Nursing students’ evaluation of the introduction of nursing diagnosis focused tutorials in a university degree programme

The School of Nursing at the University of KwaZulu-Natal has recently introduced the concept of nursing diagnosis within the Bachelor of Nursing Problem Based Learning (PBL) acute care nursing course. A descriptive survey was designed to evaluate a teaching strategy the researchers developed for Year III Bachelor of Nursing students in an acute care clinical practice course. All students in Year III PBL tutorials in 2006 were included in the study. The students were satisfied with their learning and felt competent in assessing, making and prioritizing nursing diagnoses, formulating hypotheses and using the nursing process in their care in real life nursing situations. With regard to the structured nine step process students generally were enthusiastic about this process and felt that it helped them perform better. This paper describes how the researchers introduced nursing diagnosis and how it was received by the students. Because these students are Year III students their perceptions of this change in focus is especially enlightening and provides useful feedback to further modify the course.


Background to the study
Problem solving in nursing in general, as well as nursing education specifi cally is essential for nurses. Further more, teaching nursing students how to use the nursing problem solving process (called the nursing process), is critical to their ability to provide sound quality nursing care in the clini cal area (M iiller-Staub, Needham , Odenbreit, Lavin, & Van Achterberg, 1996:5;Volpato, 2003:1;Burkhart, 2006:22). Nurses need complex think ing processes, as well as psychomotor and affective skills in order to be expert clinical practitioners (Smith Higuchi & Donald, 1996:145). Acritical step in the nursing process, and one which has not been emphasized to date in the stu dents involved in the research, is the process o f formulating a nursing diag nosis. Nursing's unique contribution to client/patient care and the scientific basis for nursing practice is demon strated through the nursing process, and in particular when developing the nursing diagnosis. Nursing diagnoses requires students to have a good grasp o f competencies such as assessment, clinical reasoning and integration of social and basic sciences. Nursing di agnosis is meaningless without the use o f all the steps in the nursing process but with them, it is a very powerful tool in nursing practice. The nursing proc ess facilitates opportunities for nurses to develop critical thinking and clinical reasoning skills in deriving nursing di agnoses, designing and selecting therapeutic interventions, and evalua tion o f outcomes. Nursing diagnosis assists in clinical decision making that is based on critical review and utiliza tion of theory and research pertinent to the p henom ena o f concern (Doenges & Moorhouse, 2003:22). The students' abilities to use these skills are tested using a strategy called a 'tri plejump' which was developed by staff at McMaster University, Canada in or der to measure the problem-solving abilities of students (Callin & Ciliska, 1983:41). The triple jump is used at the School o f N ursing, U niversity o f KwaZulu-Natal as one of the student assessment tools at the end o f each semester in the third year nursing pro gramme.
To introduce the use of the nursing di agnosis and to promote systematic problem solving, the researchers (who were also the facilitators o f these stu dents) designed a four hour teaching programme, taught in two, two hour sessions. The sessions informed stu dents of the systematic problem solv ing process that would be used in their 2006 PBL tutorials. Information on nurs ing diagnosis and its relationship to the nursing process was also included in the session. A nine-step problem solv ing process (developed by the re searchers) was demonstrated to the students and was used in all tutorials for this course during the year. The nine steps included were: Step 1: Present a brief description of the patient.
Step 2: Allow students in your group to pose hypotheses about what the possible problems are for this patient.
Step 3: Allow students to ask you for data based on these hypotheses.
Step 4: Facilitate formulation o f a re vised problem list. This may require you to tell students additional data that was not requested and sharing with them what hypotheses you had for this pa tient.
Step 5: Allow students to ask more questions and to determine a final prob lem list. These should be in the form of nursing diagnoses, including possible diagnoses and risk diagnoses.
Step 6: Determine if you need additional information, i.e., are you able to deter mine a list of diagnoses that you can support with data? Does the group have any idea of what interventions/ nursing actions might be effective to reduce or elim inate the problem s? What evidence do they have for this? This is an opportunity to get the group problem solving using information they have learned from a variety of disci plines.
Step 7: Present your list o f interven tions and rationale for them. Students can then question you about these ac tions. You will be the clinical expert. What evidence do you have that this nursing action decreases the problem you have identified in your nursing di agnosis?
Step 8: Determine what data you would need to collect to see if the problem was reduced or eliminated? If the group is unable to assist with this you will provide this along with your rationale. How will you determine if the patient is ready for discharge? What can you do to ensure that the patient is ready for discharge?
Step 9: In what other clinical situations might this information be useful? Iden tify related diagnoses and whether or not nursing actions identified would be useful in these cases.
These nine steps correspond to the ten assessment areas o f the triple jump, which are: 1.
Self assessment of learning needs 8.
Rank patient problems in order of priority 10.
Nursing interventions for one identified problem (Callin & Ciliska, 1983:42) The study described in this paper was part o f a larger study to implement a change in the acute care clinical nurs ing course in Year III of the Bachelor's degree programme and to determine if this change improved students' prob lem solving and nursing care planning (Lee & Brysiewicz, 2008:2).

Problem statement
Although students are taught to prob lem solve through PBL sessions, they do not seem to correlate the activities in the class with the assessment strat egies, such as 'triple jump, which has been shown to measure student prob lem solving capabilities (Makhathini & Uys, 1996:343). The facilitators in the Year III clinical PBL course wanted to initiate a change in the manner in which PBL tutorials were run to see if adding more structure could improve student satisfaction with their own problem solving skills. In addition, students were not routinely using a component o f the nursing process, the nursing di agnosis, and thus were not implement ing this process in their nursing care planning and struggled with effectively planning relevant nursing care o f a pa tient.

Research question
The following question was expected to be answered by this research: • What are students' perceptions o f the usefulness o f the teach ing and learning strategy imple mented in the academic year 2006 in development of their problem solving and nursing process skills, specifically the development of nursing diag nosis?

Ethical Considerations
Permission to conduct this research was sought from the Head of School as well as ethical approval from the university ethics committee. The re searchers provided all students willing to participate with a copy of the ques tionnaire, a participant information sheet as well as a written consent form, which all consenting students were asked to sign. The information sheet described the purpose o f the research as well as the rights of the student to refuse to participate in the research and that this would not jeopardize their tu torials or marks in any way. The infor mation sheet also contained the re searchers contact details should the students require more details regard ing the research. Data were de-identified and entered into SPSS v l 3 but the original data remained in a locked cup board with one o f the researchers and no one besides the researchers and the research assistant had access to it. Data could not be traced back to the individual students.

Research design
This descriptive survey was designed to evaluate a teaching strategy the re searchers developed for Year III Bach elor o f Nursing students in an acute care clinical practice course. At the end of the two semester course, after using the nine step problem solving process, the students completed a satisfaction questionnaire developed by the re searchers.

Population and sample
All students in Year III PBL tutorials in 2006 (31 students) were exposed to the nine-step problem solving process and were informed o f how to develop a nursing diagnosis. Convenience sam pling was done and all the students agreed to participate in the study.

Setting
The setting for the study was the School of Nursing at the University of KwaZulu-Natal, Durban.

Instrument
The researchers developed a student satisfaction questionnaire which had 12 questions that were designed to determine students' perceptions about the effectiveness o f the nine step strat egy in facilitating their learning in the area o f nursing process and specifically the nursing diagnosis. A Likert type scale was used with the following rat ing scale; 4 = strongly agree, 3 = agree, 2 = disagree and 1 = strongly disagree and 0 = do not wish to answer. The questionnaire included questions that measured student perceptions o f their mastery of elements of the nursing proc ess such as: I feel competent to assess patients in order to make a nursing di agnosis and I am able to plan nursing interventions that are relevant to the nursing diagnosis. The questionnaire also included one open ended ques tion namely; "Are there any comments that you would like to make, either posi tive or negative, about the way your tutorials were conducted this year?" Many problem s with questionnaire analysis can be traced back to the de sign phase o f the tool and the research ers attempted to ensure that the ques tionnaire was developed to directly address the objectives o f the study (Statpac, 2007:1).

Validity and reliability
Content validity was determined by two nurse educator experts at the Uni versity o f KwaZulu-Natal. Reliability was determ ined by calcu latin g a Cronbach's alpha on the completed questionnaires. The Cronbach's alpha on this sample was r = 0.86.

Data analysis
Data were analysed using the Statisti cal Package for Social Sciences (SPSS) version 13 to provide descriptive and comparative information regarding stu dent satisfaction. The open ended question was manually analysed and the researchers individually read through the responses and separately identified categories which emerged from the data. These categories were then discussed by the researchers and together consensus on the categories was reached.

Findings
A total o f 31 students (three o f whom were males) completed the question naire thus a response rate o f 100% was achieved. Responses to the 12 ques tions were analysed using descriptive statistics and the findings are displayed in Table 1.
The highest score was noted for items 8: Having the nine step process made doing my case presentation much easier (74.2% or n = 23) and item 10:1 feel more competent using the nursing process than in previous years (74.2%> or n = 23). For all items on the student satisfaction questionnaire the positive scores for strongly agree and agree accounted for 90.3 to 98.6%) of the re sponses, with 98.6%) the median score for these two ratings. Scores for disa gree and strongly disagree ranged from 3.2%) to 6.5% on all items except item four: I know how to construct a nurs ing diagnosis, where 90.3% answered agree or strongly agree, with three re sponses missing.
The open ended question contained a number o f responses from the students regarding other issues unrelated to the study, namely complaints regarding administrative issues, e.g., sick leave, the relocation o f the nursing school and transport issues. All the responses regarding the new way of teaching in their third year group were positive. Two students remarked that class had now made them feel more competent as nurses.
1 feel competent and ready to work as a registered nurse. Class encouraged me not to rely on doctors diagnoses but to make my own nursing diagnosis. This helped me to care fo r my patients better.
The students felt that the new system in class had helped them a great deal and one student explained; The nine steps were very helpful and I think that i f the next years students will use it they will be more compe tent.
One o f the students acknowledged that; I 've been struggling with the system at the beginning o f the year and now I 'm fu lly competent on form ulating nursing diagnoses and prioritising.

Discussion
Overall the findings of this study indi cate that the students were satisfied with their learning during the Year III PBL nursing course. The findings in dicated that students felt competent in assessing, making and prioritizing nurs ing diagnoses, formulating hypotheses and using the nursing process in their care in real life nursing situations. With regard to the structured nine step proc ess for case presentations and tutori als, students generally were enthusi astic about this process and felt that it helped them perform better in present ing their real patient cases in class.
The highest scores (96.8% agree or strongly agree) on the questionnaire were the items that related to patient assessment, understanding the impor tance o f making a nursing diagnosis, prioritizing nursing diagnoses, impor tance o f making diagnoses, ability to plan nursing interventions and more competence in nursing process and nursing diagnosis than in previous years (not really practiced prior to this year). The lowest scores (only 90% agree or strongly agree) were on the items related to improved critical think ing and problem solving abilities, made case presentation easier, and construct ing a nursing diagnosis. Since the in tervention was developed and imple mented in this student group by the facilitators in this course, literature to explain student responses is limited. There is, however, literature that sup ports the usefulness o f using system atic and more structured approach to problem solving. The importance of using a 'method' in problem solving in order to guide the m ental activity stages one uses to originate and apply kn o w led g e has been described (Edmund, 2007:1). Using a method in problem solving organises and clarifies our thoughts, prevents aimless wan dering and helps to shape ideas. It pro vides an organised approach or sys tem which in turn leads to increased self confidence and is a repeatable and remembered procedure. Having a sys tematic approach also aids in the trans fer of learning, encourages conceptual thinking and trains for change and in novation (Edmund, 2007:1). It was also reported that receiving problem solv ing training can lead to greater posi tive affect, higher job satisfaction and higher life satisfactio n (Ayres & Malouff, 2007:279).

Conclusion and recommendations
In this paper a study to determine the usefulness o f an intervention devel oped by the facilitators in a PBL Level III nursing course is described. The data indicate that the students were satisfied with the nine step problem solving method and felt that it im proved their ability to diagnose and plan patient care. The researchers feel that the data supports continued use o f this strategy for students in this course in the following years. It is rec ommended that further research be. per formed to determine if the same effect would occur with future groups in this course.
project. Mr. Myeni was responsible for the data entry and preliminary analysis of the data.