THE PROBLEM-SOLVING PROCESS WITH SPECIAL APPLICATION TO THE CLINICAL SETTING

In order to examine whether we are addressing the skill o f problem-solving in our teaching, it is essential to have a clear understanding of what the skill entails. A mere definition would not te ll u s m u ch a b o u t th e c o n c e p t o f problem-solving whereas a concept analysis would serve to clarify the meaning o f the concept. Prior to the occurrence of problem-solving, there are certain events or incidents which must occur, which are referred to as antecedents.

I would like to thank the organisers for giving m e an o p p o rtu n ity to p a rtic ip a te at th is conference.
I have been asked to speak on problem-solving.Problem-solving is regarded by many nursing theorists as the core o f the practice of nursing.It is a complex skill with cognitive as well as perceptual com ponents and is em bedded in subject specific knowledge.Like many other nursing skills, problem-solving can be taught and evaluated.
T h e question arises: W h a t kin d o f problem s do n u rses have to solve?Van Gundy (1981) gives the following useful classification: (i) W ell-structured problems, in w hich case all the information required to solve the problem is av ailab le.T h ese ty p es o f problems can be solved using standard operating procedures.E x am p le: A patient w ho com es in with an acute shortness of breath has to be gi ven oxygen i mmediatel y .
(ii) Ill-structured problems, where the problem solver is provided with little or no information on the best way to solve the p ro b le m .T h is r e q u ir e s a c re a tiv e approach.E xam ple: A term in ally ill patient w ho is obviously in severe pain but refuses to take analgesics.
(iii) Semi-structured problems fall between the other two types mentioned.A combi nation o f stan d ard op eratin g p ro ced u res and creativity w ould be required to solve this type o f problem.
All three types o f problems are encountered in nursing practice.The question I would like to address in this paper is whether we, the nurse educators, are doing enough to develop the problem -solving skill in o ur stu d en ts and w hether this ski II is being adequately evaluated.
In Prior to the occurrence o f problem-solving, there are certain events or incidents which must occur, which are referred to as antecedents.
A N T E C E D E N T S include: (i) An ability to think critically.
(ii) The existence o f a situation which hampers or retards progress or a situation or event w hich takes an unexpected or unintended course.It could be a situation in which a gap is perceived to exist between w hat is and what should be.
(iii) Knowledge and skill related to the problem area.
(iv) A willingness to take responsibility or get involved with the problem.

C R IT IC A L A T T R IB U T E S
These are the essential features of the concept problem-solving.They include: (i) The recognition that a problem situation exists and that a reaction to it is needed.Problem-solving will only take place after aw areness develops and not before.There must also be a perceived need to solve the problem.
(ii) Generation o f possible solutions to resolve the situation.This is what the clinical instructor should look out for, because it will indicate whether the student is actively problem -solving or not.These include: (i) Looking for additional information which may take the form o f extra observation, q u e stio n s o r lo o k in g at records, thus leading to recognition o f a problem.
(ii) Action is taken that directly addresses the problem.
(iii) R ecording a problem and the actions taken to solve it.
Consequences are events w hich occur as a resul t o f problem-solving.They include: (i) Problem resolution characterised by a return to the desirable state o f affairs.
(ii) Continuation o f the problem.Problem -solving is not alw ays followed by problem resolution.This may be the result o f th e q u ality o f the problem -solving process or the quality o f the problem.
T o illustrate clearly w hat problem -solving means, I shall use, firstly, a model case which is a " r e a l l i f e " e x a m p le o f th e c o n c e p t problem-solving; secondly, a contrary case, w h ic h is a c le a r e x a m p le o f w h a t problem -solving is not, since som e people find it easier to say w hat som ething is not rather than w hat it is and thirdly, a borderline case which contains som e o f the critical attributes of the c o n c e p t b e in g e x a m in e d , in th is c a s e , problem-solving.

M O D E L CA SE
A model case is a "real life" example o f the concept and includes all the critical attributes.
E xam ple: Patient X is mentally retarded and has been admitted for tubal ligation.The ward is di vi ded i nto four sections and each section has its own team of doctors.On this particular day, Patient X 's relatives requested a passout to e n a b le h e r to fe tch h er d is a b ility grant.U nfortunately, the patient's doctor w as not available on this day.Rather than the patient missing her disability grant, the professional nurse in charge of the patient decided to ask a doctor from another scction to sign the patient's passout.This is not normal procedure, but because o f the professional nurse's good human relations and creativity, the passout w as signed and the patient w as able to fetch her disability grant.
T h is is a m o d e l c a s e o f th e c o n c e p t "p roblem -solving" because all the critical attributes have been met.

C O N T R A R Y C A SE
A contrary case differs radically from the c o n c e p t in q u e s tio n ; in o u r c a s e , problem-solving.
Exam ple: Patient Y has had a normal vaginal delivery.The infant is a healthy baby girl w e ig h in g 3,5 k ilo g ra m s.P a tie n t Y w as immediately transferred to a post-natal ward as sh e d id n o t h a v e a n y p o s t -d e liv e r y complications at that stage.Tw o hours later, however, the patient reported to her professional nurse that she thought she w as having excessive vaginal bleeding.The professional nurse instructed the patient to change the sanitary pads regularly.An hour later, the patient complained o f dizziness.She was instructed not to get out of bed.
Two hours thereafter, the patient tried to get out of bed in order to get a fresh supply of sanitary pads when she started passing massive blood ■ o ts vaginally and then collapsed.A doctor was called to resuscitate the patient.This was not successful and the patient died about fifteen minutes later.This is a contrary case, since the professional nurse failed to recognise the problem and consequently gave non-specific orders which did not help the patient.If we look at point (ii) professional nurse takes actions, they are not effective because they do not address the real problem.

B O R D E R L IN E C A SE
A borderline case contains some of the critical attributes of the concept being examined, but not all of them.
Exam ple: There is a staff shortage in Unit X over weekends and public holidays because the senior staff members are not willing to work during these periods.The quality o f patient care suffers as a result o f this problem.T o solve the problem, the Nursing Service M anager decides to bring in part-time staff during the periods in question, even though this is very expensive and the quality of patient care docs not improve significantly since part-time personnel are not familiar with the unit.This is a borderline case because the suitability and cost-effectiveness o f the option taken have not been considered.It is also questionable whether the problem of the quality o f patient care has been resolved.All other attributes have been met.
In addition to the three cases there are:

RELATED C O N C EITS
These concepts are related to problem-solving but do not contain the critical attributes.

(i) Decision-making
A decision is the conclusion of a process by which one chooses among available alternatives for the purpose of achieving a set of desired objectives.
Decision-making creates systems for rational comparison of options so as to pick the best one i n terms of i ts effecti veness i n achi evi ng the goal with efficiency.
Decision-making can thus be seen as a phase in the problem-solving process; however, not all decisions are of a problem-solving nature, such as decisions about budgets or equipment.Also a major decision may have involved the solving of several related problems.

(ii) Creativity
Creativity refers to the ability to develop and implement new and better solutions.
A creative person is constantly seeking alternate and new w ays of defining or interpreting a problem so as to generate new and better strategies to resolve the problem.
Creativity may be blocked when people remain locked into particular definitions o f problems even though these are obviously unfruitful, or when people become so personally involved in their own approach to a particular problem that th e y h a v e d if f ic u lty c o n s id e r in g o th e r alternatives.

(iii) Critical Thinking
Critical thinking involves the evaluation o f ideas.A critical thinker asks questions, seeks evidence, examines different alternatives and criticises his or her own ideas and those o f others.
A critical thinker docs not accept statements outright but instead seeks reasons for supporting them .A student w ho eng ag es in critical thinking can decide for him self which ideas to accept and which to reject and he can provide the reasons underlying his decisions.
T h is u ltim ately lead s to b etter and m ore effective reasoning.Critical thinking represents the thought process underl yi ng problem-solving and decision-making.

(iv) Data Collection
The purpose o f information gathering is to assem ble existing inform ation, to m onitor, control and evaluate a situation.
It is a routine occurrence and the methods used are recording and reporting.
D ata c o lle c tio n te c h n iq u e s are fixed and standardised.
Data analysis consists o f description only and the depth o f analysis seldom goes beyond description.
The skills required are data and data systems management and processing.
Nurses arc involved with data collection on a daily basis, e.g.statistics on adm issions, r e a d m is s io n s , b ir th s , d e a th s e tc .T h e maintenance o f im pressive records and graphs reflecting the statistics mentioned above would b e a fu tile e x e rc is e if all th at v a lu a b le information is not used to identify and solve problems in the unit concerned.
This concludes the process o f problem-solving.
During their first years of training our students a re in tro d u c e d to th e th e o ry o f c lin ic a l problem -solving in the form o f the nursing process, however, the practical application of this theory in the clinical situation has been seen to be less than satisfactory.According to Chang (1991), the reasons for the incomplete use of the nursing process can be classified according to: -cognition -skill and -attitudes T h e g e n e r a l f e e l in g is th a t c lin ic a l problem-solving is too difficult, too theoretical and too time consum ing.
Effective problem-solving in nursing requires theoretical as well as procedural knowledge of both the problem-solving process itself and the principles and process of nursing.In other w ords, learning how to solve problem s in nursing involves acquiring knowledge o f and skill in problem -solving as well as integrating this with the acquisition o f nursing knowledge and skill.

W IIAT A RE TIIE IMPLICATIONS OF TIIE PROBLEM -SOLVING PROCESS FOR CLINICAL TEACHING?
R eilly and O erm an (1 9 8 5 ) identify seven p rin c ip le s fo r te a c h in g p ro b lem -so lv in g , namely: -T he nature o f the problem selected for stu d en t invo lvem en t needs to be at an appropriate level in terms of the learner's knowledge base.
-Learners, because o f their limited practical knowledge and experience in the clinical field should be assisted in identifying and delim iting problems.
-L earn ers need assistan ce in identifying m u ltip le so lu tio n s for problem s.T his p ro m o te s c o g n itiv e d e v e lo p m e n t and divergent thinking and also improves the c h a n g e o f fin d in g the b est and m ore appropriate solution for the problem.The teacher needs to support the student during this process.
-It is im portant for the learners to follow a sequence o f steps from definition of the problem to evaluation o f solutions so as to m a in ta in th e in t e g r i ty o f th e problem -solving process even though in re a lity th e p ro c e s s m ay not follow a sequence o f steps.
-The emphasis in teaching problem-solving should be on the process i tsel f rather than on the outcomes.
-In a d d itio n ta the a n a ly tic p ro c c ss o f problem-solving, the learners also should be ta u g h t the im p o rta n c e o f re c o g n iz in g hunches and searching for evidence to confirm or reject them.
-T he teach er should be su p p o rtiv e and tolerant o f differences among learners in their approaches to problem-solving.
In addition to the seven principles, good role modelling has been identified by many nurse authors, such as R obertson (1 980), as an effective teaching strategy in the clinical area.
Students should be afforded an opportunity to actually observe the problem-solving process in action either from the clinical instructor or the preceptor.Students should, however, be critical o f everything observed, as blind acceptance could be dangerous.
The clinical teacher should realise that it is not enough just to ensure that the student knows how to do the nursing procedure, but the student should be able to relate the nursing care to the patient's presenting problems and the nursing care must be seen as a solution to the patient's problem and not just a routine procedure.The student should be stim ulated to take an active part in his/her learning by the teacher asking questions such as: -Why is a particular nursing care being done?
-Why is it being done in this particular way?* What would be the consequences o f not performing the nursing care?
An effort on the part o f the student and the clinical teachers should be made to exploit the full potential o f the clinical setting with regard to the teaching and learning o f the process o f problem-solving.

W HAT ARE THE IM PLICATIONS OF THE PROBLEM SOLVING PROCESS FOR THE CLINICAL EVALUATION OF STUDENT PERFORMANCE?
W hether or not w e are evaluating our students p ro b lem -so lv in g skill ad eq u a tely depends largely on our approach to the process o f evaluation.Perhaps if we reflect on the process o f problem -solving as described earlier, we could ask ourselves the follow ing questions: * Are w e evaluating our students' ability to recognise problem situations and then ask relevant questions?
* A re w e testin g the ab ility to gen erate solutions to resolve the situation?* Do we check if the actions taken to resolve the situation are appropriate?
These and other questions may be asked to determi ne if our evaluation strategies are geared towards eval uating the students effectiveness in problem-solving.
T o this end, the M cM aster University (Canada) programme could serve as a useful example.
T h e p ro g ra m m e fa c ilita te s s e lf-d ire c te d le a r n in g a n d s e l f -e v a l u a t i v e a n d problem-solving skills.
In addition to the conventional methods o f student evaluation, the "Triple Jump" method, designed specifically to evaluate the student's problem-solving ability is employed.
It consists o f three steps namely:-

STEP 1 -Problem Definition -1/2 hour
The student is presented with a problem nursing situ a tio n from w h ich to id e n tify n u rsin g problems.
The student then proceeds to gather data from the history and physical examination.The examiner reads this information from the chart and gives it to the student.The patient's problems are then sum marised by the student to arrive at an interim problem formulation.
T h e s t u d e n t th e n i d e n t i f i e s n u r s in g interventions for the problems identified.
At this point the student is asked to pinpoint im p o r ta n t g a p s in h e r k n o w le d g e o r understanding of relevant information, e.g. it could be the anatomy and physiology related to the patient's problem.

STEP 2 -Independent Study -2 hours
This is done to enable the student to bridge the knowledge gap.The student is advised that on return she will be asked to revise the problem list based on any additional information and further to develop one problem with short and long term goals, nursing interventions with rationales for the interventions.

STEP 3 -Synthesis and Integration • 45 minutes
The student is asked if there are any changes in the problem formulation.The problems must be stated in their order of priority, the reasons for stating the problems must be specified.The student is asked how the issues were researched, what resources were consulted and the time spent.Finally the student evaluates her own performance.The entire exercise is evaluated and a score is awarded.

CONCLUSION
If w e are still h av in g p ro b lem s w ith the im plem entation o f clinical problem-solving, then maybe we need to take a second look at our teaching and evaluation strategies in relation to problem -solving to determ ine w ays in w hich we could bring ab o u t an im provem ent in this im portant area o f nursing practice.I see this as a challenge to all of us.We have an obligation to prepare professionals w ho will be able to function as independent practitioners endowed with the skill to critically analyse and evaluate information.
order to exam ine whether we are addressing the skill o f problem-solving in our teaching, it is essential to have a clear understanding o f what the skill entails.A mere definition w ould not te ll u s m u c h a b o u t th e c o n c e p t o f problem-solving w hereas a concept analysis w ould serve to clarify the m eaning o f the concept.

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xam ple: If a person in charge o f a unit is unaware that there is a staff shortage in his/her department in the evenings, then no p r o b l e m -s o lv i n g w ill c o m m e n c e .

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iii) Selection and implementation o f a course o f action from amongst the alternatives generated, taking intoconsideration factors such as suitability and cost-effectiveness.(iv)The problem-solver may or may not depart from routine procedure.E M P IR IC A L R E F E R E N T S (for the critical attributes).T h e s e a re c la s s e s o r c a te g o r ie s w h ic h dem onstrate the occurrence of problem-solving.