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Critical Thinking in Nursing: Tips to Develop the Skill

4 min read • February, 09 2024

Critical thinking in nursing helps caregivers make decisions that lead to optimal patient care. In school, educators and clinical instructors introduced you to critical-thinking examples in nursing. These educators encouraged using learning tools for assessment, diagnosis, planning, implementation, and evaluation.

Nurturing these invaluable skills continues once you begin practicing. Critical thinking is essential to providing quality patient care and should continue to grow throughout your nursing career until it becomes second nature. 

What Is Critical Thinking in Nursing?

Critical thinking in nursing involves identifying a problem, determining the best solution, and implementing an effective method to resolve the issue using clinical decision-making skills.

Reflection comes next. Carefully consider whether your actions led to the right solution or if there may have been a better course of action.

Remember, there's no one-size-fits-all treatment method — you must determine what's best for each patient.

How Is Critical Thinking Important for Nurses? 

As a patient's primary contact, a nurse is typically the first to notice changes in their status. One example of critical thinking in nursing is interpreting these changes with an open mind. Make impartial decisions based on evidence rather than opinions. By applying critical-thinking skills to anticipate and understand your patients' needs, you can positively impact their quality of care and outcomes.

Elements of Critical Thinking in Nursing

To assess situations and make informed decisions, nurses must integrate these specific elements into their practice:

• Clinical judgment. Prioritize a patient's care needs and make adjustments as changes occur. Gather the necessary information and determine what nursing intervention is needed. Keep in mind that there may be multiple options. Use your critical-thinking skills to interpret and understand the importance of test results and the patient’s clinical presentation, including their vital signs. Then prioritize interventions and anticipate potential complications. 
• Patient safety. Recognize deviations from the norm and take action to prevent harm to the patient. Suppose you don't think a change in a patient's medication is appropriate for their treatment. Before giving the medication, question the physician's rationale for the modification to avoid a potential error. 
• Communication and collaboration. Ask relevant questions and actively listen to others while avoiding judgment. Promoting a collaborative environment may lead to improved patient outcomes and interdisciplinary communication. 
• Problem-solving skills. Practicing your problem-solving skills can improve your critical-thinking skills. Analyze the problem, consider alternate solutions, and implement the most appropriate one. Besides assessing patient conditions, you can apply these skills to other challenges, such as staffing issues . 

How to Develop and Apply Critical-Thinking Skills in Nursing

Critical-thinking skills develop as you gain experience and advance in your career. The ability to predict and respond to nursing challenges increases as you expand your knowledge and encounter real-life patient care scenarios outside of what you learned from a textbook. 

Here are five ways to nurture your critical-thinking skills:

• Be a lifelong learner. Continuous learning through educational courses and professional development lets you stay current with evidence-based practice . That knowledge helps you make informed decisions in stressful moments.  
• Practice reflection. Allow time each day to reflect on successes and areas for improvement. This self-awareness can help identify your strengths, weaknesses, and personal biases to guide your decision-making.
• Open your mind. Don't assume you're right. Ask for opinions and consider the viewpoints of other nurses, mentors , and interdisciplinary team members.
• Use critical-thinking tools. Structure your thinking by incorporating nursing process steps or a SWOT analysis (strengths, weaknesses, opportunities, and threats) to organize information, evaluate options, and identify underlying issues.
• Be curious. Challenge assumptions by asking questions to ensure current care methods are valid, relevant, and supported by evidence-based practice .

Critical thinking in nursing is invaluable for safe, effective, patient-centered care. You can successfully navigate challenges in the ever-changing health care environment by continually developing and applying these skills.

Images sourced from Getty Images

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Factors influencing on problem solving ability of nursing students experiencing simulation practice.

1. Introduction

1.1. background, 1.2. study purpose, 2. methodology, 2.1. study design, 2.2. sampling strategy, 2.3. ethical considerations, 2.4. study methods, 2.5. data collection method, 2.6. data analysis, 3.1. general characteristics of study participants, 3.2. problem-solving abilities according to general characteristics, 3.3. correlation between subjects’ self-leadership, goal commitment, critical thinking, and problem-solving abilities, 3.4. influential factors on problem-solving abilities of nursing undergraduates with the experience of simulated practice training, 4. discussion, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Share and Cite

Jo, H.H.; Hwang, W.J. Factors Influencing on Problem Solving Ability of Nursing Students Experiencing Simulation Practice. Int. J. Environ. Res. Public Health 2022 , 19 , 11744. https://doi.org/10.3390/ijerph191811744

Jo HH, Hwang WJ. Factors Influencing on Problem Solving Ability of Nursing Students Experiencing Simulation Practice. International Journal of Environmental Research and Public Health . 2022; 19(18):11744. https://doi.org/10.3390/ijerph191811744

Jo, Hyun Hee, and Won Ju Hwang. 2022. "Factors Influencing on Problem Solving Ability of Nursing Students Experiencing Simulation Practice" International Journal of Environmental Research and Public Health 19, no. 18: 11744. https://doi.org/10.3390/ijerph191811744

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• Research article
• Open access
• Published: 07 October 2020

Impact of social problem-solving training on critical thinking and decision making of nursing students

• Soleiman Ahmady 1 &
• Sara Shahbazi   ORCID: orcid.org/0000-0001-8397-6233 2 , 3  

BMC Nursing volume  19 , Article number:  94 ( 2020 ) Cite this article

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The complex health system and challenging patient care environment require experienced nurses, especially those with high cognitive skills such as problem-solving, decision- making and critical thinking. Therefore, this study investigated the impact of social problem-solving training on nursing students’ critical thinking and decision-making.

This study was quasi-experimental research and pre-test and post-test design and performed on 40 undergraduate/four-year students of nursing in Borujen Nursing School/Iran that was randomly divided into 2 groups; experimental ( n  = 20) and control (n = 20). Then, a social problem-solving course was held for the experimental group. A demographic questionnaire, social problem-solving inventory-revised, California critical thinking test, and decision-making questionnaire was used to collect the information. The reliability and validity of all of them were confirmed. Data analysis was performed using SPSS software and independent sampled T-test, paired T-test, square chi, and Pearson correlation coefficient.

The finding indicated that the social problem-solving course positively affected the student’ social problem-solving and decision-making and critical thinking skills after the instructional course in the experimental group ( P  < 0.05), but this result was not observed in the control group ( P  > 0.05).

Conclusions

The results showed that structured social problem-solving training could improve cognitive problem-solving, critical thinking, and decision-making skills. Considering this result, nursing education should be presented using new strategies and creative and different ways from traditional education methods. Cognitive skills training should be integrated in the nursing curriculum. Therefore, training cognitive skills such as problem- solving to nursing students is recommended.

Peer Review reports

Continuous monitoring and providing high-quality care to patients is one of the main tasks of nurses. Nurses’ roles are diverse and include care, educational, supportive, and interventional roles when dealing with patients’ clinical problems [ 1 , 2 ].

Providing professional nursing services requires the cognitive skills such as problem-solving, decision-making and critical thinking, and information synthesis [ 3 ].

Problem-solving is an essential skill in nursing. Improving this skill is very important for nurses because it is an intellectual process which requires the reflection and creative thinking [ 4 ].

Problem-solving skill means acquiring knowledge to reach a solution, and a person’s ability to use this knowledge to find a solution requires critical thinking. The promotion of these skills is considered a necessary condition for nurses’ performance in the nursing profession [ 5 , 6 ].

Managing the complexities and challenges of health systems requires competent nurses with high levels of critical thinking skills. A nurse’s critical thinking skills can affect patient safety because it enables nurses to correctly diagnose the patient’s initial problem and take the right action for the right reason [ 4 , 7 , 8 ].

Problem-solving and decision-making are complex and difficult processes for nurses, because they have to care for multiple patients with different problems in complex and unpredictable treatment environments [ 9 , 10 ].

Clinical decision making is an important element of professional nursing care; nurses’ ability to form effective clinical decisions is the most significant issue affecting the care standard. Nurses build 2 kinds of choices associated with the practice: patient care decisions that affect direct patient care and occupational decisions that affect the work context or teams [ 11 , 12 , 13 , 14 , 15 , 16 ].

The utilization of nursing process guarantees the provision of professional and effective care. The nursing process provides nurses with the chance to learn problem-solving skills through teamwork, health management, and patient care. Problem-solving is at the heart of nursing process which is why this skill underlies all nursing practices. Therefore, proper training of this skill in an undergraduate nursing program is essential [ 17 ].

Nursing students face unique problems which are specific to the clinical and therapeutic environment, causing a lot of stresses during clinical education. This stress can affect their problem- solving skills [ 18 , 19 , 20 , 21 ]. They need to promote their problem-solving and critical thinking skills to meet the complex needs of current healthcare settings and should be able to respond to changing circumstances and apply knowledge and skills in different clinical situations [ 22 ]. Institutions should provide this important opportunity for them.

Despite, the results of studies in nursing students show the weakness of their problem-solving skills, while in complex health environments and exposure to emerging diseases, nurses need to diagnose problems and solve them rapidly accurately. The teaching of these skills should begin in college and continue in health care environments [ 5 , 23 , 24 ].

It should not be forgotten that in addition to the problems caused by the patients’ disease, a large proportion of the problems facing nurses are related to the procedures of the natural life of their patients and their families, the majority of nurses with the rest of health team and the various roles defined for nurses [ 25 ].

Therefore, in addition to above- mentioned issues, other ability is required to deal with common problems in the working environment for nurses, the skill is “social problem solving”, because the term social problem-solving includes a method of problem-solving in the “natural context” or the “real world” [ 26 , 27 ]. In reviewing the existing research literature on the competencies and skills required by nursing students, what attracts a lot of attention is the weakness of basic skills and the lack of formal and systematic training of these skills in the nursing curriculum, it indicates a gap in this area [ 5 , 24 , 25 ]. In this regard, the researchers tried to reduce this significant gap by holding a formal problem-solving skills training course, emphasizing the common social issues in the real world of work. Therefore, this study was conducted to investigate the impact of social problem-solving skills training on nursing students’ critical thinking and decision-making.

Setting and sample

This quasi-experimental study with pretest and post-test design was performed on 40 undergraduate/four-year nursing students in Borujen nursing school in Shahrekord University of Medical Sciences. The periods of data collection were 4 months.

According to the fact that senior students of nursing have passed clinical training and internship programs, they have more familiarity with wards and treatment areas, patients and issues in treatment areas and also they have faced the problems which the nurses have with other health team personnel and patients and their families, they have been chosen for this study. Therefore, this study’s sampling method was based on the purpose, and the sample size was equal to the total population. The whole of four-year nursing students participated in this study and the sample size was 40 members. Participants was randomly divided in 2 groups; experimental ( n  = 20) and control (n = 20).

The inclusion criteria to take part in the present research were students’ willingness to take part, studying in the four-year nursing, not having the record of psychological sickness or using the related drugs (all based on their self-utterance).

Intervention

At the beginning of study, all students completed the demographic information’ questionnaire. The study’s intervening variables were controlled between the two groups [such as age, marital status, work experience, training courses, psychological illness, psychiatric medication use and improving cognitive skills courses (critical thinking, problem- solving, and decision making in the last 6 months)]. Both groups were homogeneous in terms of demographic variables ( P  > 0.05). Decision making and critical thinking skills and social problem solving of participants in 2 groups was evaluated before and 1 month after the intervention.

All questionnaires were anonymous and had an identification code which carefully distributed by the researcher.

To control the transfer of information among the students of two groups, the classification list of students for internships, provided by the head of nursing department at the beginning of semester, was used.

Furthermore, the groups with the odd number of experimental group and the groups with the even number formed the control group and thus were less in contact with each other.

The importance of not transferring information among groups was fully described to the experimental group. They were asked not to provide any information about the course to the students of the control group.

Then, training a course of social problem-solving skills for the experimental group, given in a separate course and the period from the nursing curriculum and was held in 8 sessions during 2 months, using small group discussion, brainstorming, case-based discussion, and reaching the solution in small 4 member groups, taking results of the social problem-solving model as mentioned by D-zurilla and gold fried [ 26 ]. The instructor was an assistant professor of university and had a history of teaching problem-solving courses. This model’ stages are explained in Table  1 .

All training sessions were performed due to the model, and one step of the model was implemented in each session. In each session, the teacher stated the educational objectives and asked the students to share their experiences in dealing to various workplace problems, home and community due to the topic of session. Besides, in each session, a case-based scenario was presented and thoroughly analyzed, and students discussed it.

Instruments

In this study, the data were collected using demographic variables questionnaire and social problem- solving inventory – revised (SPSI-R) developed by D’zurilla and Nezu (2002) [ 26 ], California critical thinking skills test- form B (CCTST; 1994) [ 27 , 28 ] and decision-making questionnaire.

SPSI-R is a self - reporting tool with 52 questions ranging from a Likert scale (1: Absolutely not – 5: very much).

The minimum score maybe 25 and at a maximum of 125, therefore:

The score 25 and 50: weak social problem-solving skills.

The score 50–75: moderate social problem-solving skills.

The score higher of 75: strong social problem-solving skills.

The reliability assessed by repeated tests is between 0.68 and 0.91, and its alpha coefficient between 0.69 and 0.95 was reported [ 26 ]. The structural validity of questionnaire has also been confirmed. All validity analyses have confirmed SPSI as a social problem - solving scale.

In Iran, the alpha coefficient of 0.85 is measured for five factors, and the retest reliability coefficient was obtained 0.88. All of the narratives analyzes confirmed SPSI as a social problem- solving scale [ 29 ].

California critical thinking skills test- form B(CCTST; 1994): This test is a standard tool for assessing the basic skills of critical thinking at the high school and higher education levels (Facione & Facione, 1992, 1998) [ 27 ].

This tool has 34 multiple-choice questions which assessed analysis, inference, and argument evaluation. Facione and Facione (1993) reported that a KR-20 range of 0.65 to 0.75 for this tool is acceptable [ 27 ].

In Iran, the KR-20 for the total scale was 0.62. This coefficient is acceptable for questionnaires that measure the level of thinking ability of individuals.

After changing the English names of this questionnaire to Persian, its content validity was approved by the Board of Experts.

The subscale analysis of Persian version of CCTST showed a positive high level of correlation between total test score and the components (analysis, r = 0.61; evaluation, r = 0.71; inference, r = 0.88; inductive reasoning, r = 0.73; and deductive reasoning, r = 0.74) [ 28 ].

A decision-making questionnaire with 20 questions was used to measure decision-making skills. This questionnaire was made by a researcher and was prepared under the supervision of a professor with psychometric expertise. Five professors confirmed the face and content validity of this questionnaire. The reliability was obtained at 0.87 which confirmed for 30 students using the test-retest method at a time interval of 2 weeks. Each question had four levels and a score from 0.25 to 1. The minimum score of this questionnaire was 5, and the maximum score was 20 [ 30 ].

Statistical analysis

For analyzing the applied data, the SPSS Version 16, and descriptive statistics tests, independent sample T-test, paired T-test, Pearson correlation coefficient, and square chi were used. The significant level was taken P  < 0.05.

The average age of students was 21.7 ± 1.34, and the academic average total score was 16.32 ± 2.83. Other demographic characteristics are presented in Table  2 .

None of the students had a history of psychiatric illness or psychiatric drug use. Findings obtained from the chi-square test showed that there is not any significant difference between the two groups statistically in terms of demographic variables.

The mean scores in social decision making, critical thinking, and decision-making in whole samples before intervention showed no significant difference between the two groups statistically ( P  > 0.05), but showed a significant difference after the intervention ( P  < 0.05) (Table  3 ).

Scores in Table  4 showed a significant positive difference before and after intervention in the “experimental” group ( P  < 0.05), but this difference was not seen in the control group ( P  > 0.05).

Among the demographic variables, only a positive relationship was seen between marital status and decision-making skills (r = 0.72, P  < 0.05).

Also, the scores of critical thinking skill’ subgroups and social problem solving’ subgroups are presented in Tables  5 and 6 which showed a significant positive difference before and after intervention in the “experimental” group (P < 0.05), but this difference was not seen in the control group ( P  > 0.05).

In the present study conducted by some studies, problem-solving and critical thinking and decision-making scores of nursing students are moderate [ 5 , 24 , 31 ].

The results showed that problem-solving skills, critical thinking, and decision-making in nursing students were promoted through a social problem-solving training course. Unfortunately, no study has examined the effect of teaching social problem-solving skills on nursing students’ critical thinking and decision-making skills.

Altun (2018) believes that if the values of truth and human dignity are promoted in students, it will help them acquire problem-solving skills. Free discussion between students and faculty on value topics can lead to the development of students’ information processing in values. Developing self-awareness increases students’ impartiality and problem-solving ability [ 5 ]. The results of this study are consistent to the results of present study.

Erozkan (2017), in his study, reported there is a significant relationship between social problem solving and social self-efficacy and the sub-dimensions of social problem solving [ 32 ]. In the present study, social problem -solving skills training has improved problem -solving skills and its subdivisions.

The results of study by Moshirabadi (2015) showed that the mean score of total problem-solving skills was 89.52 ± 21.58 and this average was lower in fourth-year students than other students. He explained that education should improve students’ problem-solving skills. Because nursing students with advanced problem-solving skills are vital to today’s evolving society [ 22 ]. In the present study, the results showed students’ weakness in the skills in question, and holding a social problem-solving skills training course could increase the level of these skills.

Çinar (2010) reported midwives and nurses are expected to use problem-solving strategies and effective decision-making in their work, using rich basic knowledge.

These skills should be developed throughout one’s profession. The results of this study showed that academic education could increase problem-solving skills of nursing and midwifery students, and final year students have higher skill levels [ 23 ].

Bayani (2012) reported that the ability to solve social problems has a determining role in mental health. Problem-solving training can lead to a level upgrade of mental health and quality of life [ 33 ]; These results agree with the results obtained in our study.

Conducted by this study, Kocoglu (2016) reported nurses’ understanding of their problem-solving skills is moderate. Receiving advice and support from qualified nursing managers and educators can enhance this skill and positively impact their behavior [ 31 ].

Kashaninia (2015), in her study, reported teaching critical thinking skills can promote critical thinking and the application of rational decision-making styles by nurses.

One of the main components of sound performance in nursing is nurses’ ability to process information and make good decisions; these abilities themselves require critical thinking. Therefore, universities should envisage educational and supportive programs emphasizing critical thinking to cultivate their students’ professional competencies, decision-making, problem-solving, and self-efficacy [ 34 ].

The study results of Kirmizi (2015) also showed a moderate positive relationship between critical thinking and problem-solving skills [ 35 ].

Hong (2015) reported that using continuing PBL training promotes reflection and critical thinking in clinical nurses. Applying brainstorming in PBL increases the motivation to participate collaboratively and encourages teamwork. Learners become familiar with different perspectives on patients’ problems and gain a more comprehensive understanding. Achieving these competencies is the basis of clinical decision-making in nursing. The dynamic and ongoing involvement of clinical staff can bridge the gap between theory and practice [ 36 ].

Ancel (2016) emphasizes that structured and managed problem-solving training can increase students’ confidence in applying problem-solving skills and help them achieve self-confidence. He reported that nursing students want to be taught in more innovative ways than traditional teaching methods which cognitive skills training should be included in their curriculum. To this end, university faculties and lecturers should believe in the importance of strategies used in teaching and the richness of educational content offered to students [ 17 ].

The results of these recent studies are adjusted with the finding of recent research and emphasize the importance of structured teaching cognitive skills to nurses and nursing students.

Based on the results of this study on improving critical thinking and decision-making skills in the intervention group, researchers guess the reasons to achieve the results of study in the following cases:

In nursing internationally, problem-solving skills (PS) have been introduced as a key strategy for better patient care [ 17 ]. Problem-solving can be defined as a self-oriented cognitive-behavioral process used to identify or discover effective solutions to a special problem in everyday life. In particular, the application of this cognitive-behavioral methodology identifies a wide range of possible effective solutions to a particular problem and enhancement the likelihood of selecting the most effective solution from among the various options [ 27 ].

In social problem-solving theory, there is a difference among the concepts of problem-solving and solution implementation, because the concepts of these two processes are different, and in practice, they require different skills.

In the problem-solving process, we seek to find solutions to specific problems, while in the implementation of solution, the process of implementing those solutions in the real problematic situation is considered [ 25 , 26 ].

The use of D’zurilla and Goldfride’s social problem-solving model was effective in achieving the study results because of its theoretical foundations and the usage of the principles of cognitive reinforcement skills. Social problem solving is considered an intellectual, logical, effort-based, and deliberate activity [ 26 , 32 ]; therefore, using this model can also affect other skills that need recognition.

In this study, problem-solving training from case studies and group discussion methods, brainstorming, and activity in small groups, was used.

There are significant educational achievements in using small- group learning strategies. The limited number of learners in each group increases the interaction between learners, instructors, and content. In this way, the teacher will be able to predict activities and apply techniques that will lead students to achieve high cognitive taxonomy levels. That is, confront students with assignments and activities that force them to use cognitive processes such as analysis, reasoning, evaluation, and criticism.

In small groups, students are given the opportunity to the enquiry, discuss differences of opinion, and come up with solutions. This method creates a comprehensive understanding of the subject for the student [ 36 ].

According to the results, social problem solving increases the nurses’ decision-making ability and critical thinking regarding identifying the patient’s needs and choosing the best nursing procedures. According to what was discussed, the implementation of this intervention in larger groups and in different levels of education by teaching other cognitive skills and examining their impact on other cognitive skills of nursing students, in the future, is recommended.

Social problem- solving training by affecting critical thinking skills and decision-making of nursing students increases patient safety. It improves the quality of care because patients’ needs are better identified and analyzed, and the best solutions are adopted to solve the problem.

In the end, the implementation of this intervention in larger groups in different levels of education by teaching other cognitive skills and examining their impact on other cognitive skills of nursing students in the future is recommended.

Study limitations

This study was performed on fourth-year nursing students, but the students of other levels should be studied during a cohort from the beginning to the end of course to monitor the cognitive skills improvement.

The promotion of high-level cognitive skills is one of the main goals of higher education. It is very necessary to adopt appropriate approaches to improve the level of thinking. According to this study results, the teachers and planners are expected to use effective approaches and models such as D’zurilla and Goldfride social problem solving to improve problem-solving, critical thinking, and decision-making skills. What has been confirmed in this study is that the routine training in the control group should, as it should, has not been able to improve the students’ critical thinking skills, and the traditional educational system needs to be transformed and reviewed to achieve this goal.

Availability of data and materials

The datasets used and analyzed during the present study are available from the corresponding author on reasonable request.

Abbreviations

California critical thinking skills test

Social problem-solving inventory – revised

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Acknowledgments

This article results from research project No. 980 approved by the Research and Technology Department of Shahrekord University of Medical Sciences. We would like to appreciate to all personnel and students of the Borujen Nursing School. The efforts of all those who assisted us throughout this research.

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SA and SSH conceptualized the study, developed the proposal, coordinated the project, completed initial data entry and analysis, and wrote the report. SSH conducted the statistical analyses. SA and SSH assisted in writing and editing the final report. All authors read and approved the final manuscript.

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Ahmady, S., Shahbazi, S. Impact of social problem-solving training on critical thinking and decision making of nursing students. BMC Nurs 19 , 94 (2020). https://doi.org/10.1186/s12912-020-00487-x

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Academic success program, strategies for problem solving.

Nursing students will be expected to have or develop strong problem-solving skills. Problem solving is centered on your ability to identify critical issues and create or identify solutions. Well-developed problem solving skills is a characteristic of a successful student. Remember, problems are a part of everyday life and your ability to resolve problems will have a positive influence on your future.

6 Steps of Problem Solving

Step 1: Identify and Define the Problem

It is not difficult to overlook the true problem in a situation and focus your attention on issues that are not relevant. This is why it is important that you look at the problem from different perspectives. This provides a broad view of the situation that allows you to weed out factors that are not important and identify the root cause of the problem.

Step 2: Analyze the Problem

Break down the problem to get an understanding of the problem. Determine how the problem developed. Determine the impact of the problem.

Step 3: Develop Solutions

Brainstorm and list all possible solutions that focus on resolving the identified problem. Do not eliminate any possible solutions at this stage.

Step 4: Analyze and Select the Best Solution

List the advantages and disadvantages of each solution before deciding on a course of action. Review the advantages and disadvantages of each possible solution. Determine how the solution will resolve the problem. What are the short-term and long-term disadvantages of each solution? What are the possible short-term and long-term benefits of each solution? Which solution will help you meet your goals?

Step 5: Implement the Solution

Create a plan of action. Decide how you will move forward with your decision by determining the steps you must take to ensure that you move forward with your solution. Now, execute your plan of action.

Step 6: Evaluate the Solution

Monitor your decision. Assess the results of your solution. Are you satisfied with the results? Did your solution resolve the problem? Did it produce a new problem? Do you have to modify your solution to achieve better results? Are you closer to achieving your goal? What have you learned?

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Relationship Between the Problem-Solving Skills and Empathy Skills of Operating Room Nurses

AY, Fatma 1* ; POLAT, Şehrinaz; KASHIMI, Tennur

1 PhD, RN, Assistant Professor, Faculty of Health Sciences, Department of Midwifery, Istanbul University-Cerrahpaşa, Turkey

2 PhD, RN, Directorate of Nursing Services, Hospital of Faculty of Medicine, Istanbul University, Turkey

3 MS, RN, Director, Operating Room, Hospital of Faculty of Medicine, Istanbul University, Turkey.

Accepted for publication: January 21, 2019

*Address correspondence to: Fatma AY, No.25, Dr. Tevfik Saglam Street, Dr. Zuhuratbaba District, Bakirkoy, Istanbul 34147, Turkey. Tel: +90 212 4141500 ext. 40140; Fax: +90 212 4141515; E-mail: [email protected]

The authors declare no conflicts of interest.

Cite this article as: Ay, F., Polat, Ş., & Kashimi, T. (2019). Relationship between the problem-solving skills and empathy skills of operating room nurses. The Journal of Nursing Research , 28 (2), e75. https://doi.org/10.1097/jnr.0000000000000357

This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY) , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background 

The use of empathy in problem solving and communication is a focus of nursing practice and is of great significance in raising the quality of patient care.

Purpose 

The purposes of this study are to investigate the relationship between problem solving and empathy among operating room nurses and to explore the factors that relate to these two competencies.

Methods 

This is a cross-sectional, descriptive study. Study data were gathered using a personal information form, the Interpersonal Problem Solving Inventory, and the Basic Empathy Scale ( N = 80). Descriptive and comparative statistics were employed to evaluate the study data.

Results 

Age, marital status, and career length were not found to affect the subscale scores of cognitive empathy ( p > .05). A negative correlation was found between the subscale scores for “diffidence” and “cognitive empathy.” Moreover, the emotional empathy scores of the graduate nurses were higher than those of the master's/doctorate degree nurses to a degree that approached significance ( p = .078). Furthermore, emotional empathy levels were found to decrease as the scores for insistent/persistent approach, lack of self-confidence, and educational level increased ( p < .05). The descriptive characteristics of the participating nurses were found not to affect their problem-solving skills.

Conclusions/Implications for Practice 

Problem solving is a focus of nursing practice and of great importance for raising the quality of patient care. Constructive problem-solving skills affect cognitive empathy skills. Educational level and career length were found to relate negatively and level of self-confidence was found to relate positively with level of cognitive empathy. Finally, lower empathy scores were associated with difficult working conditions in operating rooms, intense stress, and high levels of potential stress-driven conflicts between workers in work settings.

Introduction

Healthcare institutions are where individuals seek remedies to their health problems. These institutions face problems, which relate to both employees and care recipients. These problems may occur spontaneously and require immediate solution. Moreover, these problems require that the preferred remedies be adapted to address the unique nature of both organizational circumstances and individual requirements. Therefore, it is important that nurses, who are a major component of the healthcare system, have problem-solving skills.

Operating rooms are complex, high-risk environments with intense levels of stress that require rapid judgment making and fast implementation of appropriate decisions to increase patients' chances of survival ( Kanan, 2011 ; Jeon, Lakanmaa, Meretoja, & Leino-Kilpi, 2017 ). Furthermore, aseptic principles may never be compromised, and a high level of coordination and cooperation among team members should be maintained in these areas ( Kanan, 2011 ; Sandelin & Gustafsson, 2015 ). The members of a surgical team may vary in the operating room ( Sandelin & Gustafsson, 2015 ; Sonoda, Onozuka, & Hagihara, 2018 ). Under these difficult conditions, time management and workload are important stress factors for nurses ( Happell et al., 2013 ; Suresh, Matthews, & Coyne, 2013 ). At the same time, operating room nurses are legally responsible for the nature and quality of the healthcare service received by patients before, during, and after their surgical intervention ( Kanan, 2011 ). The American Nurses Association defines a nurse as “the healthcare professional establishing, coordinating and administering the care while applying the nursing process in an aim to meet the identified physiological, psychological, sociocultural and spiritual needs of patients who are potentially at the risk of jeopardized protective reflexes or self-care ability because of surgery or invasive intervention” ( Association of periOperative Registered Nurses, 2015 ).

Problem solving is the most critical aspect of the nursing practice. The fact that nursing requires mental and abstract skills, such as identifying individual needs and finding appropriate remedies, was first stated in 1960s. In 1960s, the nursing theorists Abdellah, Orem, and Levin emphasized the mental aspect of nursing. They argued that the most critical requirement of nurses in the clinical field is the ability to decide on and plan the right action and that nursing care should be founded on a sound knowledge base ( Taşci, 2005 ).

The World Health Organization has stated that “taking measures and applying a problem-solving approach to provide appropriate care is one of the compulsory competencies of nurses” ( Taşci, 2005 ). Thus, enhancing the problem-solving skills of nurses is of great importance in raising the quality of patient care ( Taylor, 2000 ; Yu & Kirk, 2008 ). On the other hand, Bagnal (1981) argued that people with problem-solving skills need to be equipped with personal traits including innovation, clear manifestation of preferences and decisions, having a sense of responsibility, flexible thinking, courage and adventurousness, ability to show distinct ideas, self-confidence, a broad area of interest, acting rationally and objectively, creativity, productivity, and critical perspective (as cited in Çam & Tümkaya, 2008 ).

To provide the best surgical care to a patient, team members must work together effectively ( Sonoda et al., 2018 ). One of the most important factors affecting the quality of healthcare service delivery is effective communication between healthcare professionals and healthcare recipients, with empathy forming the basis for effective communication.

Because of the intrinsic nature of the nursing profession, nurses should have empathy skills. Thus, empathy is the essence of the nursing profession ( Fields et al., 2004 ; Vioulac, Aubree, Massy, & Untas, 2016 ). A review of resources in the literature on problem solving reveals that gathering problem-related data is the first major step toward determining the root causes of a problem. In this respect, empathy is an important skill that helps properly identify a problem. On the basis of the definition of empathy, sensing another person's feelings and thoughts and placing oneself in his or her position or feeling from within his or her frame of reference should work to improve one's problem-solving skills, particularly those skills related to social problem solving ( Taşci, 2005 ; Topçu, Baker, & Aydin, 2010 ; Vioulac et al., 2016 ). It is possible to explain empathic content emotionally as well as cognitively. Emotional empathy (EE) means feeling the emotions of another person and providing the most appropriate response based on his or her emotional state. This is very important in patient–nurse communications. Cognitive empathy (CE) is the ability to recognize the feelings of another without experiencing those feelings yourself ( de Kemp, Overbeek, de Wied, Engels, & Scholte, 2007 ).

Gender, age, level of education, marital status, years of work, duration working at current institution, and problem-solving situations have been shown in the literature not to affect the problem-solving or empathy skills of nurses ( Abaan & Altintoprak, 2005 ; Kelleci & Gölbaşi, 2004 ; Yu & Kirk, 2008 ). Empathy is especially critical to the quality of nursing care and is an essential component of any form of caring relationship. The findings in the literature regarding empathy among nurses are inconsistent ( Yu & Kirk, 2008 ), and no findings in the literature address the relationship between problem-solving skills and empathy skills in operating room nurses.

Today, the healthcare system demands that nurses use their professional knowledge to handle patient problems and needs in flexible and creative ways. Problem solving is a primary focus of the nursing practice and is of great importance to raising the quality of patient care ( Kelleci & Gölbaşi, 2004 ; Yu & Kirk, 2008 ). Enhancing the problem-solving and empathy skills of nurses may be expected to facilitate their identification of the sources of problems encountered during the delivery of healthcare services and their resolution of these problems.

The purposes of this study are to investigate the relationship between problem solving and empathy in operating room nurses and to explore the factors related to these two competencies.

Study Model and Hypotheses

This study is a cross-sectional and descriptive study. The three hypotheses regarding the relationships between the independent variables are as follows:

• H1: Sociodemographic characteristics affect problem-solving skills.
• H2: Sociodemographic characteristics affect level of empathy.
• H3: Problem-solving skills are positively and significantly correlated with empathy.

Study Population and Sample

The study was conducted during the period of May–June 2015 at three hospitals affiliated with Istanbul University. The study population consisted of 121 nurses who were currently working in the operating rooms of these hospitals. The study sample consisted of the 80 nurses who volunteered to participate and answered all of the questions on the inventory.

Data Collection Tool

Study data were gathered using a personal information form, the Interpersonal Problem Solving Inventory (IPSI), and the Basic Empathy Scale.

Personal information form

This questionnaire, created by the researchers, is composed of 10 questions on the age, gender, educational background, organization and department, position, and organizational and professional functions of the respondent.

Interpersonal problem solving inventory

The IPSI, developed and validated by Çam and Tümkaya (2008) , was used in this study. The Cronbach's α internal consistency coefficients of the IPSI subscales were previously evaluated at between .67 and .91. The IPSI includes 50 items, all of which are scored on a 5-point Likert scale, with 1 = strictly inappropriate and 5 = fully appropriate . The lack of self-confidence (LSC) subscale assesses lack of confidence in problem solving. The constructive problem solving (CPS) subscale assesses emotions, thoughts, and behaviors that contribute to the effective and constructive solution of interpersonal problems. The negative approach to the problem subscale assesses intensely the negative emotions and thoughts such as helplessness, pessimism, and disappointment that are experienced when an interpersonal problem is encountered. The abstaining from responsibility subscale assesses failure to take responsibility for solving the problem. The persistent approach (PA) subscale assesses self-assertive/persistent thoughts and behaviors in solving problems encountered in interpersonal relationships. A high score on a subscale indicates a high interpersonal-problem-solving capability for that subscale category ( Çam & Tümkaya, 2008 ). A high score on the negative approach to the problem subscale indicates a higher likelihood of experiencing intense negative feelings and thoughts such as helplessness, pessimism, and sadness when encountering a problem. A high score on CPS indicates that the respondent will show more of the emotions, thoughts, and behaviors that contribute to the problem in an effective and constructive way. A low level of self-confidence indicates that the respondent will exhibit low self-confidence toward effectively resolving a problem. A high score on the abstaining from responsibility subscale indicates a high inclination to assume responsibility to resolve a problem ( Table 1 ). The high level of insistent approach indicates that the participant is more willing to solve problems ( Çam & Tümkaya, 2008 ). In this study, the Cronbach's α reliability coefficients were .901, .899, .763, .679, and .810, respectively.

Basic empathy skill scale

The Basic Empathy Skill Scale was developed by Jolliffe and Farrington (2006) and validated by Topçu et al. (2010) in Turkish. It is a 5-Likert scale (1 = s trictly disagree and 5 = strictly agree ) consisting of 20 items, of which nine measure CE and 11 measure EE. The Cronbach's α coefficients that were calculated for the reliability study range between .76 and .80. The lowest possible scores are 9 and 45 and the highest possible scores are 11 and 55 for the CE and EE subscales, respectively. A high score on the CE subscale indicates that the CE level is high, and a high score on the EE subscale indicates that the EE level is high ( Topçu et al., 2010 ). The two subscales of the Basic Empathy Skill Scale have been found to be highly reliable. The Cronbach's α reliability coefficients in this study were .782 for the CE subscale and .649 for the EE subscale.

Data Collection

The study was conducted between May and June 2015 at three hospitals affiliated with Istanbul University. The researcher explained the study to those nurses who agreed to participate. The questionnaire form was distributed to the participants, the purpose of the investigation was clarified, and permission to use participant data was obtained. The participants completed the questionnaire on their own, and the completed questionnaires were collected afterward. The time required to complete the questionnaire was 15–20 minutes in total.

Evaluation of Data

Number Cruncher Statistical System 2007 (Kaysville, UT, USA) software was used to perform statistical analysis. To compare the quantitative data, in addition to using descriptive statistical methods (mean, standard deviation, median, frequency, ratio, minimum, maximum), the Student t test was used to compare the parameters with the regular distribution in the two groups and the Mann–Whitney U test was used to compare the parameters without normal distribution in the two groups. In addition, a one-way analysis of variance test was used to compare three or more groups with normal distribution, and a Kruskal–Wallis test was used to compare three or more groups without normal distribution. Pearson's correlation analysis and Spearman's correlation analysis were used to evaluate the relationships among the parameters. Finally, linear regression analysis was employed to evaluate multivariate data. Significance was determined by a p value of < .05.

Ethical Considerations

Ethical conformity approval was obtained from the Non-Interventional Clinical Research Ethics Board at Istanbul Medipol University (108400987-165, issued on March 30, 2015). Written consent was obtained from the administrations of the participating hospitals. Furthermore, the informed consent of nurses who volunteered to participate was obtained. Permission to use the abovementioned scales that were used in this study as data collection tools was obtained via e-mail from their original authors.

Eighty nurses (97.5% female, n = 78; 2.5% male, n = 2) were enrolled as participants. The age of participants ranged between 24 and 64 (mean = 37.56 ± 8.12) years, mean years of professional nursing experience was 15.84 ± 8.30, and mean years working in the current hospital was 13.19 ± 8.23. Other descriptive characteristics for the participants are provided in Table 2 .

A comparison of scale subdimension scores revealed a negative and statistically significant correlation at a level of 22.3%. Statistical significance was reached only between the LSC subscale and the CE subscale ( r = −.223, p = .047; Table 3 ). Thus, a higher LSC score was associated with a lower CE score.

Comparisons between participants' descriptive characteristics and subdimension scores on the problem-solving skill scale revealed no significant differences. Thus, demographic characteristics such as age, educational background, and career length were found to have no influence on problem-solving skills ( p > .05; Table 4 ).

Age, marital status, and professional career length were not found to affect the CE and EE subscale scores, with no statistically significant correlations found between the two subscales ( p > .05; Table 4 ). However, the EE scores of undergraduate nurses were found to be higher than those of postgraduate nurses, at a level that approached statistical significance ( p = .078). In addition, the average CE scores of nurses who had worked for 1–10 and 11–20 years were higher than those of nurses who had worked for 21 years or more, at a level that approached statistical significance ( p = .066).

A statistically significant difference was found between mean years working in the current hospital and educational background, respectively, and CE scores ( p = .027 and p = .013; Table 4 ). On the basis of paired comparison analysis, the CE scores of participants with 1–10 years of working experience at their current hospital were higher than those with ≥ 21 years of working experience at their current hospital ( p = .027). Also on the basis of paired comparison analysis, the CE score of participants educated to the undergraduate level was found to be higher at a statistically significant level than those educated to the master's/doctorate degree level ( p = .013).

The comparison of problem-solving skill scores by descriptive characteristics revealed no statistically significant difference between subscale scores and the variables of age, marital status, length of professional and organizational career, or educational background ( p > .05). Thus, the descriptive characteristics of the participants did not affect their problem-solving skills.

Regression Analysis of Risk Factors Affecting Cognitive and Empathy Skills

Variables found after univariate analysis to have significance levels of p < .01 were subsequently modeled and evaluated. A regression analysis was conducted to determine the effect on CE skills of educational level, duration of institutional work, CPS level, and self-insecurity level. The explanatory power of this model was 29.9% ( R 2 = .299), and the model was significant ( p < .001). As a result of the analysis, CPS ( p = .006), educational status of graduate ( p < .001), and working for the current hospital for a period of more than 20 years ( p = .004) were found to have a significant and positive influence on the CE score.

A 1-unit increase in the CPS score was found to increase CE skills by 0.139 points (β = 0.139, 95% CI [0.041, 0.237], p < .01). For education, graduate education was found to decrease the CE score by 4.520 points (β = −4.520, 95% CI [−6.986, −2.054], p < .001). For duration working for the current hospital, working for the same institution for a period exceeding 20 years was found to decrease the CE score by 3.429 points (β = −3.429, 95% CI [−5.756, −1.102], p < .05). In addition, a 1-unit increase in the LSC score was found to decrease the CE score by 0.114 points, which did not achieve statistical significance (β = 0.114, 95% CI [−0.325, 0.096], p > .05).

Regression analysis was used to evaluate the effects of education, PA, and LSC on the risk factors affecting EE. As a result of this evaluation, the explanatory power of the model was determined as 15.3% ( R 2 = .153), which was significant despite the low level ( F = 3.388, p = .001). The effects of PA ( p = .021) and educational status ( p = .015) on the EE score were shown through analysis to be statistically significant ( Table 5 ). A 1-unit increase in PA score was found to increase the EE score by 0.323 points (β = 0.323, 95% CI [0.049, 0.596], p < .05). For education, having a graduate education was found to decrease the EE score by 3.989 points (β = −3.989, 95% CI [−7.193, −0.786], p < .05). Moreover, the LSC score was found to be 0.119 points lower than the EE score. However, this result was not statistically significant (β = −0.193, 95% CI [−0.467, 0.080], p > .05). Dummy variables were used in the regression analysis of sociodemographic characteristics (educational status and years working for the current hospital).

This study found that age, marital status, educational background, years of professional working experience, and years working for the current hospital did not affect the problem-solving skills of the participants. In the literature, the findings of several studies indicate that characteristics such as age, educational background, department of service, and career length do not affect the problem-solving skills of nurses ( Abaan & Altintoprak, 2005 ; Kelleci & Gölbaşi, 2004 ; Yu & Kirk, 2008 ), whereas other studies indicate that these variables do affect these skills ( Ançel, 2006 ; Watt-Watson, Garfinkel, Gallop, Stevens, & Streiner, 2000 ; Yu & Kirk, 2008 ). However, beyond these characteristics, some studies have reported a positive correlation between the problem-solving skills of nurses and their educational level, with this correlation mediated by the physical conditions of the workplace, good relationships with colleagues, and educational background ( Yildiz & Güven, 2009 ). These findings suggest that factors affecting the empathy and problem-solving skills of nurses working in operating rooms differ from known and expected factors.

Operating room nurses deliver dynamic nursing care that requires attention and close observation because of the fast turnover of patients. In addition to the problem-solving skills that they use during the patient care process, these nurses must use or operate a myriad of lifesaving technological devices and equipment ( AbuAlRub, 2004 ; Özgür, Yildirim, & Aktaş, 2008 ). The circumstances in which nurses employ their problem-solving skills are generally near-death critical conditions and emergencies. Furthermore, operating rooms are more isolated than other areas of the hospital, which affects nurses who work in operating rooms and intensive care units ( AbuAlRub, 2004 ; Özgür et al., 2008 ).

Communication is a critical factor that affects the delivery of healthcare services. Communication does not only take place between a service recipient and a provider. To establish a teamwork philosophy between employees, it is essential to build effective communication ( Sandelin & Gustafsson, 2015 ). Empathic communication helps enhance the problem-solving skills of nurses as they work to learn about individual experiences ( Kumcağiz, Yilmaz, Çelik, & Avci, 2011 ). Studies in the literature have found that nurses who are satisfied with their relationships with colleagues, physicians, and supervisors have a high level of problem-solving skills ( Abaan & Altintoprak, 2005 ; Kumcağiz et al., 2011 ) and that higher problem-solving skills are associated with a higher level of individual achievement ( Abaan & Altintoprak, 2005 ; Chan, 2001 ). Another finding of this study is that CPS increases the cognitive emphatic level. This may be attributed to constructive problem-solving skills increasing CE, as these skills are associated with feelings, thoughts, and behaviors that contribute to problem resolution.

A review of the literature on empathy and communication skills revealed, as expected, that these skills increased with level of education ( Kumcağiz et al., 2011 ; Vioulac et al., 2016 ). However, a number of studies have reported no significant correlation between age, marital status, and professional working experience and empathy skills or communication abilities in nurses ( Kumcağiz et al., 2011 ; Yu & Kirk, 2008 ).

EE is assumed to be a more intuitive reaction to emotions. Factors that affect EE are nurses working with small patient groups, frequent contact with patient groups, and long periods spent accompanying or being in close contact with patient groups ( Vioulac et al., 2016 ). Studies in the literature have reported no correlation between the empathy skills of nurses and demographic characteristics ( Vioulac et al., 2016 ). This study supports this finding, with the empathy skills of operating room nurses found to be close to the peak value of the scale.

Studies in the literature reveal a positive correlation between empathy and career length ( Watt-Watson et al., 2000 ; Yu & Kirk, 2008 ) as well as a correlation between increased professional experience and lower empathy ( Yu & Kirk, 2008 ). This study found an association between longer periods working for the same hospital and higher levels of education with lower empathy scores. This may be attributed to the difficult working conditions in operating rooms, intense stress, and high level of potential stress-driven conflicts between employees in work settings.

Stress is a major factor that affects the empathy skills and relationship-building abilities of nurses ( Vioulac et al., 2016 ). Nurses are exposed to a wide variety of stressors such as quality of the service, duration of shifts, workload, time pressures, and limited decision-making authority ( Patrick & Lavery, 2007 ; Shimizutani et al., 2008 ; Vioulac et al., 2016 ). In particular, environments evoking a sense of death (e.g., operating rooms) is another factor known to elevate perceived stress ( Ashker, Penprase, & Salman, 2012 ). High stress may lead to negative consequences such as reduced problem-solving abilities ( Zhao, Lei, He, Gu, & Li, 2015 ). Both having a long nursing career and working in stressful environments such as operating rooms may negatively affect empathy and problem-solving skills. However, this study revealed that working for a long period at the current hospital had no influence on problem-solving skills. The low reliability of the scales means that the variance may be high in other samples that are drawn from the same main sample, with the resultant data thus not reflecting the truth.

Low reliability coefficients reduce the significance and value of the results obtained by increasing the standard error of the data ( Şencan, 2005 ). The Cronbach's α of the EE scale used in the study was between .60 and .80 and is highly trustworthy. However, the Cronbach's α value is close to .60 (i.e., .649). This result may elicit suspicion in regression analysis estimates that are done to determine the variables that affect EE. In the correlation analysis, a statistically significant weak correlation was found only between the LSC subdimension and CE. However, the fact that the subscales of empathy and problem-solving skills are significantly related to the regression models may also be related to the reliability levels of the scales.

According to the results of the regression analysis, all of the variables remaining in Model A affected level of low for the CE ( R 2 = .299). Having constructive problem-solving skills ( p = .006), having a high level of education ( p < .001), and working for the current hospital for over 20 years ( p = .004) were found to be significantly related to CE.

Other variables were found to have no significant effect. According to the results of the regression analysis, all of the remaining variables in Model B accounted for a relatively low portion of the EE ( R 2 = .153). When the t test results for the significance of the regression coefficients were examined, it was determined that PA ( p = .021) and educational status ( p = .015) were significant predictors of EE. Other variables had no significant effect ( Table 5 ). The increase in the level of education of nurses may have increased their cognitive and emotional development. Thus, working in the same hospital for over 20 years was found to increase the levels of CE and EE. This result may be because of greater professional experience and regular experience handling numerous, different problems. In addition, the low explanatory power of the models may also be because of the fact that many other arguments that may affect empathy were not modeled. When constant values are fixed and the value of the independent variables entering the regression formula is zero, constant value is the estimated value of the dependent variable. According to findings of this study, sociodemographic characteristics and problem-solving abilities did not affect empathy level, although the CE value was 31.707 and the EE value was 37.024. Repeating this research in larger and different nurse groups may be useful to verify these research results.

Conclusions

The following results were derived from this study: First, constructive problem-solving skills affect CE skills. EE is adversely affected by the PA and LSC. Second, no correlation was found between the demographic characteristics of nurses and their problem-solving skills. Third, as level of education increases, cognitive and emotional levels of empathy decrease.

Duration of time spent working at one's current healthcare institution and educational level were both found to correlate negatively with the CE score. The higher the educational level and PA and the lower the self-confidence of the participants, the lower their EE levels. Finally, higher constructive problem-solving scores were associated with higher CE skills.

Limitations

The major limitation of the study is that it was conducted in the affiliated hospitals of one healthcare organization. The study data were obtained from operating room nurses who currently worked in these hospitals and who volunteered to participate. The conditions of nurses who did not participate in the study cannot be ascertained. A second important limitation is that the data reflect the subjective perceptions and statements of the participants. A third important limitation is that participant characteristics such as trust in management, trust in the institution, burnout, and communication skills were not assessed. For this reason, the effects of these variables on problem-solving and empathy skills remain unknown.

Author Contributions

Study conception and design: SP

Data collection: TK

Data analysis and interpretation: FA, SP

Drafting of the article: FA

Critical revision of the article: FA

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Home / Programs / Healthcare / MSN / Master of Science in Nursing – Nurse Educator / Developing Critical-thinking and Problem-solving Skills in Nursing Education

Developing Critical-thinking and Problem-solving Skills in Nursing Education

• Published On: August 20, 2024

Nursing education is a cornerstone of healthcare, preparing the next generation of nurses to manage complex clinical scenarios competently and confidently. Critical-thinking and problem-solving skills are essential for nurses to navigate the uncertainties of patient care effectively.

To meet the need for educators adept at critical thinking and problem solving, programs like Northwest Missouri State University’s online Master of Science in Nursing (MSN) – Nurse Educator program offer valuable opportunities. Northwest’s program equips nurse educators with the tools necessary to cultivate these skills in their students.

In particular, program courses such as Instructional Strategies in Learning and Teaching and Curriculum Development are pivotal in shaping nurse educators . Such coursework provides a framework for effective teaching methodologies that not only convey technical nursing skills but also foster critical-thinking and problem-solving abilities.

Understanding Critical Thinking in Nursing

Nurses must have strong critical-thinking skills in order to practice with proficiency and precision. It primarily involves making well-informed and judicious clinical decisions that directly impact patient care. Critical thinking in this context involves several key elements, including the following:

• Logical questioning . Nurses must be adept at posing relevant and insightful questions about patient conditions, treatments and outcomes. This skill helps uncover necessary information that might not be immediately apparent, facilitating more accurate diagnosis and care planning.
• Effective data analysis . The ability to analyze data from patient records, lab results and other diagnostic tools is crucial. Nurses must interpret this data correctly to make informed decisions about patient care. This analysis forms the backbone of clinical reasoning and allows nurses to anticipate potential complications.
• Critical evaluation . Nurses need to critically evaluate the outcomes of their interventions. Evaluation includes assessing the effectiveness of treatments and understanding patient responses to adjust care plans accordingly. It’s a dynamic process that requires ongoing attention and adjustment based on real-time feedback.

Synchronous vs. Asynchronous Learning

The debate between synchronous and asynchronous education models in nursing has significant implications for developing critical-thinking and decision-making skills. Synchronous learning, with real-time interaction between instructors and students, often fosters a more immediate and dynamic exchange of ideas, which can enhance problem-solving skills. On the other hand, asynchronous learning allows for flexibility and self-paced study. This form of learning can support deeper reflection and self-assessment.

In fact, students in Northwest’s online MSN – Nurse Educator program and complete the coursework in as few as 12 months. The flexible format allows students to complete their work from anywhere, and students collaborate with faculty mentors and nurse experts to maximize progress and learning.

Bridging the Gap Between Education and Employer Expectations

It’s important to recognize potential gaps between nursing graduates’ skills and employer expectations. Team-based learning can address this discrepancy, promoting collaborative learning and helping students apply theoretical knowledge in practical settings.

Advanced education programs, like Northwest’s, help students develop better communication skills, learn to delegate and prioritize tasks, and make more informed clinical decisions. All of these foundational elements help bridge that gap between education and real-world expectations.

Impact of Cognitive Skills Training

Incorporating cognitive skills training within nursing curricula is critical for preparing nurses to meet the demands of contemporary healthcare settings. Research underscores the necessity of integrating cognitive training to equip nurses with a robust skill set essential for clinical excellence. Consider the following benefits of strengthening cognitive skills:

• Memory retention . Nursing practice requires the ability to recall vast amounts of medical information accurately and quickly. As a result, techniques that enhance memory retention are vital. These might include mnemonic devices, repetition exercises and simulation-based learning experiences.
• Enhanced concentration . The ability to maintain concentration amid the bustling and often chaotic environment of healthcare facilities is crucial. Training that improves focus can include mindfulness exercises, time management strategies, and cognitive exercises designed to boost mental resilience and the ability to stay focused on tasks for extended periods.
• Improved problem-solving skills . Problem solving is at the heart of nursing, requiring nurses to swiftly assess situations, recognize potential complications and devise effective solutions. Training that hones these skills often involves case studies, critical-incident analyses and scenario-based simulations that challenge nurses to think critically and react under pressure.

The Future of Modern Healthcare Practice

Developing critical-thinking and problem-solving skills in nursing education is not just about teaching the fundamentals of nursing. It also involves preparing nurses to think on their feet in varied and challenging situations.

As healthcare continues evolving, educational programs must evolve as well, ensuring they remain relevant and effective. The online MSN – Nurse Educator program at Northwest is an example of how institutions are responding to these needs, preparing nurse leaders to handle and impart the complexities of modern healthcare practice.

Learn more about Northwest’s online Master of Science in Nursing – Nurse Educator program .

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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?

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Thinking your way to successful problem-solving

13 September, 2001 By NT Contributor

VOL: 97, ISSUE: 37, PAGE NO: 36

Jacqueline Wheeler, DMS, MSc, RGN, is a lecturer at Buckinghamshire Chilterns University College

Problems - some people like them, some do not think they have any, while others shy away from them as if they were the plague. Opportunities, in the form of problems, are part of your life.

The most difficult decision is deciding to tackle a problem and implement a solution, especially as it is sometimes easier to ignore its existence. Problem-solving takes time and effort, but once a problem has been addressed the nurse can feel satisfied that the issue has been resolved and is therefore less likely to re-emerge.

Nurses make clinical decisions using two different approaches. The first is the rationalist approach, which involves an analysis of a situation so that subsequent actions are rational, logical and based on knowledge and judgement. The second approach is based on a phenomenological perspective, where a fluid, flexible and dynamic approach to decision-making is required, such as when dealing with an acutely ill patient.

Types of problems

Problems come in different guises and the solver can perceive them either as a challenge or a threat. One of the most common types of problem is when the unexpected happens. As a nurse you plan and implement care for a patient based on your knowledge and experience, only to find that the patient’s reaction is totally different from that expected but without any apparent reason.

Another type of problem is an assignment where others set a goal or task. Throughout your working life you will be required to undertake duties on behalf of other people. For some this is difficult as they feel unable to control their workload. Others see it as an opportunity to develop new skills or take on additional responsibilities. Opportunities can be perceived as problems by those who fear failure.

A third type of problem is when a dilemma arises. This is when it is difficult to choose the best solution to a problem because the nurse is confronted with something that challenges his or her personal and/or professional values.

Diagnosing problems

The sooner a problem is identified and solutions devised, the better for all involved. So try to anticipate or identify problems when they occur through continuously monitoring staff performance and patient outcomes.

Listening to and observing junior staff will help you to detect work or organisational concerns, because when there are problems staff are likely to behave in an unusual or inconsistent manner.

Initial analysis

Remember that people view things differently, so what you perceive as a problem may not be one to anyone else. So before you begin thinking about what to do - whether to keep it under surveillance, contain it or find a solution - you should undertake an initial analysis. This will help you to understand the problem more clearly.

An analysis will also enable you to prioritise its importance in relation to other problems as problems do not occur one at a time.

Routine problems often need little clarification, so an initial analysis is recommended for non-routine problems only. Even then, not all problems justify the same degree of analysis. But where it is appropriate, an initial analysis will provide a basis from which to generate solutions.

Perception is also important when dealing with patients’ problems. For example, if a patient gives up reading because he or she cannot hold the book (objective), the nurse may assume it is because the patient has lost interest (subjective, one’s own view).

Generating solutions

It is essential for the problem-solver to remember that, where possible, solutions must come from those connected with the problem. If it is to be resolved, agreement must be owned by those involved as they are probably the best and only people who can resolve their differences. The manager should never feel that he or she must be on hand to deal with all disputes.

To solve a problem you need to generate solutions. However, the obvious solution may not necessarily be the best. To generate solutions, a mixture of creative and analytical thinking is needed (Bransford, 1993).

Creativity is about escaping from preconceived ideas that block the way to finding an innovative solution to a problem. An effective tool for assisting in this process is the technique of lateral thinking, which is based largely on the work of Edward de Bono, who regards thinking as a skill.

There are several ways to encourage creative decision-making. One method that works best for specific or simple problems is brainstorming. If the ground rules of confidentiality and being non-judgemental are applied, it will produce a free flow of ideas generated without fear of criticism (Rawlinson, 1986).

Time constraints and staff availability may make it difficult for all those involved in a problem to meet. In such cases an adaptation of brainstorming - where a blank piece of paper is given to those involved and each writes down four solutions to the problem - may be the answer. A similar technique is the collective notebook, where people are asked to record their thoughts and ideas about a problem for a specified period.

An alternative is where one person writes down a list of solutions in order of priority, which is then added to by others. This helps to prioritise the ideas generated. All these methods produce data that can then be analysed by the problem-solver.

When the problem affects people in different geographical areas, solutions can be generated by obtaining the opinion of experts through the use of a questionnaire, which is known as the Delphi technique (McKenna, 1994).

When an apparently insurmountable problem presents itself, it is often useful to divide it into smaller pieces. This is known as convergent thinking. Using divergent thinking - where you consider a problem in different ways to expand your view - may also help. 

A final alternative is the stepladder technique, which is time-consuming but effective if the issue is stirring up strong feelings. This requires the people involved in the problem to be organised into groups. First, two people try to solve the problem, then a third member is drawn in, to whom the solution reached by the first two is presented. All three then try to agree a solution. More people are added to the group, if necessary, in a similar way, until there is agreement of all involved. Provided the individuals are motivated to solve the problem, this technique creates ownership and commitment to implementing the agreed solution.

Analytical thinking, which follows a logical process of eliminating ideas, will enable you to narrow the range down to one feasible solution.

Although someone has to make the ultimate decision on which solution to implement, there are advantages to group decision-making: a greater number of possible solutions are generated and conflicts are resolved, resulting in decisions being reached through rational discussion.

This does, however, require the group to be functioning well or the individuals involved may feel inhibited in contributing to the decision-making. One individual may dominate the group or competition between individuals may result in the need to win taking precedence over deciding on an agreed practical solution.

As nursing becomes less bureaucratic individuals are being encouraged to put forward their own ideas, but social pressures to conform may inhibit the group. We do not solve problems and make decisions in isolation, but are influenced by the environment in which we work and the role we fulfil in that environment. If group members lack commitment and/or motivation, they may accept the first solution and pay little attention to other solutions offered.

Making a decision

There are three types of decision-making environments: certain, risk and uncertain. The certain environment, where we have sufficient information to allow us to select the best solution, is the most comfortable within which to make a decision, but it is the least often encountered.

We usually encounter the risk environment, where we lack complete certainty about the outcomes of various courses of action.

Finally, the uncertain environment is the least comfortable within which to make decisions as we are almost forced to do this blind. We are unable to forecast the possible outcomes of alternative courses of action and, therefore, have to rely heavily on creative intuition and the educated guess.

Taking this into consideration, you should not contemplate making a decision until you have all the information needed. Before you make your decision, remind yourself of the objective, reassess the priorities, consider the options and weigh up the strengths, weaknesses, opportunities and threats of each solution.

An alternative is to use the method that Thomas Edison used to solve the problem of the electric light bulb. Simply focus on your problem as you drift off to sleep, and when you wake up your subconscious mind will have presented you with the answer. But bear in mind that this is not a scientific way of solving problems - your subconscious can be unreliable.

If you are not sure about your decision, test the solution out on others who do not own the problem but may have encountered a similar dilemma. Once you have made your choice stick to it, or you may find it difficult to implement because those involved will never be sure which solution is current. They will also be reluctant to become involved in any future decision-making because of your uncertainty.

The next step is to ensure that all the people involved know what decision has been made. Where possible, brief the group and follow this up with written communication to ensure everyone knows what is expected of them. You may need to sell the decision to some, especially if they were not involved in the decision-making process or the solution chosen is not theirs.

Implementing the solution

Finally, to ensure the solution is implemented, check that the people involved know who is to do what, by when and that it has happened. Review the results of implementing your solution (see Box) and praise and thank all those involved.

- Part 1 of this series was published in last week’s issue: Wheeler, J. (2001) How to delegate your way to a better working life. Nursing Times; 97: 36, 34-35.

Next week. Part three: a step-by-step guide to effective report writing.

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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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Nurses' perceptions of their problem-solving ability

Affiliation.

• 1 Department of Nursing Studies, Queensland Institute of Technology, Brisbane, Australia.
• PMID: 1918644
• DOI: 10.1111/j.1365-2648.1991.tb01761.x

A problem-solving approach to nursing practice has been advocated in the nursing literature for some time. However, the extent to which nurses perceive themselves as capable problem solvers or improve their problem-solving ability during their nursing education is not generally known. The purpose of this study was to determine the relationship between nurses' perceptions of their problem-solving ability and their course of study. The Problem-Solving Inventory (PSI) was developed by Heppner and colleagues (1982) to assess attitudes towards and perceptions of problem-solving behaviour. The instrument provides a global appraisal of oneself as a problem solver and assesses perceptions of problem-solving ability. In this study, data were collected from 67 pre and post-registration nursing students in two phases; during their course and on completion of their course. Data from each phase were compared to identify changes in perception of problem-solving behaviour over time. While there was no overall improvement in perceptions of problem-solving ability by phase 2, confidence in problem solving had improved significantly (P less than 0.01). There were improvements according to age, experience, and course being undertaken for the likelihood of approaching rather than avoiding problems, and having personal control over problem solving.

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New quality enhancement plan focuses on problem-solving skills.

RALEIGH, N.C. (August 22, 2024) – Wake Tech is excited to launch a major effort to help students improve their problem-solving skills.

Solve It! Say It! Problem-Solving With an Emphasis on Communication is the college's new Quality Enhancement Plan, or QEP.

The QEP is a five-year institutional plan for improving an area of learning and is a cornerstone of the college's reaffirmation from the Southern Association of Colleges and Schools Commission on Colleges (SACSCOC). The plan aligns with Wake Tech's Reach and Rally strategic plan.

The QEP has a dual focus:

• Improving students' problem-solving skills
• Supporting faculty and staff in building problem-solving exercises and guidance into their courses and services

Both students and faculty will have the opportunity to earn competency-based recognition for their efforts through digital badging programs.

The QEP topic was chosen based on data that showed problem-solving is one of the top skills sought by employers in Wake County and beyond. However, data showed that half of Wake Tech's general education courses with learning outcomes that align with problem-solving did not meet proficiency targets, and surveys of Wake Tech students, employers and graduates indicate students' problem-solving skills need to improve. 

Through Solve It! Say It!, students will learn how to solve complex problems and communicate solutions so that, as they climb their educational and career ladders, they will be able to thrive in a rapidly changing workforce.

Solve It! Say It! will teach students a standardized problem-solving process and provide them opportunities to develop their problem-solving skills.

Solve It! Say It! was developed through research, faculty focus groups and student surveys that identified problem-solving challenges and the most effective ways to improve it.

Wake Tech's Board of Trustees approved the plan in June, and the plan was submitted to SACSCOC this week for review. Once approved by SACSCOC, implementation will begin in January.

Learn more at qep.waketech.edu .

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Developing Strategy: A Guide For Nurse Managers to Manage Nursing Staff's Work-related Problems

The purpose of this study was to assess nursing staff's work-related problems as perceived by their managers and thereafter develop strategies that would serve as a guide for nurse managers to manage these problems.

A descriptive research design was used. The participants included in the study consisted of the following two groups: Group 1—a convenience sample of 150 first-line managers working at three different hospitals; and Group 2—a panel of experts for the Delphi technique, selected using the Snowball sampling technique. Tools for data collection included the following: Tool 1—questionnaire about nursing staff's problems; Tool 2—Delphi technique to develop strategies for managing nursing staff's problems; and Tool 3—opinionnaire format.

The recruited first nurse managers were of the opinion that job stress, work overload, conflict, workplace violence, poor performance, staff turnover, demotivation, lack of empowerment, and staff absenteeism were among the common problems faced by staff nurses at work.

From the expert panelists’ perspectives, the newly developed strategy in this study was considered valid; the researchers recommend the strategy developed in this study to be universalized in different health care settings and used as a guide for nurse managers.

Introduction

Nursing is a high-pressure job. Contrary to popular belief, nurses’ duties consist of more than just checking vital signs and administering medication. They have many responsibilities to attend: helping patients, assisting in procedures, documenting care, as well as filling leadership roles at hospitals, health systems, and other organizations. However, issues at the organizational, state, and national levels have brought about considerable challenges, making it difficult for nurses to do their job effectively. It is essential to first recognize and understand every possible challenges faced by nurses to deal with them efficiently and find the best possible solutions to mitigate them [ 1 ].

Workplace-related problems are common nationally and internationally. Among the most frustrating personnel problems is that of absenteeism—the rate at which an individual misses work on an unexpected basis. In the health care industry, this results in the impediment of the provision of health care to patients, specifically the health care institutions that are associated with a shortage of available staff [ 2 ]. Work stress, particularly in the nursing profession, has become a major problem that nurses face; excessive pressure, a heavy workload, job insecurity, low levels of job satisfaction, internal conflicts, and lack of autonomy contribute to that stress [ 3 ].

In addition, interpersonal conflict is another area of frustration in the nursing profession. It is often considered a negative term because individual interests are perceived to be in conflict or negatively affected. Furthermore, workplace conflict is always associated with lower-quality patient care, higher rates of adverse effects, a higher level of staff burnout, and greater direct and indirect costs of care [ 4 ].

Lack of empowerment is a significant work-related problem that nurses may be exposed to. Powerless nurses make for unproductive, discontent nurses, who are more vulnerable to burnout and depersonalization. Empowerment for nurses consists of three components: a workplace that has the necessary structures to support empowerment, a psychological belief in one's ability to be empowered, and acknowledgment that there is power in the relationships and care that nurses afford. To help nurses become empowered and use their power for better patient care, a more comprehensive understanding of these three components is required [ 5 ].

The nursing shortage is one of the many issues that needs attention and necessitates involvement of all health care parties. Nurses always work in a high-risk environment; they are prone to numerous occupational health hazards that have harmful effects both on their mental and on their physical health, as well as on their productivity and efficacy at work [ 6 ]. Workplace violence is an incident of hostility that may be physical, sexual, verbal, emotional, or psychological and it takes place when nurses are abused, threatened, or assaulted in situations related to their work. Such violence upsets the organization in different ways, for example, the loss of competent and trained nurses, a decrease in nursing productivity, and a bad reputation of the organization in society and legal issues related to the safety of employees [ 7 ].

In Egypt, nursing as a profession is affected by numerous factors that are considered dilemmas for working as a nurse. These factors included media, public image, social prestige, lack of role models, physician–nurse interaction, ineffective learning environment, risk for violence, exposure to health hazards, conflict, stress, and exposure to infection [ 8 ]. Challenging workplace conditions that nurses face in Egypt include little institutional recognition or support, shortage of nurses, insufficient funds, and high turnover of ministers and decision makers at the Ministry of Health and Population (MOHP) , which in turn hinders the setting of rules to support nursing reforms, maldistribution of nurses in different health services, poor image and poor public perception of nursing, insufficient salaries, and risks during night shifts [ 9 ].

Nurse managers are tasked with the near-impossible to ensure the care provided in the unit is of high quality, keep patients and families satisfied with the care, as well as achieve productivity goals, all while addressing the needs of the staff. [ 10 ]. The complex work environment necessitates that nurse managers remain up to date with the latest scientific developments in their field. They must also be able to analyze problems effectively and consequently determine the right course of action for each situation to achieve the most favorable outcome. Thus, nurses working in managerial positions must develop their problem-solving skills. Current literature recommends that nurse manager candidates should receive additional training in several areas including problem-solving skills. This training should be an essential part of orientation programs designed before promotion to managerial positions [ 11 ].

Significance of the study

Tailoring strategies to solve nurses' work-related problems requires a rich understanding of the most common problems that nurses face during their work by their nurse managers who are expected to handle all problems that evolve in their areas of work. Moreover, in Egypt, many nurse managers in different clinical settings are promoted to managerial positions based on their years of experience regardless of their educational or managerial qualifications, thus remain unfamiliar with and untrained in problem solving skills as a paramount managerial requirement. Consequently, effective strategies must be put in place to inform them about ideal processes for managing their staff work-related problems. Thus, the purpose of this study was to assess nursing staffs' work-related problems as perceived by their managers and thereafter develop strategies that would serve as a guide for nurse managers to manage these problems.

Research questions

Q1. What are the common work-related problems of the nursing staff?

Q2. What are the strategies that can be used by nurse managers to manage nursing staff work-related problems?

Q3. What are the panel of experts' opinions regarding the newly developed strategy?

Conceptual framework

The American Association of Critical-Care Nurses developed a model for a healthy work environment (HWE), consisting of six standards, which are used by researchers as a conceptual framework for the present study. Strategies for solving work-related problems were derived as criteria through which the six evidence-based essential standards could help to create work and patient care environments that are respectful, safe, and humane to staff and all. These standards include the following: Skilled c ommunication —nurses must be proficient in communication skills (written, verbal, and nonverbal communication) as they are in practical skills. Ineffective professional relationships lead to mistrust, disrespect, stress, and dissatisfaction. True c ollaboration —this is the process that is based on mutual respect for knowledge and abilities of other professionals who are involved in patients’ care. Nurses must be relentless in pursuing and fostering true collaboration. Effective d ecision m aking —nurses must be valued and committed partners in formulating policy, directing and evaluating clinical care, and leading organizational processes. Staffing o ptimization —staffing process must ensure the effective match between patient needs and nurse competencies. Meaningful r ecognition —nurses must be recognized and must recognize others for the value each brings to the work of the organization. Authentic l eadership —nurse leaders must fully embrace the imperative of an HWE, authentically live it, and engage others in its cultivation. Nurse leaders must be positioned to influence decisions that affect nursing practice and the work environment. [ 12 ].

The relationship between the study's conceptual framework, the developed strategies, and staff nurses' workplace-related problems was represented as follows: the six HWE standards provided the evidence-based mechanisms for guiding actions and behaviors of nurse managers with their subordinates and considered the origin on which the current developed strategies was based. Therefore, the developed strategies will be the methodological framework to manage different arising work-related problems, including decreasing stress and workload, eliminating sick leave and absenteeism, optimizing staff in the unit, promoting nurses' satisfaction and retention, improving nurses' motivation and empowerment, reinforcing team spirit and moral, and reducing interpersonal conflict and workplace violence.

Study design

The study adopted a descriptive research design.

Setting and samples

The study was conducted at three different hospitals in Egypt, two in the Delta Region and one in Cairo, all which provide secondary health care services.

Hospital (1): it is affiliated to the Ministry of Higher Education. It consists of four buildings: the main building, the specialty hospital building, the emergency building, and the oncology institution. Its bed capacity stands at 1200 beds.

Hospital (2): It is affiliated to the higher authority of educational hospitals and institutions. It consists of four buildings: the main building, the economy building, the outpatient clinics, and the hemodialysis building. Its bed capacity is 863 beds.

Hospital (3): It is affiliated to the Ministry of Health. It includes the health services sector in addition to a research center. Its bed capacity is 945 beds.

The participants included in the study were composed of two groups

Group 1: first-line nurse managers: nonprobability convenience sampling technique was used to select 150 first-line nurse managers working at hospital (1) ( n  = 50), hospital (2) ( n  = 50), and hospital (3) ( n  = 50).

Inclusion c riteria: the study included first-line managers of different ages, different educational qualifications in nursing (including a bachelor and technical degree in nursing), both gender, different marital status, working at different units and departments at the respective hospitals, and who have six or more months of experience at their current position.

Methods of recruiting nurse managers

To recruit nurse managers as study participants, the researchers revised the employees' database within each hospital to specify the nurse managers who met the inclusion criteria. A sampling frame was established for all nurse managers meeting the criteria. The researchers contacted them personally to explain the aims of the study in addition to procure their acceptance to participate in the study.

Group 2: experts of nursing management: the snowball sampling technique was used to select the panel experts for the Delphi technique that was used for the development of the strategy.

Inclusion criteria: the snowball sampling technique was useful in this research to achieve the inclusion criteria that are listed below:

• 1. The expert must be either a professor of nursing management at a faculty of nursing in Egypt or have a nursing director position within Egyptian hospital, with at least 1-year experience in the current position.
• 2. The expert must have a specific interest in the research topic, either through previous research work or practical experience at hospitals.

This technique resulted in a panel of seven professors of nursing management from different nursing faculties across Egypt and eight nursing directors from different hospitals in Egypt. They were then contacted personally to be recruited for the study.

Ethical consideration

To conduct the study, this study was approved by the institutional review board of the Menoufia University (Approval no. 86). Written approval was obtained from the medical and nursing authority at the aforementioned study setting following an explanation of the purpose and procedures of the study. The respondents' rights were protected by ensuring voluntary participation, and informed consent was obtained after explaining the purpose, study procedures, and potential benefits of the study. The respondents were assured that the data would be treated as strictly confidential.

Measurements/instruments

1 — Questionnaire about nursing staff s' problems.

This was a self-administered questionnaire designed by the researchers after reviewing the relevant literature. This questionnaire was used for conducting a preliminary study about the common nursing staffs' work-related problems as perceived by first-line nurse managers, and the proposed strategies for managing these problems. It included two open-ended questions, namely:

• 1. What are the common problems faced by nursing staff?
• 2. From your point of view, what are the strategies you can use to manage these problems?

The face and content validity of this questionnaire was tested by a panel of five experts in nursing management.

Scoring of questionnaire:

The nurse managers’ responses regarding work-related problems were rated on three-point Likert scale as follows:

• • Uncommon problems <40%
• • Average common 40–<60%
• • Common problems ≥60%

2 — Delphi technique to develop the strategies for managing nursing staff problems.

The Delphi technique is a widely used and accepted method for arriving at a consensus of opinion concerning real-world knowledge solicited from experts within certain topic areas [ 13 ]. A questionnaire that included strategies for managing nursing staffs’ problems was distributed for each Delphi round.

Expert panelists rated each item within strategy on three-point Likert scale from as follows: agree, need of modifications, and disagree.

The responses with highest score was considered as follows:

• • Agree, which requires to be fixed in the following rounds.
• • Need modification, which requires restatement in the following rounds.
• • Disagree, which requires to be excluded in the following rounds.

3 — Opinionnaire format.

This tool was designed by the researchers to validate the new strategy format. It contained items that examined the clarification of the strategy purpose, its comprehensiveness, clarity, and simplicity, along with how comprehendible, applicable, and feasible it was.

Data collection/procedures

• o The preliminary study was conducted from September 15, 2018, till November 17, 2018.
• o The questionnaire concerning the nursing staffs’ problems was distributed to first-line nurse managers to determine the common nursing staffs’ work-related problems. These responses were then analyzed to prioritize and rank the nursing staffs’ problems. Problems that scored ≥60% were considered common problems. The implementation of this scoring method lowered a total of 13 reported problems to nine, which were later included in the developed strategies. In addition, the proposed strategies by first-line managers were used by the researchers as a guide for developing the strategy format.
• o The Delphi technique was used to develop the strategies for managing the nursing staffs’ problems. The Delphi process lasted 3 months, starting from December 1 till the end of February 2019, until consensus regarding the strategies was achieved. The Delphi process consisted of three rounds: the first round traditionally begins with an open-ended questionnaire, which is used to elicit the experts' opinions regarding the strategies that can be used by managers to manage nursing staffs’ problems. Nine of 13 problems were included as the strategies' dimensions, each of the dimensions included had its own explanatory note and a blank area for experts to write proposed solutions for managing each problem. After receiving the participants' responses (from experts and first-line managers), researchers organized, refined, and added other strategies derived from previous literature on nursing problems (including published research findings and recommendations and textbooks), and then converted the collected information into a well-structured questionnaire. This questionnaire was used as the survey instrument for the second round. In the second round, each Delphi participant received a questionnaire comprising 79 items and was asked to review the items summarized by the researchers. Accordingly, Delphi panelists were required to rate or “rank-order” items to establish preliminary priorities among items. Each item within strategy was rated on three-point Likert scale from as follows: agree, need of modifications, and disagree. The highest score throughout the three scale was considered. In the third round, each Delphi panelist received a questionnaire that included the items summarized by the researchers in the previous round and was asked to revise their judgments.
• o The newly designed strategies were validated by an opinionnaire format distributed to the panel of experts after the third round of the Delphi technique.

Data analysis

Results were collected, tabulated, and statistically analyzed by an IBM personal computer and statistical package SPSS 22.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics such as numbers and percentages were used to determine common nursing staff problems, analyze Delphi rounds and the expert panelists’ opinions regarding the face and content validity of the developed strategies.

The distribution of sociodemographic characteristics of the studied nurse managers is displayed in Table 1 . As shown in the table, the highest percentage of studied first-line managers were between the age of 30–40 years (43.3%). All of them were women (100%) because the male gender only recently joined the faculty of nursing. Regarding years of experience, most of them had 5–10 years of experience (37.4%). More than half of the studied first-line managers were married (55.4%). In addition, most of them had a bachelor degree in nursing (91.4%). More than half of them were working in critical and emergency care units (51.3%). Lastly, most of them had attended workshops on human resource management (56.6%).

Table 1

Distribution of Sociodemographic Characteristics of Studied Nurse Managers ( N  = 150).

Note . yrs =years.

As is evident from Table 2 , the most common staff nurses’ work-related problems as perceived by nurse managers were job stress, work overload, staff absenteeism, demotivation, lack of empowerment, staff turnover, workplace violence, staff conflict, and poor staffs’ performance (≥60%). On the other hand, lack of organizational justice, limited resources, nursing shortage, and unclear job description were average common staff nurses’ work-related problems (40–<60%).

Table 2

Staff Nurses' Work-related Problems as Perceived by Nurse Managers at the Study Setting ( N  = 150).

The experts’ opinions regarding items to be included in the strategy to solve nursing staffs’ work-related problems are illustrated in Table 3 , which displays the second Delphi round with a response rate of 100%. Most experts (95.2%) agreed on most of the proposed items to manage staff problems after they had been summarized by the researchers following the first round. The total percentage for modified items was 3.9%, whereas the total percentage for disagreed on items was 1.9%. One item of the proposed strategy (decrease the threat to worker safety) with percentage 73.4% was disagreed on by the panel of experts, thus it was excluded from the strategy in the third round. The number of modified items came in at two as follows, representing 66.0% and 54.0%, receptively: (1) develop group goals and projects that will build a team spirit and (2) creates and disseminates a clear policy that violence, verbal and nonverbal threats, and related actions, will not be tolerated.

Table 3

Number and Percentage Distribution of Experts Opinions Regarding Items of the Strategy to Solve Nursing Staff's Work-related Problems (Second Round; N  = 15).

Final experts’ opinions regarding items to be included in the strategy to solve nursing staff’s work-related problems are shown in Table 4 , that represents the round three with a response rate of 100%. This represents the final draft of the strategy to manage nursing staff’s work-related problems developed by the researchers. The total percentage of panel of experts' agreement regarding the developed strategy was 98.9%, whereas modified items stood at 1.1%.

Table 4

Number and Percentage Distribution of Experts’ Opinions Regarding Items of the Strategy to Solve Nursing Staff's Work-related Problems (Third Round; N  = 15).

The panel of experts' opinions regarding face and content validity of the developed strategy are presented in Table 5 . According to this table, the developed strategy was valid from the panel of experts' perspectives as all of them [100%] agreed that the strategy is comprehensive, clear, simple, understandable, applicable, and feasible.

Table 5

Panel of Experts' Opinion Regarding Face and Content Validity of the Developed Strategy ( N  = 15).

Workforce issues and challenges at the workplace are significant because they have an important impact on nurses’ ability to deliver safe, effective, and high-quality care. Maintaining a conducive work environment is the shared responsibility of employers, management, and staff. Staff nurses have a paramount role in keeping a supportive work environment, but nurse managers can certainly have a significant impact [ 12 ]. Thus, the aim of this study was to assess nursing staff’s work-related problems as perceived by their managers and thereafter develop strategies that would serve as a guide for nurse managers to manage these problems.

With regards to the first study question, the common staff nurses' work-related problems as perceived by nurse managers were job stress, work overload, staff absenteeism, demotivation, lack of empowerment, staff turnover, workplace violence, staff conflict, and staff poor performance. Although lack or organizational justice, limited resources, nursing shortage, and unclear job description were average common problems. From the researchers’ point of view, the selected study hospitals were large public hospitals with high patient flow, thus these problems were common.

The current findings was in agreement with the study conducted by Mahran et al [ 9 ], who reported that the most common challenges and crisis facing critical care nurses were large number of patients in intensive care units, work overload, working atmosphere filled with tension and stress, fear of the possibility of infection from patients, increased working hours and long shift, and have conflict between nurses and doctors.

The study carried out by Rani and Thyagarajan [ 14 ] was in line with present study findings, which reported that most nurses complained of a heavy workload, which is considered the primary contributing factor for work-related stress. Similarly, results from the study performed by Godwin et al [ 15 ] reinforced the proposition that nurses experienced an above-average level of work-related stress. Accordingly, the study by Vernekar and Shah [ 16 ] concluded that 98.4% (from a total of 253 nurses) experienced moderate to very severe stress. In addition, increased nursing workload is one of the main challenges of national and international nursing. The study conducted by Madadzadeh et al [ 17 ] concluded that 83.3% of a total of 80 respondent nurses reported a high workload.

The present study found absenteeism as the third highest work-related problem. Accordingly, Kurcgant et al [ 18 ] revealed that absenteeism is a world-wide problem increasing at an alarming rate, which could result in the hindrance of delivery of health care to patients, particularly in health care organizations associated with shortage of number of available health staff. Furthermore, ineffective routine, work pressure, inability to manage the working tasks, as well as an uncomfortable environment have a major influence on the rates of absence.

The present study findings showed staff conflict as a work-related problem. In accordance, nurses in the study conducted by Jerng et al [ 19 ] reported that the conflicts they experienced were mainly with other health care professionals, with a majority more specifically reporting intragroup conflicts with physicians. In light of this, our study results may be interpreted as follows: in hospitals, individual professionals have different goals, expectations, values, and beliefs making conflict unavoidable when working as a team.

This study shows that lack of empowerment was a common work-related problem among nurses as reported by first-line managers. Fittingly, Al-Dweik et al [ 20 ] concluded that lack of nurses’ empowerment is a significant problem and many nurses do not feel empowered and feel that organizational support is lacking. Moreover, when nurses are not properly empowered, many negative consequences will ensue, such as feelings of lack of control and having little influence on outcomes, which in turn leads to frustration at work, decreased job satisfaction, and increased risks of burnout.

Regarding the problem of nurses' demotivation, it represented a common work-related problem according to first-line managers' opinion, which contradicted the findings of Weldegebriel et al [ 21 ] about nurses’ work motivation. The latter study revealed that most nurses were intrinsically motivated, and about half of the respondents also reported external work motivation. The contrasting study findings can be attributed to differences in working conditions, policies, and regulations that govern nursing jobs.

Violence was reported as a common problem within the study's settings. This problem was also evident in the study conducted by Fute et al [ 22 ], who reported that, a significant proportion of nurses faced violence while providing care at public health facilities. In addition, this exposure to violence perpetrated by their patients or relatives was 86.0% alone and 80.0% among physician's violence in different health care settings in Beni Suef Governorate, Egypt [ 23 ].

Health care workers usually work in an unsafe environment because of a lack of security guards in some departments or ineffective security staff, as security is unarmed and patients are usually accompanied by several relatives. With a lack of awareness in Egypt concerning the nature of the health care service and its complications, there is an increased risk of misunderstanding and misconception of rules and regulations that govern health care facilities, which can lead to certain types of violence [ 24 ].

This study used the Delphi technique, which can usefully influence many areas for managing clinical activity and solving operational problems by identifying and obtaining agreement on the underlying factors and strategies of resolutions. In the same way, Sim et al [ 25 ] used the Delphi technique in their study to conclude that consensus was achieved between nurses on the most important concepts, which can provide the basis for measuring the quality and safety of nursing practice in a comprehensive way. The Delphi technique was also used to reach the findings of Bjorkman et al [ 26 ], which presented a consensus view of tele-nurses’ experiences of important obstacles and prerequisites in their work environment.

With reference to the second study question, nurse managers from different study settings suggested certain strategies for managing nursing staff's work-related problems, which were later organized by the researchers and validated by expert panelists. In addition, reviewing related literature by the researchers helped in formulating the current strategies in light of the present study conceptual framework (The American Association of Critical-Care Nurses' 6 HWE standards). The developed strategies were in accordance with the assumption by Munro and Hope [ 27 ], who proposed that developing an HWE in which the nursing staff feels supported physically and emotionally; where one feels safe, respected, and empowered is a crucial role of nurse managers who are always looking for effective strategies and solutions for advocating their staff nurses. In addition, nurse managers should uphold the responsibility to strive for a positive work environment for their subordinates.

The current developed strategies for managing work-related stress and workload incorporated certain criteria that reinforce the standards of skilled communication, true collaboration, meaningful recognition, staff optimization, and authentic leadership, which agreed with the findings of Vernekar and Shah [ 16 ], who found that most nurses adopt the following stress management strategies: identify the source of stress and avoid unnecessary stress, manage time better, adjust standards and attitudes, and express feelings instead of bottling them up. In the same line, Madadzadeh et al [ 17 ] concluded that a deep and comprehensive imbalance between resources and tasks and expectations has been perceived by the participants to be the main source of work overload and further recommended that paying more attention to resource allocation, education of the quality workforce, and commitment with job description by managers is of paramount importance.

The present study developed various strategies for managing the problem of absenteeism that derived from the standards of authentic leadership, meaningful recognition, and staff optimization within the study conceptual framework, which was corroborated by Kurcgant et al [ 18 ], who further recommended the introduction of policies that would address absenteeism in the workplace and assist and recognize nurses who handled the workload of colleagues who are continuously absent. In addition, ward managers are required to use nursing staff abilities and build trusting relationships with them so that nurses feel they can rely on and confide in them. Other strategies for mitigating absenteeism in the present study were formulated as solutions for overcoming the common causes of this problem, as reported by Kanwal et al [ 2 ] in their study.

Referring to the current strategies for managing conflict, they were based on the HWE standards of skilled communication, true collaboration, and effective decision making. The study by Shah [ 28 ] suggested different strategies than the current one for dealing with staff conflict, including the application of formal reporting systems such as incident reporting systems to improve interpersonal conflicts based on the proposition that management of the reported events are mainly task-oriented, helped to weaken the tension between the workers, and focus more on the goal of the task and the expected level of provided care.

The developed strategies for boosting nurses’ empowerment in the present study stemmed from the standards of skilled communication, meaningful recognition, and authentic leadership, which was in agreement with those of Al-Dweik et al [ 20 ], who showed that nursing leaders play a significant role in creating a positive work environment by emphasizing self-related performance and authentic leadership to enable nurses to perceive more access to workplace empowerment structures.

By reference to current strategies for managing demotivated staff, they were originated from various standards within the HWE conceptual framework. The study by Drake [ 29 ] coincided with current strategies, which reported that managers should have clear expectations for workers and communicate these expectations effectively, be fair and consistent when dealing with all employees, provide opportunity for participation and input from all subordinates in decision making whenever possible, give subordinates recognition and credit, and develop the concept of teamwork and group goals.

In the same context regarding the previous strategies, the study conducted by Adjei et al [ 30 ] recommended that hospital management should continue to praise and recognize the nurses individually or as a team for their achievement and contribution toward the organization. In addition, career development, job enrichment, and providing greater autonomy would also enhance nurses' performance level in their jobs. It is suggested that implementing interventions in terms of training, guidance, and counseling would be able to produce motivated and high-performing nurses in the hospitals.

Regarding the topic of violence management, the strategy at hand focused primarily on being proactive in dealing with violence events and reinforcing protection and safety measures for the staff, which was in correspondence with the study by Boafo and Hancock [ 31 ], which recommended various strategies for managing violence as follows: ensuring a safe and respectful workplace environment, as well as integrating comprehensive prevention programs, reporting mechanisms, and disciplinary policies, policymakers and other stakeholders should establish health and safety programs for the prevention and management of workplace violence. Finally, according to the present study, it is important that security is boosted at various governmental hospitals, especially the regional ones. It is also advisable to give precedence to women and young nurses.

Lastly, on managing turnover as a work-related problem in the study settings, the current measures focused on maintaining workplace environment with necessary elements that can keep nurses from leaving their job, which mainly based on all the standards of HWE. In agreement, Bogonko and Kathure [ 32 ] recommended to improve salaries and allowances (terms of service) proportional with qualifications and experience, review and improve scheme of service for nurses for clear career advancement, support and recognize nurses, create more training opportunities such as seminars/updates and workshops, and award recognition to those who develop their skills.

Study implications

The developed strategy is recommended to be adopted for newly appointed first-line nurse managers during their transition from practicing nursing' roles to managerial roles, as well as for different nurses in managerial positions as an evidence-based tool to deal with existing workplace-related problems. Health care organizational policies need to be refined to be more flexible in adopting different strategies. The spread of COVID-19 has put new pressures on already strained health systems across the world. So far, hospitals are facing severe crises trying to deliver necessary care, whereas managers are making heart-breaking decisions on how to allocate scarce resources. It would be helpful to replicate this study at different hospitals with larger sample size to assess the emerging nursing staff’s problems in times of crises and refining current strategies to be suitable to deal with emerging problems during times of adversity.

Study limitations

The use of nonprobability convenience sampling and small study sample size may limit the generalization of the study findings. In addition, different policies in health care settings from which nurse managers were recruited limited the possibility of reaching the most effective strategies as they listed only the strategies that were available to them.

In the light of the present study, it can be concluded that the nurse managers who participated in this study perceived job stress, work overload, conflict, workplace violence, poor performance, staff turnover, demotivation, lack of empowerment, and staff absenteeism as common problems faced by staff nurses at work. On the other hand, other problems such as lack of organizational justice, unclear job description, the nursing shortage, and limited resources were less common. The developed strategy to manage staff nurses' work-related problems was valid and in line with the panel of experts' opinions and perspectives; all of the experts agreed that the strategy was comprehensive, clear, simple, understandable, applicable, and feasible.

Conflict of interest

The researchers declared no conflict of interest.

Acknowledgments

Our great thanks are submitted to ALLAH who provided us with the ability to complete this work. We would like to offer special thanks to nurse managers and the panel of experts for their participation and cooperation to complete this study.