater improvement in critical thinking scores (see Supplemental Digital Content 7, available at: https://links.lww.com/NE/B456 ). This may suggest that nursing students who receive more intensive PBL course arrangements exhibited a higher improvement in critical thinking scores.

Furthermore, during the PBL process, nursing students who visualize the ideas, concepts, and terms using concept mapping show better improvement in critical thinking abilities (see Supplemental Digital Content 7, available at: https://links.lww.com/NE/B456 ). Additionally, students who receive help from teachers to clarify concepts and solve problems also demonstrate better improvement in critical thinking abilities. It is worth noting that among the 9 studies where teachers played a significant role in guiding students (clarifying concepts and answering questions rather than simply directing the slow of the PBL), all were published in 2008 or later. In contrast, among the 9 clinical studies where teachers only assisted in implementing PBL, 4 were published before 2008. This suggests that teachers play a more important role during the development of the PBL teaching strategy.

We conducted a funnel plot analysis to determine the degree of symmetry in our results and conducted Egger's regression test to determine publication bias (see Supplemental Digital Content 8, available at: https://links.lww.com/NE/B457 ). The results showed no publication bias, with bias = 0.7445 ( t = 0.6, df = 7, P = .5580).

In this meta-analysis, we found that PBL has a greater impact on CT skills of nursing students compared with traditional lectures. In the past 2 decades, there have been several meta-analyses published on this topic, but the earlier meta-analysis did not support our current conclusion, that the PBL teaching strategy can improve nursing students’ critical thinking ability compared with traditional lectures. 18 After incorporating more studies, our meta-analyses has new findings that differ from previous meta-analysis.

The discrepancy between our conclusions and those of earlier meta-analyses can be attributed to the continuous improvement of the PBL teaching strategy itself. 22 , 23 Our meta-analysis supported that teachers played a more important role in the development of the PBL teaching strategy. Teachers in the earlier studies mainly helped implement the PBL teaching strategy, teachers in the more recent studies encouraged students to think critically and gave timely feedback. Originally introduced as a novel teaching strategy in medical education, teachers primarily act as a procedural guide, our meta-analysis suggests that increased teacher engagement in the PBL teaching process can enhance nursing students’ critical thinking abilities. Although exhaustively providing students with answers to their questions as a directive lecturer is not conducive to fostering students’ critical thinking abilities, students might be dismayed when their teachers rarely directly answer a question, but instead ask questions back and let the student find the answer independently. 24

Throughout the ongoing improvement of the PBL teaching strategy, case-based learning has been integrated. Cases present clinical problems to nursing students in a fragmented manner, fostering their autonomy in constructing a knowledge framework to investigate the problems and address the presented challenges. 25 Furthermore, the assistance of concept mapping and teamwork during the PBL teaching process further improved the PBL teaching strategy. 26 , 27

Despite various advantages demonstrated by the PBL teaching strategy over the past few decades, it is imperative that we carefully evaluate both the benefits and drawbacks of adopting this teaching strategy over traditional lecture-based learning methods. One of the most celebrated aspects of the PBL teaching strategy is its ability to situate information within the context of real-life clinical problem-solving, bridging the gap between textbook knowledge and practical application. 23 On the other hand, PBL necessitates teachers to invest substantial effort in guiding students’ self-directed learning, while medical institutions should acknowledge adequate resources to support the PBL teaching strategy. 28 Nevertheless, it is worth noting that implementing the PBL teaching strategy effectively may pose challenges for teachers who are accustomed to traditional lecture-based strategy, necessitating additional training to ensure competence in the PBL teaching strategy.

Furthermore, we must acknowledge that clinical problem-solving through the PBL teaching strategy is a complex cognitive task that involves hypothesis generation from ambiguous clues. It requires reasoning based partly on fuzzy categorical knowledge, partly on probabilities, and partly on understanding the urgency and risk-benefit relationship of potential treatments. 29 In essence, for clinical problem-solving to become a meaningful experience, nursing students must possess knowledge and experience directly tied to the clinical problems. Traditional lecture-based learning methods afford teachers the opportunity to assist students in constructing knowledge frameworks based on their own expertise experience. 30 However, in the realm of PBL teaching, students, due to their limited foundational knowledge, may pose numerous seemingly inconsequential questions, potentially appearing chaotic, time-consuming, and misguided in the eyes of teachers. 31 To mitigate this challenge, some studies have leveraged concept mapping and the internet to facilitate rapid access to relevant knowledge, aiding nursing students in comprehending clinical problems. 32 , 33 Moreover, experienced PBL teachers play a pivotal role in helping nursing students build a robust knowledge base by promptly answering their questions. 34

Moreover, the current trend in PBL teaching involves employing cases as guides for learning in specific content areas. In this situation, nursing students typically only learn the definition of possible treatments when the clinical problems are presented. This approach often simplifies the complexities and exceptional aspects of clinical cases, which may serve as illustrative examples of important concepts, which may lack practicality in the actual practice of clinical problem-solving. 31 , 35 However, as nursing students engage in independent collection of background information, teachers help guide them in applying and refining their critical thinking skills to attempt to understand the reading materials, not limiting themselves to textbooks or the small world of their peers and teachers. They are quickly guided into a broader world, namely the current cutting-edge medical issues, by the latest medical articles as well as expert teachers. 25

Our meta-analysis indicates that the PBL teaching strategy can enhance critical thinking skills in nursing students.

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critical thinking skill; meta-analysis; nursing students; problem-based learning

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Nurse Selection Criteria + Example Responses

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When it comes to nursing positions, education and experience are important, but they are not the only factors employers take into consideration. Employers also look for certain key selection criteria that demonstrate a candidate’s ability to perform the role effectively. As with any interview, it’s often recommended that you follow the STAR method when provding a response. The STAR method is a structured manner of responding to behavioral-based interview questions by providing the specific Situation, Task, Action, and Result of the particular scenario. This article will go beyond education and experience, and provide insight into the key selection criteria for nursing positions, along with example STAR responses.

1. Communication & Interpersonal Skills

Effective communication and interpersonal skills are critical in the nursing profession. You need to be able to communicate with patients, their families, and other healthcare professionals in a clear and concise manner. Additionally, being able to form strong relationships with others is important in building trust and providing the best care for your patients. Employers will be looking for evidence of your communication and interpersonal skills during the interview.

Example response:

• Situation: During my time working as a nurse in a hospital, I was faced with a patient who was non-verbal and unable to communicate their needs.
• Task: I needed to assess their condition and administer medication.
• Action: I used non-verbal communication techniques, such as gestures and facial expressions, to understand their needs and communicate with them effectively. I also formed a rapport with the patient, by talking to them in a calm and reassuring tone.
• Result: The patient was able to receive the necessary treatment and was much more comfortable with the process. The patient and their family also expressed their gratitude for my compassionate and empathetic approach.

2. Compassion & Empathy

Compassion and empathy are key traits for nurses as they must be able to understand and connect with their patients. This requires an ability to listen, understand, and respond to the emotional and physical needs of patients. Nurses must be able to show compassion and empathy towards their patients and provide comfort and support.

Employers are looking for nurses who can demonstrate their compassion and empathy skills and show that they are able to connect with and understand their patients. They want to see that you have a genuine concern for the well-being of your patients and are able to provide comfort and support. They also want to know that you are able to maintain a professional demeanor and provide care in a respectful and empathetic manner.

By demonstrating your compassion and empathy skills, you show that you are a caring and empathetic nurse who is able to understand and connect with your patients. You also show that you are able to provide comfort and support to your patients, which is essential for providing high-quality patient care. Your compassion and empathy skills demonstrate your commitment to providing patient-centered care and helping your patients feel supported and understood.

• Situation: I was working in a hospice where a patient was in their final stages of life.
• Task: The patient was in a lot of pain and their family was upset and worried.
• Action: I listened to the patient’s concerns and provided comfort and reassurance to both the patient and their family. I also kept in close communication with the patient’s physician to ensure that their pain was managed appropriately.
• Result: The patient was able to pass away peacefully, and the family felt comforted knowing that their loved one was not alone. They also expressed their appreciation for my compassionate and empathetic approach.

3. Teamwork

Nursing is a team-oriented profession, and it is important to be able to work well with others. This involves being able to collaborate with other healthcare professionals, such as physicians and nursing assistants, to provide the best care for your patients. Nurses must be able to work towards a common goal and support their colleagues, while also being able to take initiative and lead when necessary.

Employers are looking for nurses who can demonstrate their teamwork skills and show that they are able to collaborate effectively with others. They want to see that you have a positive attitude, are supportive of your colleagues, and can work well under pressure. They also want to know that you have the ability to take initiative and lead when necessary, as this is essential for providing high-quality patient care.

By demonstrating your teamwork skills, you show that you are a collaborative and supportive nurse who is able to work well with others. You also show that you have the ability to take initiative and lead when necessary, which is essential for providing high-quality patient care. You demonstrate your commitment to teamwork and collaboration, which is essential for ensuring the best outcomes for your patients and the success of the healthcare team.

• Situation: I was working on a busy medical-surgical unit where the staff was stretched thin.
• Task: I needed to ensure that all of my patients received the care they needed in a timely manner.
• Action: I worked closely with my fellow nurses and nursing assistants to prioritize patient care, delegate tasks, and provide support when needed. I also kept open communication with the physician to ensure that everyone was on the same page.
• Result: We were able to provide the best care for our patients and maintain a positive and productive work environment. The unit received positive feedback from patients and their families for our teamwork and collaboration.

4. Quality Improvement

Quality improvement is an essential aspect of the nursing profession as it helps to ensure that patients receive the best care possible. It involves identifying areas for improvement and implementing changes to improve the quality of care. This could include improving patient outcomes, reducing errors, increasing patient satisfaction, or improving efficiency.

Quality improvement requires a systematic approach, collaboration, and an ongoing commitment to continuous improvement. Nurses play a vital role in this process as they are often on the front lines, working with patients and providing care. By being involved in quality improvement initiatives, nurses can make a positive impact on patient outcomes and contribute to the overall success of the healthcare organisation.

Employers will be looking for evidence of your ability to identify areas for improvement, implement changes, and monitor the results during the interview. They want to see that you have a commitment to providing the best care for your patients and are proactive in seeking ways to improve the quality of care.

• Situation: I was working in a hospital where the discharge process was taking longer than it should.
• Task: I needed to find a solution to improve the discharge process for patients.
• Action: I analyzed the current process, identified areas for improvement, and made suggestions for changes. I also collaborated with the rest of the nursing staff and physicians to implement the changes and monitor the results.
• Result: The discharge process was streamlined, and patients were able to be discharged faster, which improved their experience and satisfaction. The hospital also received positive feedback from patients and their families for the improved discharge process.

5. Continuous Professional Development (CPD)

Continuous professional development is important for nurses, as it helps them to stay up-to-date with the latest developments in the field and maintain their competency. Employers are looking for nurses who are committed to their ongoing professional development and have a strong desire to learn and grow in their careers. By demonstrating a commitment to CPD, nurses show that they are dedicated to providing the best care for their patients and are interested in staying current in their field.

• Situation: I was working as a nurse and wanted to further my knowledge in a specific area of nursing.
• Task: I needed to find ways to continue my professional development.
• Action: I researched and attended conferences, workshops, and courses related to my area of interest. I also sought out mentorship opportunities with experienced nurses.
• Result: I was able to expand my knowledge and skills in my area of interest, which helped me provide better care for my patients. I also received recognition from my peers and supervisors for my commitment to continuous professional development.

6. Problem-Solving

Problem-solving is a crucial skill for nurses as they often face complex and challenging situations in their daily work. It requires critical thinking, effective communication, and the ability to identify and analyse problems and find solutions. Nurses must be able to make informed decisions, prioritise tasks, and work effectively under pressure.

Employers are looking for nurses who can demonstrate their problem-solving skills and show that they can handle challenging situations in a calm and effective manner. They want to see that you can think creatively and come up with innovative solutions to problems. They also want to know that you have the ability to make decisions that benefit your patients, your team, and the organisation.

By demonstrating your problem-solving skills, you show that you are a competent nurse who can handle complex and challenging situations and make informed decisions. You also show that you have the ability to think critically and creatively, which is essential for providing high-quality patient care.

• Situation: I was working as a nurse in a busy emergency room where a patient was in critical condition.
• Task: I needed to find a solution to provide the best care for the patient in a limited amount of time.
• Action: I assessed the patient’s condition, gathered relevant information, and considered multiple options for treatment. I then collaborated with the physician to determine the best course of action.
• Result: The patient received the necessary treatment, and their condition stabilized. The patient and their family also expressed their gratitude for my quick thinking and effective problem-solving skills.

7. Legal Understanding

Legal understanding is an important aspect of nursing as nurses must be aware of and adhere to the laws and regulations that govern their practice. This includes understanding the laws and regulations related to patient privacy, informed consent, and medical ethics. Nurses must also be aware of the legal implications of their actions and understand how to handle difficult and complex legal situations.

Employers are looking for nurses who have a good understanding of the laws and regulations that govern their practice and who can demonstrate their ability to apply this knowledge in their daily work. They want to see that you have a commitment to upholding the ethical and legal standards of the nursing profession and are able to make informed decisions that are in line with these standards.

By demonstrating your legal understanding, you show that you are a responsible and ethical nurse who is committed to providing high-quality care to your patients. You also show that you are aware of the laws and regulations that govern your practice and have the ability to handle difficult and complex legal situations in a professional and responsible manner.

• Situation: I was working as a nurse and was faced with a situation where a patient’s privacy was in question.
• Task: I needed to ensure that the patient’s privacy was protected.
• Action: I consulted the relevant laws and regulations, and determined the appropriate course of action. I also kept the patient informed of the situation and their rights.
• Result: The patient’s privacy was protected, and the hospital was able to comply with the relevant laws and regulations. The patient also expressed their appreciation for my understanding of their rights and protection of their privacy.

In conclusion, education and experience are important factors when it comes to nursing positions, but they are not the only factors that employers take into consideration. Employers also look for evidence of key selection criteria such as communication and interpersonal skills, compassion and empathy, teamwork, quality improvement, continuous professional development, problem-solving, and legal knowledge.

It is essential for nursing candidates to understand these criteria and be able to provide examples of how they demonstrate them during the interview. By following the STAR method and being able to articulate your experiences and accomplishments, you can show the interviewer that you possess the skills and qualities necessary for a successful nursing career.

So, when preparing for a nursing interview , take the time to reflect on your experiences and think about how you can demonstrate these key selection criteria. Show the interviewer that you are a well-rounded and competent nurse who is committed to providing the best care for your patients. Good luck!

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Clinical problem-solving in nursing: insights from the literature

Affiliation.

• 1 [email protected]
• PMID: 10759980
• DOI: 10.1046/j.1365-2648.2000.01342.x

This paper reviews the literature surrounding the research on how individuals solve problems. The purpose of the review is to heighten awareness amongst nurses in general, and nurse academics in particular about the theories developed, approaches taken and conclusions reached on how clinicians problem-solve. The nursing process, which is heavily used and frequently described as a problem-solving approach to nursing care, requires a deductive reasoning process which is not the problem-solving process in use during care-giving activities. More knowledge is required on what process is in place as we develop as a profession. The literature highlights the complexities involved in attempting to uncover thinking processes. The main research approaches to discovering problem-solving strategies in the past three decades have been from a cognitive perspective, with two main theories, decision-theory and information processing-theory, underpinning the majority of studies conducted. None of the research approaches used to date has resulted in the identification of a general model of problem-solving that is consistent across tasks or disciplines. However, early hypothesis activation with subsequent testing of the hypothesis seems to be consistent in clinicians across disciplines.

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• Open access
• Published: 05 September 2024

Breaking the taboo of using the nursing process: lived experiences of nursing students and faculty members

• Amir Shahzeydi   ORCID: orcid.org/0000-0001-9095-2424 1 , 2 ,
• Parvaneh Abazari   ORCID: orcid.org/0000-0003-4024-2867 3 , 4 ,
• Fatemeh Gorji-varnosfaderani   ORCID: orcid.org/0000-0001-6830-982X 5 ,
• Elaheh Ashouri   ORCID: orcid.org/0000-0002-7566-6566 6 ,
• Shahla Abolhassani   ORCID: orcid.org/0000-0002-5191-7586 6 &
• Fakhri Sabohi   ORCID: orcid.org/0000-0003-1448-6606 6  

BMC Nursing volume  23 , Article number:  621 ( 2024 ) Cite this article

Metrics details

Despite the numerous advantages of the nursing process, nursing students often struggle with utilizing this model. Therefore, studies suggest innovative teaching methods to address this issue. Teaching based on real clinical cases is considered a collaborative learning method that enhances students’ active learning for the development of critical thinking and problem-solving skills. In this method, students can acquire sufficient knowledge about patient care by accessing authentic information.

The aim of the present study was to investigate the experiences of nursing students and faculty members regarding the implementation of nursing process educational workshops, based on real case studies.

A qualitative descriptive study.

Participants

9 Nursing students and 7 faculty members from the Isfahan School of Nursing and Midwifery who attended the workshops.

This qualitative descriptive study was conducted from 2021 to 2023. Data was collected through semi-structured individual and focus group interviews using a qualitative content analysis approach for data analysis.

After analyzing the data, a theme titled “Breaking Taboos in the Nursing Process” was identified. This theme consists of four categories: “Strengthening the Cognitive Infrastructure for Accepting the Nursing Process,” “Enhancing the Applicability of the Nursing Process,” “Assisting in Positive Professional Identity,” and “Facilitating a Self-Directed Learning Platform.” Additionally, thirteen subcategories were obtained.

The data obtained from the present study showed that conducting nursing process educational workshops, where real clinical cases are discussed, analyzed, and criticized, increases critical thinking, learning motivation, and understanding of the necessity and importance of implementing the nursing process. Therefore, it is recommended that instructors utilize this innovative and effective teaching method for instructing the nursing process.

Peer Review reports

Introduction

The nursing process is a systematic and logical method for planning and providing nursing care [ 1 ] that provides an opportunity for nurses to efficiently and dynamically utilize their knowledge and expertise. It also creates a common language, known as nursing diagnosis, which facilitates action, promotes creative solutions, and minimizes errors in patient care [ 2 ]. Clinical education, based on the nursing process, provides an appropriate setting for nursing students to gain clinical experiences and foster professional development [ 3 ].

Despite the numerous advantages, nursing students face difficulties in implementing this model in various countries [ 4 , 5 ], lack of appropriate knowledge, lack of clinical practice, and insufficient learning are among the most significant obstacles to the implementation of the nursing process by students. This can be attributed to the poor quality of education regarding this important nursing care model. Therefore, it is necessary for educators in this field to use innovative and participatory teaching methods [ 3 , 6 ]. According to research conducted in Iran, 72% of nursing faculty members use passive teaching methods. Meanwhile, 92% of nursing students prefer active and innovative learning methods over traditional and passive methods [ 7 ]. Therefore, the use of modern methods, which aim to stimulate students’ thinking and enhance their responsiveness in acquiring and applying knowledge, can be effective [ 6 ].

Case-based learning is a collaborative learning method that aims to develop and enhance critical thinking and problem-solving skills [ 8 ]. Teaching the nursing process based on clinical and real cases can be very important in terms of promoting critical thinking, simulating real experiences, enhancing clinical judgment, and ultimately improving the quality and effectiveness of education [ 8 , 9 ]. In this method, students gain sufficient knowledge about patient care by accessing real information, improving their skills in patient assessment, and gaining personal nursing experience. This leads to a better understanding of comprehensive care and prepares individuals for future professional roles [ 9 ].

Very few studies have been conducted on teaching methods and their impact on the quality of nursing process [ 10 , 11 ]. In Iran, case-based trainings have mostly focused on hypothetical cases [ 1 , 12 ]. In other countries, most studies conducted on the case-based educational method have not focused on the nursing process. The few studies that have been conducted on the nursing process have either not been based on real clinical cases [ 13 ] or, if clinical cases have been researched, the studies have been conducted quantitatively [ 8 , 9 ] While qualitative research provides researchers with more opportunities to discover and explain the realities of the educational environment and gain a better understanding of many challenging aspects related to the nursing education process. Researchers are able to provide a practical model that helps improve and enhance the current process by gaining insight and a deep understanding of what is happening in the field of study [ 14 ]. This study represents the first qualitative research that describes the lived experiences of nursing students and faculty members regarding the teaching of the nursing process through real-based case workshops.

Study design

This qualitative descriptive study was conducted from 2021 to 2023. Qualitative descriptive studies typically align with the naturalistic inquiry paradigm, which emphasizes examining phenomena in their natural settings as much as possible within the context of research. Naturalistic inquiry, rooted in a constructivist viewpoint, enables a deeper understanding of phenomena by observing them within the authentic social world we inhabit [ 15 ]. In this type of study, researchers provide a comprehensive summary of an extraordinary occurrence or circumstance of interest and its related factors, but they do not delve into deep interpretation [ 16 ]. This study was undertaken to explore students and faculty members perceptions of the effect of the educational workshops on knowledge, skills and attitudes of students to the nursing process.

Setting and sample

Participants were selected from nursing students and faculty members who participated in nursing process workshops (Table  1 ). The criteria for entry into the study included volunteering to participate in the study and attending at least 3 sessions of the workshops.

Workshop details

The workshops were held in the conference hall of the Nursing and Midwifery Faculty. They consisted of 9 sessions, each lasting 2 h, from 16:00 to 18:00. Students from terms 2 to 8 and faculty members participated in these workshops. Each session was attended by an average of 60 members. Despite the inconvenience of scheduling the sessions outside of the official class hours, all the members stayed until the end of the meeting, showing a keen interest in the material and actively participating in discussions. Attendance was open to all students and faculty members, and participants in each of the workshop sessions were not the same.

It should be noted that all workshops were accompanied by a specialized instructor in the field of the nursing process, as well as a specialized instructor in the field of the specific disease being discussed. The details of these workshops are summarized in three stages:

First Stage

Step 1 . The researcher visited one of the inpatient clinical wards of the hospital based on the assigned topic for each workshop. They selected a patient, conducted a comprehensive assessment, and recorded the information using Gordon’s assessment form. This included the patient’s current and past medical history, paraclinical tests, physical examinations, medications, and information gathered from credible sources such as interviews with the patient and their family, medical records, and the patient’s treatment and care interventions documented in their medical file and Cardex.

Step 2 . Preparing the presentation file, which includes the following items:

Writing the comprehensive patient assessment based on step one.

Writing actual and at-risk nursing diagnoses according to PES (Problem/ Etiology/ Signs and Symptoms) and PE (Problem/ Etiology) rules, as well as collaborative problems, and then prioritizing them based on Maslow’s Hierarchy of Needs.

Writing objectives and outcomes for each nursing diagnosis based on the SMART (Specific/ Measurable/ Attainable/ Realistic/ Time Bound).

Writing nursing interventions (based on objectives and outcomes), along with the rationales according to evidence-based, up-to-date, and reliable sources for each intervention.

Step 3 . Sending the presentation file to an expert professor in the field of nursing process for review and implementing her comments.

Second stage

Step 1 . Announcing the date and time of the workshop session to students and faculty members.

Step 2 . Providing students and faculty members with a comprehensive patient assessment.

Third stage (workshop implementation)

Step 1. Presenting all stages of the nursing process based on the case study:

Providing a comprehensive assessment of the patient’s condition. (Giving time for students, faculty members, and presenters to discuss with each other, express their comments, and summarize)

Presenting diagnoses along with the objectives and expected outcomes. (Giving time for students, faculty members, and presenters to discuss with each other, express their comments, and summarize)

Presentation of nursing interventions. (Giving time for students, faculty members, and presenters to discuss with each other, express their comments, and summarize)

Presentation on assessing the level of achievement of expected outcomes and evaluating interventions. (Giving time for students, faculty members, and presenters to discuss with each other, express their comments, and summarize)

Data Collection Tools

Demographic questionnaire.

It included age, gender, Position, degree and number of sessions attended in the workshop.

Semi-structured interview

It included the following questions:

What was your motivation to attend these meetings?

Before entering the nursing process meetings, what did you expect from the meeting?

How many of your expectations were met by participating in the meetings?

How much did these meetings help you in applying the nursing process in the clinical setting?

What do you think about the continuation of such meetings?

Data collection

After obtaining official permission from the university in 2021, the phone numbers of students and faculty members who participated in more sessions of the workshop were collected in 2023. A specific time and location were subsequently arranged to contact and interview participants who had indicated their willingness to take part in the study. Approximately 40 individuals expressed their consent to participate; however, data saturation was achieved after interviewing 16 participants. It is important to note that interviews were conducted through both individual sessions and focus groups. Individual interviews were carried out with 3 faculty members, while two focus groups were conducted separately with 9 students and 4 faculty members.

Individual Interviews

The interviews were conducted in a semi-structured manner and began with a general question to establish initial and closing communication. These interviews were conducted by one of the researchers who holds a PhD in nursing and has published several qualitative articles in reputable journals. In each of these sessions, the interviewer introduced themselves and welcomed the participants. The goals of the session were discussed, and participants were given complete freedom to express their opinions. The interviewer refrained from interfering or reacting to their opinions, and the information discussed was kept completely confidential under the guise of a code. Participants were subsequently asked to provide consent for voice recording during the interviews. Once consent was obtained from the participants, their voices were recorded. Each individual interview lasted between 30 and 45 min.

Focus Group Interviews

All the conditions of these interviews were similar to individual interviews. However, in focus group sessions, an additional researcher acted as an assistant to the main interviewer. The assistant’s role was to determine the order of speaking based on the participants’ requests, observe their facial expressions while speaking, and take necessary notes. Each of the focus group sessions lasted approximately 5 h. It should be noted that participant selection and sampling continued until data saturation was achieved. Saturation of data refers to the repetition of information and the confirmation of previously collected data.

Data analysis

The qualitative content analysis approach proposed by Graneheim and Lundman was used for data analysis [ 16 ]. The recorded interviews were transcribed verbatim (The transcripts were sent to the participants for feedback and were approved by them), and then each word was carefully examined to identify codes Two independent individuals encoded the data. Words that accurately represented thoughts or concepts within the data were highlighted. Then, the researcher added her own notes about his thoughts, interpretations of the text, and initial analysis of the text. With the progression of this process, appropriate names for the codes emerged, and the codes were organized into subcategories. These subcategories were created to organize and categorize the codes within clusters. The researcher reorganized the subcategories based on their relationships, condensing them into a smaller number of organizational categories. And then the concepts of each category, subcategory, and code were developed.

Trustworthiness

Data was managed using the Lincoln and Guba criteria. These criteria include acceptability, which is equivalent to internal validity; transferability, which is equivalent to external validity; similarity, which is equivalent to reliability; and verifiability, which is equivalent to objectivity [ 17 ]. The use of member checks by participants is considered a technique for exploring the credibility of results. In this regard, the interview text and the primary codes extracted from it were made available to several participants to verify the accuracy with their experiences. External supervision was employed to ensure that the criterion of internal consistency was met. For this purpose, the data was given to a researcher who did not participate in the study. If there was agreement in the interpretation of the data, it confirmed the presence of internal consistency. Finally, an audit or verification inquiry was conducted. The researcher accurately recorded and reported all stages and processes of the research from beginning to end. This allows external supervisors to conduct audits and assess the credibility of the findings.

Data analysis resulted in the emergence of 13 subcategories, 4 categories, and 1 theme (Table  2 ).

Strengthening the intellectual infrastructure of accepting the nursing process

Subcategories such as “improving nursing perception,” “strengthening critical thinking,” “evidence-based nursing practice,” and “filling an educational gap” contributed to the emergence of the category “Strengthening the intellectual infrastructure of accepting the nursing process.”

Improving nursing perception

Participants’ experiences indicate the significant positive impact of the workshop on improving students’ perception of the nursing process. Most nurses in departments do not provide patient care based on the nursing process. As a result, students do not have the opportunity to practically experience the real application of the nursing process in the department. Instead, they only perceive the nursing process as a written task.

For me, it was a question of what the nursing process is, for instance. How difficult is it?” and it really helped me overcome my fear in a way. (P3 student) Usually, they would explain the nursing process to us, but it was not practical or based on real cases, like this. (P1 Student)

Strengthening critical thinking

Critical thinking is a fundamental skill in the nursing process that involves various stages and activities. These include questioning to gather adequate information, validating and analyzing information to comprehend the problem and its underlying factors, evaluating interventions, and making appropriate decisions for effective problem-solving. The experiences of the participating students clearly reflected the formation of these stages during the workshop sessions.

I learned in the workshop about the importance of using critical thinking to successfully connect knowledge and practice. It’s a shame that critical thinking has not been cultivated in the minds of students, and these workshops have laid the foundation for it in our minds. (P6 student) Students often come across hypothetical cases in textbooks, but when they are confronted with real cases, the circumstances are different… This is when critical thinking becomes crucial and the art of nursing is demonstrated… These sessions have made a significant contribution to this subject. (P15 Faculty member)

Evidence-based nursing practice

One of the features of the sessions was that in introducing the case from assessment to evaluation, to justify the rationale and process of collecting and formulating nursing diagnoses, establishing expected outcomes, and providing reasons for each intervention, relied on up-to-date and reliable nursing and medical resources

It had a strong scientific foundation, consistently emphasizing the importance of evidence-based practices and a scientific approach, effectively communicating this perspective to audience. (P2 Student). I became familiar with the book ‘Carpenito,’ and it helped me a lot in understanding my shortcomings. (P3 student). In my opinion, one of the factors that contributed to the effectiveness of the work was consulting the references. They emphasized that as a nurse, I should not solely rely on my personal opinion but should instead base my actions on the reference materials (P14 Faculty member).

Filling an educational gap

From the perspective of workshop participants, the workshop has increased their awareness of their limited knowledge about the application of the nursing process. It has also helped them recognize their shortcomings, and motivated them to pursue additional studies in this field.

Exactly, there was a vacant spot for this educational program in our classes. And there should have been sessions that would prove to us that nursing is not just about the theoretical concepts that faculty members teach in class. (P5 Student) The nursing process has a theoretical aspect that students learn, but when they attempt to apply it in practice, they often encounter difficulties. These sessions helped to fill the gap between theory and practice. (P15 Faculty member)

Practicality of the nursing process

Subcategories of “linking the nursing process with team care,” “demonstrating the role of the nursing process in improving care quality,” “comprehensive view in care,” and “student’s guiding light in the clinic,” Created the category “Practicality of the Nursing Process”.

Linking the nursing process with team care

Participants’ experiences indicated that participating in nursing process sessions helped them realize that the nursing process is a model that will lead to collaborative team care. Prior to attending these sessions, nursing students like nurses considered their duty to be solely executing medical orders under the supervision of clinical faculty members and staff nurses.

I realized that in certain situations, I am able to confidently express my opinion to the doctor. For instance, if I believe that a particular course of action would yield better results, I can easily communicate this and provide reasons to support my viewpoint (P7 Student). Teaching the pathway when it’s categorized with knowing what we’re assessing… Let’s go up to the patient; our confidence can really guide them along with us as we progress step by step and systematically. Often, the patient accompanies us, and sometimes they voice their unspoken concerns, which helps improve their care. It means the patient themselves are partnering with us. (P6 student)

Demonstrating the role of the nursing process in improving care quality

Strengthening the attitude and belief in the role and application of the nursing process in improving the quality of care was another concept that emerged from the experiences of the students. Presenting reports on the implementation of the nursing process on real cases led them to believe that providing care based on the nursing process results in organized care planning and enhances the quality of care.

In these workshops, the needs of patients were prioritized, documented, and then organized systematically. This concept remains ingrained in a person’s mind and enables us to deliver comprehensive care to the patient without overlooking any aspect. This has been very helpful for me, and now it greatly assists me in the clinic. (P4 Student) Another great aspect of these sessions was the emphasis they placed on the nurse-patient relationship. I could see that the students had been following up with patients for a while and implementing the process. This was very helpful to me. For instance, diagnosing based on the patient’s current health status was an ongoing process. In my opinion, the connection between the patient and nurse was more important and practical for me.(P1 Student).

Comprehensive view in care

Attention to the patient’s care needs went beyond focusing solely on physiological aspects. It involved a holistic approach that addressed the patient’s needs related to all aspects of biology, psychology, society, spirituality, and economics. This was clearly reflected in the students’ experiences during the nursing process sessions.

…I paid attention to all aspects of the patient. For example, perhaps I overlooked her anxiety issue and never took it into consideration. However, I eventually came to realize that addressing anxiety is crucial, as it is one of the primary concerns and needs of patients. (P2 Student) …that the students had a holistic view of the patient (they had examined the patient thoroughly, including the patient’s skin, etc.) and had compiled a list of the patient’s issues, paying attention to all aspects of the patient (P14 Faculty member).

Student’s guiding light in the clinic

One of the significant accomplishments of nursing process sessions, as evidenced by the students’ experiences, was the role of these sessions in assisting students in overcoming confusion and uncertainty during their internships. These sessions enabled them to establish a mental connection between the theoretical knowledge learned in the classroom and its application in the real clinical setting, also helped them understand how to effectively utilize their theoretical knowledge in a clinical learning environment.

.I was feeling incredibly lost and confused. I didn’t know what steps to take next. Many of us find ourselves in this situation, unsure of what to do. At least for me, as someone who grasps concepts better through examples, the case-based studies conducted during the workshop had a significant impact. (P6 Student)

Supporting a positive professional identity

Two subcategories, “highlighting the importance of nursing science” and “reforming the perception of nursing nature,” have contributed to the development of the category “supporting a positive professional identity.”

Highlighting the importance of nursing science

Based on students’ experiences, the nursing process sessions have been able to answer an important question. Why should they be bombarded with information and expected to possess extensive knowledge in the field of disease recognition, pathophysiology, diagnosis, treatment, and nursing care during their studies? The students believed that the content of the nursing process sessions clarified the necessity and importance of nursing knowledge for them. In these sessions, they came to believe that providing care based on the nursing process requires extensive nursing knowledge.

. In my opinion, this work showcases a significant strength by highlighting the importance of working scientifically as a nurse. Personally, I feel its impact on myself is profound. (P2 Student) In my opinion, it was very touching and captivating because it accurately portrayed the immense power of a nurse. However, amidst the demanding and difficult nature of the job, what specific details should a nurse pay attention to? and it is precisely these details that shape the work of a nurse. It was very interesting and beneficial for me. (P5 student)

Reforming the perception of nursing nature

The student is seeking ways to comprehend and value the practical aspects of nursing as a genuine science, assuming that nursing is indeed regarded as a science. Participants’ experiences have shown that nursing process sessions have been able to address this identity challenge and modify and enhance students’ understanding of the nature of nursing.

I used to believe that nursing was primarily an art complemented by science until I entered term 2 and participated in these workshops. And now I realize that it has the scientific foundation that I expected from an evidence-based practice. (P5 student). . The important point was that lower-term students, who sometimes lacked motivation and thought nursing had nothing to offer, gained motivation and had a change in perspective by attending these sessions. (P2 faculy members)

Self-directed learning facilitator

Subcategories of “stimulating a thirst for learning,” “creating a stress-free learning atmosphere,” and “teaching fishing,” formed the category of “self-directed learning facilitator.”

Stimulating a thirst for learning

Participants’ experiences indicated that the format of conducting sessions, ranging from step-by-step training to training accompanied by multiple examples, had a significant impact on creating a sense of necessity and stimulating learners’ motivation to learn.

First of all, the challenges that you yourself raised (faculty member) for example, why did you make this diagnosis?” Why did you include this action? Why is this a priority? Really, it shook me and made me think that maybe there is more to this, maybe there is more to the nursing process that I haven’t understood yet…. That’s why it became my motivation. (P3 student) …But these sessions helped me a lot. At least, they sparked my curiosity and motivated me to delve deeper into the subject. I began actively participating in these sessions and found them to be highly effective for my personal growth. (P6 student) In my opinion, one of the things that empowered the work was the act of seeking references. They emphasized that as a nurse, I should not solely rely on my personal opinion but should instead base my actions on credible sources. (P14 Faculty member)

Creating a stress-free learning atmosphere

Students believed that the absence of a legal requirement to attend these workshops, coupled with the understanding that their participation or non-participation would not be evaluated for grading purposes, would enable them to engage in these sessions without concern for their academic performance and in accordance with their own volition.

I was more scared… In my internships, for example, we would sit and talk with the instructor. However, the discussions primarily revolved around grades and other academic matters, which created a stressful environment where students were hesitant to freely express their thoughts. But the sessions here are very relaxed, and students no longer have the fear of grades. (P7 student) The essence of these sessions was that they came from the heart and inevitably touched the heart. The beauty of this program was that it was built on love. (P10 Faculty member)

Teaching fishing

Direct reference to teaching fishing in the participants’ experiences points to one of the very important features that effectively prepares the way for self-guided learning. The term “teaching fishing” was repeatedly mentioned in the participants’ experiences. They believed that these sessions served as a roadmap to easily enhance their knowledge and skills in the field of nursing process application.

.And actually, teaching fishing, as mentioned by other students, is important. In my opinion, it has a positive impact both professionally and in terms of the effectiveness of the nursing process. (P2 student) The important aspect was the involvement and full participation of the students, who prepared the materials themselves… The meaning and concept of being a student were more evident, and the talents of the students flourished. They actively participated in discussions about learning and education. (P15 Faculty member)

Planners, in their efforts to help students gain a better understanding of the nature and application of the nursing process, are constantly striving to innovate in teaching this model. The aim of the present study was to describe and explain the experiences of nursing students and faculty during clinical-based nursing process workshops involving real cases.

Hanisch et al. (2020) recommend using data from actual patients [ 18 ], and Yilmaz et al. (2015) suggest providing nursing students with opportunities to apply the nursing process in diverse patient populations during clinical training [ 19 ]. The study conducted by Karimi et al. (2011) demonstrated that organizing nursing process classes as workshops stimulated a sense of competition and superiority both among and within groups. This approach also enhanced participants’ concentration on learning the content of each session. In addition, the workshop fostered a sense of cooperation and cohesion among the students, which was evident in their increased interest and excitement [ 1 ]. The importance of utilizing workshop-based training with real clinical cases is clearly evident. When students receive data related to a real patient, they directly experience the clinical environment. This, in turn, leads to an improvement in their critical thinking and decision-making skills when they encounter similar cases. For this purpose, nursing educators can present the rich clinical cases they encounter during their internships in theory classes based on the stages of the nursing process. They can also ask students to present these cases for their peers to comment on and critique the care provided, in order to stimulate discussion.

The category of " Strengthening the intellectual infrastructure of accepting the nursing process " indicates that the teaching method used in this study has been able to help students better understand and recognize the nature and improvement of insight into the nursing process. In the study by Thuvaraka et al. (2018), 52% of participants strongly agreed on the necessity of having a positive attitude and insight towards the nursing process for its proper implementation [ 20 ]. According to the study by Mert et al. (2020), a lack of insight into the nursing profession and process can even lead students to consider dropping out of their studies [ 21 ]. The importance of reviewing the nursing education process to enhance this perception has been emphasized in various studies. Zamanzadeh et al. (2015) discuss several challenges in the implementation of the nursing process. These challenges include a lack of clarity regarding its meaning, differences in perspectives, and insufficient training leading to a lack of awareness on how to properly implement it [ 22 ]. More than 90% of students (93.5%) in the study conducted by Rajabpoor et al. (2018) [ 4 ] and over two-thirds (75.6%) of students in the study conducted by Sharghi et al. (2015) identified lack of proper training and insufficient time allocated for teaching as the most significant barriers to implementing the nursing process. They attributed this to traditional and routine teaching methods [ 23 ]. This causes students to undervalue the nursing process, perceiving it only at a theoretical level rather than practical. As a result, they become overwhelmed by the routine when working as clinical nurses [ 7 ]. Therefore, by teaching the case method based on real clinical cases, nursing instructors can strengthen students’ positive outlook and ability to apply the nursing process. This increases the percentage of students implementing the nursing process in clinical wards.

Strengthening critical thinking is one of the concepts derived from analyzing the experiences of the students and faculty who participated in the present study. Based on a review study by Carvalho et al. (2017), the utilization of the nursing process, particularly the stage of nursing diagnosis formulation, enables nurses to employ critical thinking in making judgments and providing clinical care [ 24 ]. This process also helps ensure the delivery of high-quality care [ 25 ]. But if the nursing process is presented in an undesirable manner, it suppresses critical thinking. According to Heidari et al. (2016), the nursing process resulted in students relying on copying from books, which led to a decline in creativity and an increase in their dissatisfaction [ 26 ]. According to the study conducted by Ghanbari et al. (2017), the implementation of collaborative workshops focused on the nursing process resulted in an improvement in critical thinking skills among nursing students [ 3 ]. Therefore, nursing instructors can teach theoretical classes based on the clinical cases they have experienced in the hospital. By doing so, students can immerse themselves in the clinical environment during theoretical classes, which significantly enhances their critical thinking skills.

The evidence-based nursing display was one of the achievements of nursing process educational workshops, which were based on real cases. Mackey et al. (2017) consider evidence-based practice as a means to bridge the gap between theory and practice in nursing education for undergraduate and graduate students [ 27 ]. And likewise, Sin et al. (2017) believe that nursing faculties are obligated to enhance the competence and knowledge of students for evidence-based practice by employing innovative methods [ 28 ]. Therefore, it is recommended that nursing instructors use up-to-date scientific references for nursing interventions when teaching about the nursing process of diseases. This practice helps students feel that the care they provide is supported by scientific evidence and motivating them to carry out nursing care more effectively.

One of the emerging concepts in this study was the focus on the practicality of the nursing process. In the study conducted by Agyeman-Yeboah et al. (2017), participants reported that new students and nurses tend to neglect the implementation of the nursing process when they observe experienced nurses failing to apply it in a scientific and systematic manner [ 5 ]. The lack of implementation of the nursing process by nurses is due to a lack of knowledge and a negative attitude towards it. Zerihun Adraro and Adugna Cherkos (2021) conducted a study in Ethiopia and found that the majority of nurses had inadequate knowledge, and half of them lacked a positive attitude towards the implementation of the nursing process [ 29 ]. In the study by Thuvaraka et al. (2018), only 17% of nurses had sufficient knowledge about the nursing process and implemented it [ 20 ]. One of the important experiences for students in the “Practicality of the Nursing Process” category is the development of their participatory and interprofessional spirit. They are encouraged to express their opinions about the care and treatment process of patients, rather than blindly following the doctor’s orders. According to a systematic review study, the level of physicians’ proficiency in their management systems is a significant issue for the healthcare system [ 22 ]. According to the study conducted by Nakhaee et al. (2017), doctors are the ones responsible for making decisions regarding all patient matters, while the efforts of nurses often go unappreciated. This lack of recognition can result in a decline in their self-esteem [ 30 ]. While according to Adamy et al. (2019), the implementation of the nursing process at a professional level is highly effective in creating an independent nursing role, rather than just serving as assistants to physicians. This implementation also enhances the credibility of the nursing profession [ 31 ]. The recommendation of the present researchers to nursing instructors is to take a significant step in enhancing the knowledge and independent spirit of nursing students by basing their teaching on real clinical cases. When students perceive that they have independence and are not merely following doctors’ orders, their engagement in operationalizing the nursing process and evidence-based care will increase.

Strengthening the holistic perspective was one of the positive experiences for students and faculty members who attended these workshops. According to the study by Hackett et al. (2017), physical problems can result in mental stress among patients. Therefore, it is essential to consider all dimensions of care [ 32 ]. According to Ericsson (1995), humans should be considered as a whole, and nursing care should be tailored to address biological, psychological, social, and spiritual aspects [ 33 ]. The importance of holistic care has been emphasized by Florence Nightingale, who encouraged caregivers to practice it [ 34 ]. Holistic care emphasizes partnership and dialogue between nurse and patient about health care needs [ 35 ]. Adequate training is crucial in ensuring that nurses and nursing students are well-prepared to meet the diverse needs of patients and deliver comprehensive care [ 36 ]. It is recommended for nursing instructors to focus on the mental aspect in addition to the physical aspect when teaching the nursing process and encourage students to apply this approach during clinical internships.

Another advantage of these sessions was the successful implementation of the nursing process in apprenticeship. Work disorder and confusion in implementing the nursing process are significant challenges. According to the study by Korkut et al. (2021), students were unable to collect appropriate data from their patients and were confused when formulating and prioritizing nursing diagnoses, determining goals, and planning care. However, due to the fear of receiving a low grade, they were compelled to present fabricated data [ 37 ]. Therefore, nursing instructors should incorporate real clinical cases encountered during internships into their theoretical classes. This simulation helps students perform better in implementing the nursing process in the hospital environment later on.

During these workshop sessions, the students’ awareness of the professional identity of nursing was heightened. They came to understand that this professional identity is a crucial principle that underpins their comprehension of nursing and scientific care. As a result, they recognized the significance of studying pathophysiology and the fundamental principles of scientific care for different diseases. Professional identity is described as a person’s perception of themselves within a profession or the collective identity of the profession [ 38 ]. In nursing, professional identity plays a crucial role in delivering high-quality services to patients [ 39 ] because it effectively enhances clinical competence, self-assurance, self-esteem, and interpersonal communication skills [ 40 , 41 ]. In this regard, the study by Sun et al. (2016) found that professional identity and education level had the greatest impact on the stress levels of nursing students. The results of that study showed that developing and enhancing professional identity could be beneficial for nursing students in managing stress [ 42 ]. Similarly, according to the study by Sabanciogullari et al. (2015), there was a positive and significant correlation between nurses’ job satisfaction and professional identity. This study found that 15.5% of nurses who intended to leave their profession had insufficient professional identity and lower job satisfaction. Professional identity is a significant factor in job satisfaction [ 41 ]. According to the study by Van der Cingel et al. (2021), a lack of attention to the professional identity of nursing contributes to the departure of nursing students and young nurses from the nursing profession [ 43 ]. Therefore, focusing on professional identity in nursing education is crucial and should be a primary objective [ 38 ], despite findings from Haghighat et al. (2019) indicating that nursing education programs in Iran have not effectively nurtured nursing students [ 44 ]. This highlights a greater focus on teaching based on real clinical cases, which enhances the professional identity of nursing and facilitates the implementation of the nursing process.

“Self-directed learning facilitator” is one of the important categories identified in the present study. It encompasses three crucial concepts: “stimulating a thirst for learning”, “creating a stress-free learning atmosphere”, and “teaching fishing”. The students’ experiences indicated that engaging in discussions, asking questions, and providing answers had a significant impact on motivating them to study and enhancing their motivation for learning. This learning took place in a calm and stress-free environment. Participants were able to analyze the content calmly, as grades were not involved. As a result, they were able to diagnose what to prioritize in a clinical setting, even without the assistance of a clinical instructor. In fact, during these sessions, the instructors focused on teaching the students how to fish instead of simply giving them fish. As a result, the students’ spirit of independent learning increased. Kholmuratovich et al. (2020) stated in their study that independent learning helps students to learn effectively and efficiently [ 45 ]. It increases their independence and critical thinking skills, while also effectively enhancing their self-esteem and motivation [ 46 ]. For this reason, Lau et al. (2017) recommend promoting this teaching method in their study [ 47 ]. Based on the aforementioned studies, independent and self-directed learning leads to improved comprehension and learning, increased motivation, enhanced self-confidence, and critical thinking among students. Consequently, it can be argued that teaching based on clinical cases and workshop-based approaches, beyond aiding students in better understanding and applying the nursing process, has the potential to transform students’ overall learning approach.

Teaching the nursing process through workshops based on clinical cases has broken the taboo surrounding the application of the nursing process. The organization of these workshops in a friendly and stress-free environment, where real clinical cases were discussed, analyzed, and criticized, motivated the students to apply the nursing process in clinical setting. This approach led to a correction in their perception that they considered the implementation of the nursing process as time-consuming and unnecessary, and it also increased the students’ critical thinking abilities. The nature and process of conducting the workshops proved to be beneficial in implementing the theoretical standards in practical settings. The nursing interventions program was evidence based. This approach not only fostered students’ motivation for self-directed learning but also heightened their curiosity for acquiring knowledge. In these sessions, the approach involved teaching students how to fish rather than simply giving them fish. On the other hand, one of the significant challenges in the application of the nursing process in clinical practice by students is the lack of knowledge and skills among nurses to provide care based on the nursing process, it is recommended that these workshops also be conducted for nurses. Furthermore, action research should be employed to evaluate the role of this educational approach in enhancing the knowledge and skills of clinical nurses.

Limitations

Considering that the workshops had to be held outside of the regular class hours of the faculty, which is at 16:00, and taking into account the transportation issues of the students, the workshops could only continue until 18:00. The limitations of this study include the restricted hours and duration of these workshops. Another limitation of this study is the lack of implementation of nursing interventions by the researchers for the patient and subsequently the real evaluation of the interventions performed, due to ethical considerations. In fact, considering that the biggest problem for students is the application of the nursing process related to assessment, diagnosis, and planning, the focus of the workshops was on these stages. However, it seems that by covering all stages of the nursing process in educational workshops, the challenges faced by students in the implementation and evaluation stages can also be addressed.

Data availability

The data that support the findings of this study are available from the cor - responding author upon reasonable request.

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Acknowledgements

The researchers would like to express their gratitude to the students and professors who participated in the workshops and Student Research Committee of Isfahan University of Medical Sciences.

This study was financed by the Student Vice Chancellor for Research of Isfahan University of Medical Sciences (Project number 1400254).

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ASH, PA, FG designed the study. ASH, PA, FG, EA, SHA, FS helded the Workshops. PA interviewed the participants. ASH and FG wrote the interviews. PA, EA and SHA analyzed the interviews. ASH, PA and FS prepared the manuscript, and all authors read and approved the final manuscript.

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This study has been approved by the ethics committee of Isfahan University of Medical Sciences (IR.MUI.NUREMA.REC.1400.139) in 2021. Initially, the research purpose was explained to the patients and their caregivers. They were informed that participation in the research is entirely voluntary and free of charge. Not participating in the research would not affect their care and treatment interventions. They were assured that they could withdraw from the research at any time. Furthermore, it was emphasized that their information would be presented in the workshop in a strictly confidential manner, without disclosing their names, photos, file numbers, etc. Subsequently, both oral and written consent were obtained from them. After that, the study’s purpose was also explained to nursing students and faculty members, and informed oral and written consent was obtained from them. Numeric codes were used instead of personal names to ensure the confidentiality of the interviews. The participants were free to withdraw from the study at any time. All methods were conducted following the applicable guidelines and regulations.

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Shahzeydi, A., Abazari, P., Gorji-varnosfaderani, F. et al. Breaking the taboo of using the nursing process: lived experiences of nursing students and faculty members. BMC Nurs 23 , 621 (2024). https://doi.org/10.1186/s12912-024-02233-z

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

Eunhee choi.

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

Jaehee Jeon

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

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

1. Introduction

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

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

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

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

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

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

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

2. Materials and Methods

2.1. design.

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

2.2. Participants and Procedures

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

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

2.3. Instruments

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

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

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

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

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

2.4. Statistical Analysis

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

2.5. Ethical Considerations

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

3.1. General Characteristics

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

General Characteristics of Participants (N = 192).

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

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

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

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

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

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

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

† Scheffé test; ‡ PBL, problem based learning.

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

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

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

3.5. Factors Influencing Problem-Solving Ability

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

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

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

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

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

4. Discussion

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

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

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

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

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

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

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

5. Conclusions

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

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

Acknowledgments

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

Funding Statement

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

Author Contributions

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

Institutional Review Board Statement

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

Informed Consent Statement

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

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

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