PROBLEM SOLVING IN

NURSING METHODE
 OBJECTIVE

• History
• Definition
• Theory PS
• PS in Nursing
• PS related Disciplines
This development of a problem-solving
Early attempts to develop patient-
approach to nursing has been one of the
more important changes that has
centred care employedpatient-
takenplace in nursing during the last allocated nursing. In this situation, a
decade. team of nurses provides the total
There has been a major shift from care for a small group of patients.
nursing's traditional disease- Because the work is co-ordinated by
a team leader, the nurse's problem-
oriented approach to care, to a
solving skills are still under-utilised
patient-centred, problem-solving (Beswetherick 1979, Kershaw 1987).
approach (Beswetherick 1979, However, further developments have
Henderson 1982).
led to the introduction of
Traditional nursing is dominated by the
medical model, that is, thepatient's
individualised nursing care, an
nursing care is directed by doctors' approach in which the nurse plans,
orders(Clarke 1978, Boylan 1982). delivers, and evaluates the care of
Traditional practitioners seethe patient one based on the assessment of that
as a repository of disease, the main patient. Nurse practitioners and
goalbeing to alleviate symptoms. educators realised that
Consequently, the curriculum for this individualized nursing care
type of nursing included the didactic depended upon intellectual as well
transmission of general nursing
Problem solving.
Nurses have, in recent years,
concentrated on the provision of
individualised care. In so doing
British
nurses have paid considerable
attention to nursingdevelopments
in North America, in particular,
the nursing
process and nursing models
(Aggleton and Chalmers 1986).
The nursing process, one
systematic method of delivering
individualised nursing care,
consists of, in turn, patient
assessment, identification of
nursing problems, application of
nursing care to solve these
The definition of problem The definition given by
solving de Tornyay (1970, p.85)
The definition of problem solving is logically
dependent on the definition of problem and solution. summarises these key features:
A problem issaid to exist either when there is a "Problem solving, an extremely
discrepancy betweenthe actual and the ideal state of
affairs, or when anindividual cannot immediately important objective in learning,
assimilate the situationwhich confronts him or her consists of discovery because the
and cannot satisfy a need; for example, see Schmuck
et al (1966, p.15), Newell and Simon (1972, p.72-73), learner is expected to generate a
Bailey and Claus (1975, p.20), and Simon
and Hayes (1985, p.253). The former definition is
novel combination of previously
usuallyapplied to well-defined problems. An ill- learned principles. It is a
defined problem,on the other hand, is said to be a
situation where thereis no apparent relationship
synthesising of understanding
between certain initialinformation and the goal, for towards a solution."
example, see Merrifield et al (1962, p.l), Chi and Glaser
(1984, p.246), and Kahney (1986, p.15). A solution is
usually defined as theachievement of a specified goal
following a series ofactions to reach the goal
(Wickelgren 1974, p.16).
THEORIES OF PROBLEM SOLVING THE INFORMATION PROCESSING SYSTEM
THEORY
Newell and Simon introduced this new and
Two main theories explaining thehighly
process of problem solving are influential theory of problem solving in the
1960s and
discussed. First, is the published their major research in 197 2
information processing system (Newell and Simon 197 2). This seminal work
theory, particularly the concepts has been developed and refined in recent
years by Simon and Hayes (1985, Chapter
of problem space and problem- 12), and by other writers, for example, see
solving strategies. Second, is theChi and Glaser (1984,Chapter 10) and Kahney
stages model theory of problem (1986, pp.39-49).
solving. Several stages models The theory postulates that problem solving is
are discussed, from which a five- a product of elementary information
stage model is derived for the processing activities which form a framework
of three inter-linked components: (a) task
purposes of environment; (b) problem space; and (c)
this research. problem-solving strategy (Simon and Hayes
1985, pp.254-261).

When faced with a problem, and depending

on the complexity of the problem, the solver
Searching the problem space is primarily a move from
one node (a chunk of related information) to another
(Simon and Hayes 1985, p.260), and one (or a
combination) of the following strategies may be used:
1. random searching (indiscriminate searching
forgoals);
2. heuristic search (using rules of thumb);
3. means-ends analysis (reducing
discrepancybetween actual and ideal state);
4. sub-goaling (breaking down the problem into
intermediate states);
5. generation and testing (of possible solutions). (Chi
and Glaser 1984, pp.234-239, Kahney 1986,
pp .39-46).
 This complex picture is simplified
STAGES MODEL THEORY by Priestley et al
The second major approach to describing the
problem solving process is the stage, or step-
(1979, pp.100-101) who explain:
wise model of problem solving (Green 1966,
p.11, Hill 1979, p.16). The number of accounts "In essence they are simply
explaining the process of problem solving in formulae that guide us into
this way is extensive (Johnson 1944, Hill 1979, activities - things to do that will
p.16). One list, displaying 55 different
representations
make solutions to problems more
of stages models gathered from a major readily available ... they cannot
review of the general and specific literature on guarantee answers: they do lead
problem solving spanning the past 50 years, is us
summarised in Table 1, p.16. The number of by a series of logical steps to
stages in each separate model varies
considerably - ranging from three (Johnson
conclusions that are unique and
1944) to ten (Bailey and Claus 1975, Chapter inviolable. For the most part
3). There are many similarities in the names they produce ideas in quantity,
used and the processes identified (Priestley et from which a solution can be
al 1979, pp.99-101). chosen; ..."
Table 1: Stages models of problem
solving citing the author's naming and In summarising and
sequence of stages
simplifying the extensive
Key to stages
(PId) Problem identification/orienting literature on
(Im) Selection/implementation
(PDe) Problem definition of strategies
stages models of problem
(PAn) Problem/sub-problem analysis solving in this way, we arrive
(Ge) Generation/production
(PAs) Problem assessment/data collection of at a five-stage model which
solutions
(Go) Goal/objective setting can be applied to research in
(T) Testing
(Hy) Hypothesis formation/testing
many disciplines. The stages
(L) Learning model used in this research
(Di) Diagnosing
(Ev) Evaluation/verification has as its basis this five-
(Pr) Preparation of solution
(Pin) Planning interventions stage model.
(Re) Re-appraisal of problem
(G) Generalisation
The stages model theory has several strengths.
Perhaps its main strength is that the step-by-step method of identifying and solving problems encourages
systematic thinking habits which can be transferred to other problem contexts (Priestley et al 1979, p.99-
101).

A second strength is that in the case of unsuccessful problem

solving, it is possible to isolate the weak link or links and set up remedial action (Bailey and Claus 1975,
p.110).

Third, the model demonstrates flexibility, both in its application to different problem situations and in the
partial use of stages according to the complexity of the problem (Johnson et al 1980, Chapter 1). And fourth,
stages models are used to teach and facilitate learning
(Hill 1979, pp.85-100) as well as explain the process of problem solving (Hill 1979, pp.18-21).
 In fact, those studies which have
The mean place of the five most examined successful and
frequently cited unsuccessful problem solving,
indicate that subjects who
stages approach the problem in a
systematic, selective, and reflective
way tend to be successful (Attree
Sequence Stage Mean place 1982, pp.2-7). As Yeaw (1979,
p.18), explains:
"The successful problem solvers
1. Problem identification 1.0 were more systematic. They
2. Problem assessment/data collection divided the problems and simplified
the facts. Students who were less
1.5 successful tended to "dive in"
3. Planning interventions 3.0 attempting to solve the whole
problem.“
4. Selection and implementation of
strategies 4.0 Successful problem solving
requires several skills depending
5. Evaluation/verification of solution 4.4 on the problem situation.
Generally, these can be grouped
under the headings 'intellectual'
and
'practical' skills,
PROBLEM SOLVING IN NURSING
This chapter builds on the discussion of
the
problem-solving theories introduced

The literature on problem solving in

nursing, which borrows from both
information
processing system and stages model
theories, is
examined in detail. Diagnostic
reasoning, one
form of problem
Problem Solving in Nursing Contexts For example
The definition of a nursing problem by Abdellah Johnson et al (1980, pp.1-2) explain that
(1957, p.6) is based on nurse-patient interaction problem solving:
and is therefore, context-tied. According to her a
nursing problem is:
" ... a condition and/or situation faced by a " ... consists of a series of definite steps
patient, or his family, which the nurse can which proceed in a logical manner
assist him to meet through the performance of toward a specific goal. These steps are:
her professional function." assessment, development of a plan,
The more detailed definition of a nursing
problem, provided by Ashworth and Castledine
implementation of the plan and
(1981, p.88), also recognises the nurse-patient evaluation."
relationship. They state that:
The similarity of Yura and Walsh's definition of
"A nursing problem can be defined as any
the nursing process given earlier (p.3) with the
condition or situation in which a patient definition above by Johnson et al, is very clear.
requires nursing assistance or help to attain, In fact nursing process and nursing problem
maintain or regain, a state of health which is solving are concepts that tend to be used
desirable for him, or to achieve a peaceful synonymously in the literature (Henderson
death ..."
1982).
 The stages model of problem solving in relation
Nusing diagnosis to
Diagnostic reasoning is defined as a process of the nursing process
determining the patient's health needs using diagnostic
hypotheses (Itano 1989). Carnevali (1984, pp.40-42) and Stages from
the literature
Jones (1988) emphasise that the term diagnosis in nursing
is not used in the narrow sense of identifying disease, Steps in nursing process
but rather to describe the process which leads to
conclusions derived from assessment of the patient's
1. Problem identification .
1 Assessment
2. Problem assessment 2. Planning
health and related factors. Once the nursing diagnosis is
3. Planning interventions 3. Implementation
made, the nurse then implements nursing actions to offset
4. Implementation 4. Evaluation
the patient's problem (Yura and Walsh 1978, pp.59-60, 5. Evaluation (Bloch 1974, p.689)
Tanner et al 1987). Jones (1988) believes that nursing
diagnoses help foster professional autonomy and
accountability because their use emphasises the unique
function of the nurse.
 Criticisms of the Stages Model Theory in Nursing
Although much of the literature supports the stages model Hardy and Engel (1987, p.38), in a similar
theory of problem solving in nursing, there are a number vein, offer
of notable criticisms. Many of the criticisms centre on other criticisms:
the nursing process, and there is an implicit demand for
further articulation and/or research as Chenitz and "The adoption of one method of problem
Swanson (1984 pp.205-206) explain: solving
may not confer a cloak of respectability,
"Nursing process consists of those problem solving
actions and interactions between nurse
rather
and client that are directed toward a specific it may reveal more about nursing as a static
end. These goal-directed behaviours are the profession. In the past 20 years, the world
ways in which nurses carry out the basic nursing has
process ... However, the numerous applications changed drastically, yet the nursing process
of the basic nursing process used by nurses in has
daily practice cannot capture the level of been clung to tenaciously. Is this because it
sophistication and the complexity that explains
works well or because too much money has
and predicts what nurses do and why, until
systematic articulation of the nursing process been
is done ... It is essential that we attend to invested in it to let go and explore other
this task, since the basic nursing process has methods? ... The nursing process came into
already been defined and analysed, yet the fashion when assumptions were made that
sub-processes that compose this process are
lacking."
PROBLEM SOLVING IN RELATED DISCIPLINES

This chapter summarises the literature on

problem solving in medicine, management, and
education. A brief comparison is made between
the theories of problem solving encountered in
these disciplines and those in nursing. A
summary of the review of the literature is given
and research concerns identified.

PROBLEM SOLVING IN MEDICINE The stages model

Medical problem solving is a process of making an
below, consisting of the four elements described
‘accurate diagnosis' and a 'management plan' for the
individual patient with the intention of improving health by Vu (1979, p.282), is typical of others to be
(Vu 1979, p.282, Berner 1984, p.626). found in the medical literature:
As in nursing,
1. data collection;
problem solving in medicine is discussed in the literature
in terms of the two main theories: information processing 2. interpretation of data;
system and the stages model theories (Elstein et al 1978, 3. hypothesis generation;
Chapter 2, McGuire 1985) with the emphasis being on the 4. evaluation.
former. Other, less-well documented interpretations
include the clinical judgement approach and the
decision-analysis/probability model (McGuire 1985).
2. PROBLEM SOLVING IN
MANAGEMENT The stages model below, described by
Greenwood et al (1983, p.25-26), is similar to the one the
A managerial problem is a gap between researcher derived from the general literature (Table 4,
an actual state and a desired state. p.21) and is also representative of others in the management
literature:
Problem solving in management,
therefore, is a process of identifying and 1. identifying the type of problem faced;
justifying solutions in a systematic 2. analysing the problem;
question-posing way to close the 3. decision making;
gap and solve the problem, for example, 4. decision taking - implementation;
see Margerison (1974, pp.19-22), 5. outcome evaluation.
Kaufman (1982, p.12), Greenwood et al
(1983, p.12). An effective solution to a
managerial problem is cost-effective,
reliable, efficient, adaptable, and
acceptable to those who have to
implement it (Margerison 1974, p.31).
He goes on to describe two problem-centred and three
solution-centred approaches. Problem-centred approaches:
1. consultative oriented, where the manager
generates and shares knowledge about the problem
by discussing the problem with subordinates;
2. reflective oriented, in which the manager uses a
non-directive, listening and advising approach.
Here, an attempt is made to persuade
subordinates to 'own' the problem.

Solution-centred approaches:
1. directive oriented, where the manager tells
others what is to be done. He or she takes a
direct line by issuing an order. Although this
approach has a place in management, it tends to
be played down by managers;
2. prescriptive oriented, where the manager advises
what should be done. This is a common approach,
but its success depends on the subordinate’s
trust in the manager's judgement;
3. negotiative oriented, where the manager seeks
compliance from subordinates in return for a
reward. This form of bargaining is a
well-recognised style of management in industry.
Problem solving in education Stewart (1985)
The process of problem solving in education is
seen as Divides knowledge into
(a) facilitating teaching and learning (Schmuck (a) conceptual knowledge important to the way
et al 1966, p.l), the problem is perceived, and
(b) acquiring problem-solving skills (Hill 1979, (b) strategic knowledge which governs the
pp.85-100), and heuristics the solver will employ in the problem
(c) understanding the cognitive processes space. In an educational setting, it is both the
involved (Stewart 1985, Garrett 1986). conceptual knowledge of the discipline and the
procedural knowledge related to the problem
But the process of problem solving in education that will determine the problem space, the
is still unclear (Hill 1979, pp.15-16). As Garrett heuristics used, and the speed and accuracy of
(1986, p.90) explains: problem solving.
" ... the whole field of endeavour in problem
solving is particularly vast and largely
disorganised ... we are as removed from an
understanding of the process of problem
solving
and its relationship to solver and task
variables as we have ever been."
The authors begin by explaining that teachers are
constantly faced with classroom problems which can
They go on to recommend a
be dealt with in many ways. According to the authors,
teachers may use one of the following 'problem- stages model of problem solving,
solving styles' (p.6): consisting of the following steps
to help improve the teacher's
1. problem denial, where the teacher lacks insight
into the problem, or energy to tackle it; problem-solving skills (pp.8-11):
2. authoritarian problem solving, where solutions
are enforced without logical rationale;
1. identifying classroom
3. least-effort problem solving, where little work
is put into dealing with a problem; problems;
4. personal satisfaction problem solving, where 2. diagnosing classroom
only information supporting the desired outcome
problems;
is gathered;
5. pure-empiricist style, where data are used to 3. developing a plan;
solve the problem; 4. adaptation and action;
6. intuitive problem solving, where priority is
5. feedback and evaluation.
given to thought processes and reasoning;
7. empirical-rational problem solving, where
empirical data and theoretical approaches are
used.
Only one vignette (Number 1 in
Appendix 1, p.Al) was
complete, that is, included an
explanation of:

1. the way the problem was

identified;
2. the way the patient was
assessed;
3. the nursing plan;
4. the way the plan was
implemented;
5. how the outcome was
evaluated.