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Clinical problem solving and diagnostic decision making: selective review of the cognitive literature

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This article has a correction. Please see:

• Clinical problem solving and diagnostic decision making: selective review of the cognitive literature - November 02, 2006
• Arthur S Elstein , professor ( aelstein{at}uic.edu ) ,
• Alan Schwarz , assistant professor of clinical decision making.
• Department of Medical Education, University of Illinois College of Medicine, Chicago, IL 60612-7309, USA
• Correspondence to: A S Elstein

This is the fourth in a series of five articles

This article reviews our current understanding of the cognitive processes involved in diagnostic reasoning in clinical medicine. It describes and analyses the psychological processes employed in identifying and solving diagnostic problems and reviews errors and pitfalls in diagnostic reasoning in the light of two particularly influential approaches: problem solving 1 , 2 , 3 and decision making. 4 , 5 , 6 , 7 , 8 Problem solving research was initially aimed at describing reasoning by expert physicians, to improve instruction of medical students and house officers. Psychological decision research has been influenced from the start by statistical models of reasoning under uncertainty, and has concentrated on identifying departures from these standards.

Summary points

Problem solving and decision making are two paradigms for psychological research on clinical reasoning, each with its own assumptions and methods

The choice of strategy for diagnostic problem solving depends on the perceived difficulty of the case and on knowledge of content as well as strategy

Final conclusions should depend both on prior belief and strength of the evidence

Conclusions reached by Bayes's theorem and clinical intuition may conflict

Because of cognitive limitations, systematic biases and errors result from employing simpler rather than more complex cognitive strategies

Evidence based medicine applies decision theory to clinical diagnosis

Problem solving

Diagnosis as selecting a hypothesis.

The earliest psychological formulation viewed diagnostic reasoning as a process of testing hypotheses. Solutions to difficult diagnostic problems were found by generating a limited number of hypotheses early in the diagnostic process and using them to guide subsequent collection of data. 1 Each hypothesis can be used to predict what additional findings ought to be present if it were true, and the diagnostic process is a guided search for these findings. Experienced physicians form hypotheses and their diagnostic plan rapidly, and the quality of their hypotheses is higher than that of novices. Novices struggle to develop a plan and some have difficulty moving beyond collection of data to considering possibilities.

It is possible to collect data thoroughly but nevertheless to ignore, to misunderstand, or to misinterpret some findings, but also possible for a clinician to be too economical in collecting data and yet to interpret accurately what is available. Accuracy and thoroughness are analytically separable.

Pattern recognition or categorisation

Expertise in problem solving varies greatly between individual clinicians and is highly dependent on the clinician's mastery of the particular domain. 9 This finding challenges the hypothetico-deductive model of clinical reasoning, since both successful and unsuccessful diagnosticians use hypothesis testing. It appears that diagnostic accuracy does not depend as much on strategy as on mastery of content. Further, the clinical reasoning of experts in familiar situations frequently does not involve explicit testing of hypotheses. 3 10 , 11 , 12 Their speed, efficiency, and accuracy suggest that they may not even use the same reasoning processes as novices. 11 It is likely that experienced physicians use a hypothetico-deductive strategy only with difficult cases and that clinical reasoning is more a matter of pattern recognition or direct automatic retrieval. What are the patterns? What is retrieved? These questions signal a shift from the study of judgment to the study of the organisation and retrieval of memories.

Problem solving strategies

Hypothesis testing

Pattern recognition (categorisation)

By specific instances

By general prototypes

Viewing the process of diagnosis assigning a case to a category brings some other issues into clearer view. How is a new case categorised? Two competing answers to this question have been put forward and research evidence supports both. Category assignment can be based on matching the case to a specific instance (“instance based” or “exemplar based” recognition) or to a more abstract prototype. In the former, a new case is categorised by its resemblance to memories of instances previously seen. 3 11 This model is supported by the fact that clinical diagnosis is strongly affected by context—for example, the location of a skin rash on the body—even when the context ought to be irrelevant. 12

The prototype model holds that clinical experience facilitates the construction of mental models, abstractions, or prototypes. 2 13 Several characteristics of experts support this view—for instance, they can better identify the additional findings needed to complete a clinical picture and relate the findings to an overall concept of the case. These features suggest that better diagnosticians have constructed more diversified and abstract sets of semantic relations, a network of links between clinical features and diagnostic categories. 14

The controversy about the methods used in diagnostic reasoning can be resolved by recognising that clinicians approach problems flexibly; the method they select depends upon the perceived characteristics of the problem. Easy cases can be solved by pattern recognition: difficult cases need systematic generation and testing of hypotheses. Whether a diagnostic problem is easy or difficult is a function of the knowledge and experience of the clinician.

The strategies reviewed are neither proof against error nor always consistent with statistical rules of inference. Errors that can occur in difficult cases in internal medicine include failure to generate the correct hypothesis; misperception or misreading the evidence, especially visual cues; and misinterpretations of the evidence. 15 16 Many diagnostic problems are so complex that the correct solution is not contained in the initial set of hypotheses. Restructuring and reformulating should occur as data are obtained and the clinical picture evolves. However, a clinician may quickly become psychologically committed to a particular hypothesis, making it more difficult to restructure the problem.

Decision making

Diagnosis as opinion revision.

From the point of view of decision theory, reaching a diagnosis means updating opinion with imperfect information (the clinical evidence). 8 17 The standard rule for this task is Bayes's theorem. The pretest probability is either the known prevalence of the disease or the clinician's subjective impression of the probability of disease before new information is acquired. The post-test probability, the probability of disease given new information, is a function of two variables, pretest probability and the strength of the evidence, measured by a “likelihood ratio.”

Bayes's theorem tells us how we should reason, but it does not claim to describe how opinions are revised. In our experience, clinicians trained in methods of evidence based medicine are more likely than untrained clinicians to use a Bayesian approach to interpreting findings. 18 Nevertheless, probably only a minority of clinicians use it in daily practice and informal methods of opinion revision still predominate. Bayes's theorem directs attention to two major classes of errors in clinical reasoning: in the assessment of either pretest probability or the strength of the evidence. The psychological study of diagnostic reasoning from this viewpoint has focused on errors in both components, and on the simplifying rules or heuristics that replace more complex procedures. Consequently, this approach has become widely known as “heuristics and biases.” 4 19

Errors in estimation of probability

Availability —People are apt to overestimate the frequency of vivid or easily recalled events and to underestimate the frequency of events that are either very ordinary or difficult to recall. Diseases or injuries that receive considerable media attention are often thought of as occurring more commonly than they actually do. This psychological principle is exemplified clinically in the overemphasis of rare conditions, because unusual cases are more memorable than routine problems.

Representativeness —Representativeness refers to estimating the probability of disease by judging how similar a case is to a diagnostic category or prototype. It can lead to overestimation of probability either by causing confusion of post-test probability with test sensitivity or by leading to neglect of base rates and implicitly considering all hypotheses equally likely. This is an error, because if a case resembles disease A and disease B equally, and A is much more common than B, then the case is more likely to be an instance of A. Representativeness is associated with the “conjunction fallacy”—incorrectly concluding that the probability of a joint event (such as the combination of findings to form a typical clinical picture) is greater than the probability of any one of these events alone.

Heuristics and biases

Availability

Representativeness

Probability transformations

Effect of description detail

Conservatism

Anchoring and adjustment

Order effects

Decision theory assumes that in psychological processing of probabilities, they are not transformed from the ordinary probability scale. Prospect theory was formulated as a descriptive account of choices involving gambling on two outcomes, 20 and cumulative prospect theory extends the theory to cases with multiple outcomes. 21 Both prospect theory and cumulative prospect theory propose that, in decision making, small probabilities are overweighted and large probabilities underweighted, contrary to the assumption of standard decision theory. This “compression” of the probability scale explains why the difference between 99% and 100% is psychologically much greater than the difference between, say, 60% and 61%. 22

Support theory

Support theory proposes that the subjective probability of an event is inappropriately influenced by how detailed the description is. More explicit descriptions yield higher probability estimates than compact, condensed descriptions, even when the two refer to exactly the same events. Clinically, support theory predicts that a longer, more detailed case description will be assigned a higher subjective probability of the index disease than a brief abstract of the same case, even if they contain the same information about that disease. Thus, subjective assessments of events, while often necessary in clinical practice, can be affected by factors unrelated to true prevalence. 23

Errors in revision of probability

In clinical case discussions, data are presented sequentially, and diagnostic probabilities are not revised as much as is implied by Bayes's theorem 8 ; this phenomenon is called conservatism. One explanation is that diagnostic opinions are revised up or down from an initial anchor, which is either given in the problem or subjectively formed. Final opinions are sensitive to the starting point (the “anchor”), and the shift (“adjustment”) from it is typically insufficient. 4 Both biases will lead to collecting more information than is necessary to reach a desired level of diagnostic certainty.

It is difficult for everyday judgment to keep separate accounts of the probability of a disease and the benefits that accrue from detecting it. Probability revision errors that are systematically linked to the perceived cost of mistakes show the difficulties experienced in separating assessments of probability from values, as required by standard decision theory. There is a tendency to overestimate the probability of more serious but treatable diseases, because a clinician would hate to miss one. 24

Bayes's theorem implies that clinicians given identical information should reach the same diagnostic opinion, regardless of the order in which information is presented. However, final opinions are also affected by the order of presentation of information. Information presented later in a case is given more weight than information presented earlier. 25

Other errors identified in data interpretation include simplifying a diagnostic problem by interpreting findings as consistent with a single hypothesis, forgetting facts inconsistent with a favoured hypothesis, overemphasising positive findings, and discounting negative findings. From a Bayesian standpoint, these are all errors in assessing the diagnostic value of clinical evidence—that is, errors in implicit likelihood ratios.

Educational implications

Two recent innovations in medical education, problem based learning and evidence based medicine, are consistent with the educational implications of this research. Problem based learning can be understood as an effort to introduce the formulation and testing of clinical hypotheses into the preclinical curriculum. 26 The theory of cognition and instruction underlying this reform is that since experienced physicians use this strategy with difficult problems, and since practically any clinical situation selected for instructional purposes will be difficult for students, it makes sense to provide opportunities for students to practise problem solving with cases graded in difficulty. The finding of case specificity showed the limits of teaching a general problem solving strategy. Expertise in problem solving can be separated from content analytically, but not in practice. This realisation shifted the emphasis towards helping students acquire a functional organisation of content with clinically usable schemas. This goal became the new rationale for problem based learning. 27

Evidence based medicine is the most recent, and by most standards the most successful, effort to date to apply statistical decision theory in clinical medicine. 18 It teaches Bayes's theorem, and residents and medical students quickly learn how to interpret diagnostic studies and how to use a computer based nomogram to compute post-test probabilities and to understand the output. 28

We have selectively reviewed 30 years of psychological research on clinical diagnostic reasoning. The problem solving approach has focused on diagnosis as hypothesis testing, pattern matching, or categorisation. The errors in reasoning identified from this perspective include failure to generate the correct hypothesis; misperceiving or misreading the evidence, especially visual cues; and misinterpreting the evidence. The decision making approach views diagnosis as opinion revision with imperfect information. Heuristics and biases in estimation and revision of probability have been the subject of intense scrutiny within this research tradition. Both research paradigms understand judgment errors as a natural consequence of limitations in our cognitive capacities and of the human tendency to adopt short cuts in reasoning.

Both approaches have focused more on the mistakes made by both experts and novices than on what they get right, possibly leading to overestimation of the frequency of the mistakes catalogued in this article. The reason for this focus seems clear enough: from the standpoint of basic research, errors tell us a great deal about fundamental cognitive processes, just as optical illusions teach us about the functioning of the visual system. From the educational standpoint, clinical instruction and training should focus more on what needs improvement than on what learners do correctly; to improve performance requires identifying errors. But, in conclusion, we emphasise, firstly, that the prevalence of these errors has not been established; secondly, we believe that expert clinical reasoning is very likely to be right in the majority of cases; and, thirdly, despite the expansion of statistically grounded decision supports, expert judgment will still be needed to apply general principles to specific cases.

Series editor J A Knottnerus

Preparation of this review was supported in part by grant RO1 LM5630 from the National Library of Medicine.

Competing interests None declared.

“The Evidence Base of Clinical Diagnosis,” edited by J A Knottnerus, can be purchased through the BMJ Bookshop ( http://www.bmjbookshop.com/ )

• Elstein AS ,
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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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Communication Skills, Problem-Solving Ability, Understanding of Patients’ Conditions, and Nurse’s Perception of Professionalism among Clinical Nurses: A Structural Equation Model Analysis

This study was intended to confirm the structural relationship between clinical nurse communication skills, problem-solving ability, understanding of patients’ conditions, and nurse’s perception of professionalism. Due to changes in the healthcare environment, it is becoming difficult to meet the needs of patients, and it is becoming very important to improve the ability to perform professional nursing jobs to meet expectations. In this study method, structural model analysis was applied to identify factors influencing the perception of professionalism in nurses. The subjects of this study were 171 nurses working at general hospitals in city of Se, Ga, and Geu. Data analysis included frequency analysis, identification factor analysis, reliability analysis, measurement model analysis, model fit, and intervention effects. In the results of the study, nurse’s perception of professionalism was influenced by factors of communication skills and understanding of the patient’s condition, but not by their ability to solve problems. Understanding of patient’s condition had a mediating effect on communication skills and nursing awareness. Communication skills and understanding of the patient’s condition greatly influenced the nurse’s perception of professionalism. To improve the professionalism of clinical nurses, nursing managers need to emphasize communication skills and understanding of the patient’s condition. The purpose of this study was to provide a rationale for developing a program to improve job skills by strengthening the awareness of professional positions of clinical nurses to develop nursing quality of community.

1. Introduction

Changes in the environment related to climate and pollution are causing health problems and various diseases such as respiratory and circulatory problems, metabolic disorders, and chronic diseases. Moreover, access to modern healthcare facilities has created greater expectations among patients receiving personalized healthcare and high-quality healthcare. As the difficulty of satisfying the demands of patients increases, enhancing nursing capabilities has become increasingly important [ 1 ]. To improve this, hospitals are making efforts to change the internal and external environments so as to increase the number of nurses, reduce the length of hospital stays, and enable efficient nursing practice. Despite these efforts, the workloads of nurses and the demand for clinical nurses are continuously increasing [ 2 , 3 ]. As a result, nurses are developing negative attitudes and prejudices toward patients, as well as negative perceptions of professionalism. To address this, the cultivation and strengthening of nursing professionals’ capabilities is essential.

Nurses’ perception of professionalism is an important element influencing their ability to perform independent nursing, and a good perception of their profession results in a positive approach to solving patients’ problems [ 4 , 5 ]. In addition, the characteristics and abilities of individual nurses can influence the level of care and enable them to understand patients, solve problems, and provide holistic care, which is the ultimate goal of the nursing process [ 6 , 7 ]. Thus, patients expect nurses to not only have medical knowledge of the disease but to also be able to comprehensively assess the patient’s problems and be independent and creative in nursing [ 8 ]. This attitude can have a major impact on the quality of nursing services and can inspire pride in the nursing occupation and professional achievement. These findings can also be used by nurses to prevent burnout and maintain professionalism [ 9 , 10 ].

To respond to the increasing demands for diverse qualitative and quantitative nursing services and to strengthen the capabilities of nursing professionals, efforts have been made to move nursing education toward scientific and creative education. However, in point-of-care environments, not only are nurses prevented from making independent decisions regarding nursing, but also the diverse personal capabilities necessary for such independent behavior are not sufficiently developed [ 11 ]. Therefore, it is important to enhance clinical nurses’ perceptions of the nursing profession; maintain a balance of nursing capabilities; provide novel, high-quality nursing services; and identify assistive nursing education methods and obstructive environmental factors [ 10 ].

Communication skills involve a person’s ability to accurately understand (through both verbal and non-verbal indications) another person, and sufficiently deliver what the person desires [ 12 , 13 ]. Good communication skills are a primary requirement for providing professional nursing services because they enable an in-depth understanding of patients, solving of complicated problems, and reasonable and logical analysis of situations [ 14 , 15 , 16 ]. When effective communication takes place, nurses’ problem-solving abilities and perceived professionalism strengthen [ 17 , 18 ].

According to Park [ 19 ], nurses have difficulties in interpersonal relationships when social tension and interaction skills are low and communication is poor. In addition, these factors are negatively affected not only in the work of the nurse but also in the perception of the profession. Communication skills are associated with both the formation of relationships with patients and the ability to perform holistic nursing [ 20 ]. In order to improve and develop the overall nursing function of a clinical nurse like this, it is important to complement the relevant integrated nursing abilities [ 21 , 22 ].

Previous studies have investigated the importance of communication skills for nurses, and the relationships between nurses’ problem-solving ability and their understanding of the patients’ conditions. Nonetheless, data that can comprehensively explain the structural relationships between these qualities and how they affect the job perception of nurses remains insufficient.

Therefore, the present study aims to identify the structural model for the relationships between nurses’ communication skills, problem-solving ability, understanding of patients’ conditions, and nurse’s perception of professionalism. Additionally, the study provides basic data necessary for developing programs for improving nursing abilities.

The purpose of this study is to construct a theoretical model that explains the structural relationships among nurses’ communication skills, problem-solving ability, understanding of patients’ conditions, and nurse’s perception of professionalism. In addition, the study aimed to verify this model using empirical data.

2. Materials and Methods

2.1. study design.

To create and analyze the structural model for clinical nurses’ communication skills, problem-solving ability, understanding of patients’ conditions, and nurse’s perception of professionalism, the theoretical relationships among the variables were developed based on related theories.

In this study, communication skills were set as the exogenous variables, whereas problem-solving ability, understanding of patients’ conditions, and perception of the nursing occupation were set as the endogenous variables. In addition, communication skills were set as the independent variables and nursing job perceptions as the dependent variable. This is because the ability of communication helps to maintain an intimate relationship with the patient and to assess the patient’s condition through each other’s relationship and to solve problems and develop correct understanding. Communication skills, problem-solving ability, and understanding of patients’ conditions were set as the parameters for determining causality. The research model is shown in Figure 1 .

Study model.

2.2. Study Participants

The structural equation model has less than 12 measurement variables. The sample size usually requires 200 to 400 participants [ 23 ]. A total of 250 participants were selected for the study. In line with ethical standards and practices, participants received a full explanation on the purpose of the study. They were briefed that the information collected would be used for research purposes only. Furthermore, they were informed that they could withdraw from the study at any time.

2.3. Data Collection Method

Data collection for this study was performed by two researchers unrelated to the hospital from April 20 to May 1, 2019. A questionnaire was used to collect data from clinical nurses working in five hospitals in Seoul, Gyeonggi, and Gangwon provinces. Of the 250 questionnaires disseminated, we received 225 completed returns. However, 54 were considered inaccurate, inconsistent, or unsatisfactory for coding purposes. Thus, 171 fully completed valid questionnaires comprised the final dataset for analysis.

2.4. Research Instruments

2.4.1. communication skills.

In this study, the communication skill instrument developed by Lee and Jang [ 24 ] was used. Its contents were modified and supplemented to clearly understand the communication skills of nurses. Our questionnaire comprised 20 questions with five questions each concerning “interpretation ability,” “self-reveal,” “leading communication,” and “understanding others’ perspectives.” The answers were rated on a five-point Likert scale ranging from 0 = “strongly disagree” to 4 = “strongly agree.” For this study, the Cronbach’s alpha value was 0.81.

2.4.2. Problem-Solving Ability

The tool developed by Lee [ 25 ] was used to measure the problem-solving ability of clinical nurses. The survey comprised 25 questions, with five questions each concerning “problem recognition,” “information-gathering,” “divergent thinking,” “planning power,” and “evaluation.” Items were scored on a five-point Likert scale ranging from 0 = “strongly disagree” to 4 = “strongly agree.” The internal consistency confidence value Cronbach’s alpha was 0.79.

2.4.3. Understanding Patients’ Condition

To measure nurses’ understanding of patients’ conditions, we developed 10 questions by revising and supplementing items from an existing understanding-measurement tool [ 26 ]. With a total of ten questions, we measured “diagnostic name,” “patient-treatment planning,” and “nursing intervention processes.” Items were scored using a five-point Likert scale ranging from 0 = “strongly disagree” to 4 = “strongly agree.” The internal consistency confidence value Cronbach’s alpha was 0.81.

2.4.4. Nurse’s Perception of Professionalism

Nurse’s perception of professionalism was measured using a tool developed by revising the 25 questions created by Kang et al. [ 1 ]. With a total of ten questions, we measured “vocation” and “autonomy.” Items were scored using a five-point Likert scale. The internal consistency confidence value Cronbach’s alpha was 0.81.

2.5. Data Analysis

To identify the relationships among the set variables, the data were computed statistically using the program included in IBM SPSS 24.0 and AMOS 23.0. (IBM Corp., Armonk, NY, USA). The analysis methods were as follows:

• Frequency analysis was conducted to identify the subjects’ demographic and general characteristics.
• The reliability of the questionnaire was verified using Cronbach’s α coefficients.
• Confirmatory factor analysis (CFA) was performed to verify the convergent validity of the selected measurement tool.
• The normality of the data was determined through analyzing the skewness and kurtosis of the measurement variables.
• The fitness of the model was verified using structural equation modeling (SEM).
• Bootstrapping was utilized to verify the mediating effect in the set study model, as well as the mediating effects of the nurses’ problem-solving ability and understanding of patients’ conditions.

3.1. Demographic Characteristics

The demographic and general characteristics of the study subjects are shown in Table 1 . Overall, 71 respondents were aged 25–29 years (41.5%), representing the most numerous age group. University graduates comprised 113 (66.1%) of the sample, while 50 (29.2%) held graduate degrees, with eight (4.7%) holding master’s degrees. Fifty-three respondents (31.0%) had over seven years of clinical experience, 43 (25.1%) had two to three years of experience, 42 (24.6%) had four to six years of experience, and 33 (19.3%) had less than two years of experience. Additionally, 121 respondents (70.8%) worked at secondary hospitals, while 50 (29.2%) worked at tertiary hospitals; 159 respondents (93.0%) reported that they were general nurses.

Participants’ general characteristics ( N = 171, %).

3.2. Technical Metrics of the Measurement Variables

The multivariate normality of the findings related to the factors of the latent variables was verified through standard deviations, skewness, and kurtosis. The present study meets the criteria for the skewness and kurtosis values mentioned by Hu and Bentler [ 27 ].

All sub-factors of the latent variables secured normality.

In this study, a normal distribution was obtained for each of the four sub-factors of communication skills, five sub-factors of problem-solving ability, three sub-factors for understanding the patient’s condition, and two sub-factors of the nurse’s perception of professionalism as shown in Table 2 .

Technical metrics of the measurement variables ( N = 171).

3.3. Correlations between the Measured Variables

The correlations between the measurement variables were analyzed using Pearson’s product–moment correlation coefficient analysis ( Table 3 ). The correlations among all individual measurement variables were found to show a positive correlation.

Correlations between the observed variables.

3.4. Confirmatory Factor Analysis of the Measurement Model

This study examined how well the measurement variables represented the latent variables in the measurement model. Each set path coefficient was evaluated using non-standardization factors, standardization factors, and standard errors. The path coefficients refer to the factor loadings in CFA. The standardization factors of the individual paths were shown to be at least 0.50 (except for vocation: 0.36), and the critical ratio (CR) was at least 1.96. This indicated that the measurement tool had good convergent validity ( Table 4 ).

Confirmatory factor analysis of the measurement model.

*** p < 0.001; CR: critical ratio.

3.5. Verification of the Structural Model

The structural model for relationships among clinical nurses’ communication skills, problem-solving ability, understanding of patients’ condition, and nurse’s perception of professionalism that would be suitable for predicting the influencing relationships was verified. Since the fitness index of the modified model was shown to be higher than that of the initial model, the final model for this study was set as shown in Figure 2 .

Final model. * χ 2 = 124.074 (df = 61, p <0.001), GFI(Goodness of Fit Index)= 0.90, RMSEA(Root Mean Square Error Approximation)=0.07, NFI(Normed Fit Index)=0.87, IFI(Incremental Fit Index)= 0.93, TLI(Tucker-Lewis Index)= 0.91, CFI(Comparative Fit Index)= 0.92.

3.6. Influencing Relationships between Variables of the Study Model

The standardization factors and CR values of the final model were examined to determine whether there were direct relationships between communication skills, problem-solving ability, understanding of patients’ conditions, and nurse’s perception of professionalism. The results are shown

For the relationship between communication ski in Table 5 .lls and problem-solving ability, the standardization factor was 0.85 and the CR value was 7.37; communication skills showed a statistically significant effect. Consequently. The relationship between communication skills and understanding of patients’ conditions also showed a statistically significant effect. Consequently, Hypothesis 1 was supported.

The relationships between the human effects of the measurement model.

* p < 0.05, *** p < 0.001; CR: critical ratio.

For the relationship between communication skills and nurse’s perception of professionalism, the standardization factor was 0.54, and the CR value was 2.02. Communication skills showed a statistically significant effect. Consequently. For the relationship between problem-solving ability and nurse’s perception of professionalism, the standardization factor was −0.056, and the CR value was −0.39. Problem-solving ability had no statistically significant effect. Consequently.

The relationship between nurses’ understanding of patients’ conditions and nurse’s perception of professionalism had a statistically significant effect. Consequently Figure 2 shows the influencing relationships between the study variables of the final study model, considering non-standardization and standardization factors of the relationships between the study variables.

3.7. Direct and Indirect Effects of the Variables

To grasp the significance of the mediating effect in the final study model, the direct and indirect effects of each variable were examined. To examine the mediating effect of the problem-solving ability and understanding of patients’ conditions variables, the bootstrapping method provided by the AMOS 23.0 program included in IBM was utilized. The results are shown in Table 6 .

Mediating effect analysis.

* p < 0.05, *** p < 0.001

The indirect effect of communication skills on nurse’s perception of professionalism through nurses’ understanding of patients’ conditions was statistically significant. That is, clinical nurses’ communication skills have an indirect positive effect on their nurse’s perception of professionalism, with nurses’ understanding of patients’ conditions acting as a parameter. We also found that the effect of communication skills on nurse’s perception of professionalism was statistically significant. Therefore, communication skills have a partially mediated effect on nurse’s perception of professionalism, with understanding of patients’ conditions acting as a parameter. However, communication skills were found to have no indirect positive effect on nurse’s perception of professionalism when problem-solving ability was set as a parameter.

4. Discussion

In this study, we developed and analyzed a hypothetical model regarding clinical nurses’ communication skills, problem-solving ability, and understanding of patients’ conditions, and how these factors influence their nurse’s perception of professionalism.

4.1. Effect of Communication Skills on Nurses’ Perception of Professionalism

Communication skills were found to have statistically significant effects on their relationship with nurses’ problem-solving ability, understanding of patients’ conditions, and nurse’s perception of professionalism. Nurses’ communication skills not only affected their problem-solving ability but also their understanding of patients’ conditions and nurse’s perception of professionalism. Good communication among nurses can reduce uncomfortable situations and improve interactions with patients, which can consequently enhance problem-solving [ 28 ]. Supporting our findings, Ancel [ 17 ] reported that communication skills afford the maintenance of amicable cooperative relationships with patients across diverse medical classes, thereby enhancing the efficiency of nursing-related problem-solving.

Nurses’ communication is also closely related to their understanding of patients’ conditions, particularly regarding the treatment processes. Nurses frequently experience difficulties as a result of poor communication with not only patients and their family members but also other medical personnel. Further, poor delivery of explanations and questions affects nurses’ understanding of patients’ situations and problems, and patients can also feel concern regarding whether nurses accurately understand their problems [ 29 ]. Nurses frequently experience psychological abuse when communicating with patients and develop stress or discomfort [ 30 ]; this can lead to distrustful relationships with and inhibited understanding of patients [ 31 , 32 ]. Vermeir et al. [ 18 ] reported that scientific approaches are required to understand patients in-depth. To accurately understand both oneself and others, the most important method is successful communication. Such findings support the present study’s indication that nurses’ communication is a basic means of solving nursing problems, with both actions being interrelated.

Our finding that nurses’ communication skills are structurally related to their nurse’s perception of professionalism supports the findings of many previous studies. Regarding nurse’s perception of professionalism, Adams et al. [ 33 ] as well as Lee and Kim [ 34 ] explained that a good perception leads to higher-level capabilities, fostering high-level nursing of patients and the development of autonomous vocation. The above studies reported that, since nurses’ communication skills are related to their nurse’s perception of professionalism, communication skills should be considered a predictor of success. Further, McGlynn et al. [ 35 ] recommended positively reinforcing communication skills to improve nurse’s perception of professionalism. This supports the findings of the present study, indicating that communication and nursing professional perception are interrelated.

Thus, communication skills are important for nursing patients. They enable nurses to accurately understand patients’ problems, serve (by forming patient trust) an important function in the process of administering nursing interventions, and positively affect nurses’ perception of their profession. As such, each concept is important. However, nurses working in the clinic are critically aware of their professionalism. In order to reinforce this, communication skills are required, and the emphasis is placed on strengthening the nurses’ ability to solve problems as well as assess and understand patients. As a result, communication skills play an important role in helping nurses understand patients’ problems accurately, build patient trust in nursing interventions, and create structural relationships that have a positive impact on the perception of nursing occupations. Therefore, efforts to improve nurses’ communication skills not only improve their problem-solving abilities and understanding of patients’ conditions but also improve their nurse’s perception of professionalism. To maintain the professionalism of nurses, “competency development programs” would be helpful, thereby emphasizing the need for their application in nursing colleges and clinical practice.

4.2. Relationship between Nurses’ Problem-Solving Ability and Nurse’s Perception of Professionalism

We found clinical nurses’ problem-solving ability to have no positive effect on their perception of professionalism. This contrasts with previous studies, which reported that problem-solving ability is helpful for such perception of professionalism [ 36 ]. We also found that problem-solving ability does not affect nursing professional perception through a mediating effect.

The present findings indicate that the distinctiveness of the fields of nursing should not be overlooked. In nursing organizations that have a culture of discouraging diversity, when negative results are obtained from attempts to solve nursing problems, confusion regarding the identity of nursing professionals means perception of the profession is not reinforced; in many cases, the opposite perception is formed. Furthermore, for those in lower-level positions, nurse’s perception of professionalism is thought to be low because they cannot voice their opinions and have difficulties such as excessive workloads. Although few previous studies have directly examined this, Vermeir et al. [ 18 ] explained that, as the role expectation for nurses increases, factors for job turnover increase as a result of a sense of confusion regarding the nurses’ role and increases in stress. These findings indicate that factors that degrade nurses’ problem-solving ability induce skepticism regarding nursing and possibly career change, thereby supporting the findings of this study.

However, in the present study, positive results with low levels of relevancy in the structural model but high correlations were found. It is expected that, if nurses’ environmental conditions are improved and their nursing capabilities are developed so that they can solve nursing problems with confidence, their nursing professional perception will improve.

4.3. Relationship between Nurses’ Understanding of Patients’ Conditions and Nurse’s Perception of Professionalism

Our findings indicated that the relationship between nurses’ understanding of patients’ conditions and nurse’s perception of professionalism was statistically significant. This supports Nilsson et al. [ 21 ] and Philip et al. [ 29 ], who reported that, in the fields of nursing, when patients accurately understand nurses’ instructions or explanations and health information, they can participate in, independently adjust, and engage in creative decision-making related to self-nursing.

McGlynn et al. [ 35 ] suggested that understanding patient problems is an important element in resolving negative situations; meanwhile, Heo and Lim [ 37 ] indicated that clinical nurses provide high-quality nursing services and develop self-efficacy when they apply professional knowledge and a desire to understand patients’ problems. These study findings accord with our own findings.

The aforementioned findings suggest that the development and application of programs that can enhance nurses’ understanding of patients’ conditions should be emphasized, and that studies of various patient types, the characteristics of patients by age group and hospital areas, as well as the introduction of simulation education programs to improve nurses’ understanding of patients’ conditions should be continuously implemented.

5. Conclusions

This study aimed to verify the structural relationships between clinical nurses’ communication skills and their problem-solving ability, understanding of patients’ conditions, and nurse’s perception of professionalism. We also aimed to identify, through a structural model, the mediating effects of nurses’ problem-solving ability and understanding of patients’ conditions in the relationship between communication skills and nurse’s perception of professionalism.

The findings of this study are as follows (all significance levels = 0.05). In the relationship between communication skills and problem-solving ability, the value of the standardization factor was 0.85 and the CR value was 7.37, indicating that communication skills had a statistically significant effect. In the relationship between nurses’ communication skills and understanding of patients’ conditions, the value of the standardization factor was 0.61 and the CR value was 6.35, indicating that communication skills had a statistically significant effect. In the relationship between communication skills and nurse’s perception of professionalism, the value of the standardization factor was 0.54 and the CR value was 2.02, indicating that communication skills had a statistically significant effect. However, in the relationship between problem-solving ability and nurse’s perception of professionalism, the value of the standardization factor was −0.05 and the CR value was −0.39, indicating that problem-solving ability has no statistically significant effect. Finally, in the relationship between nurses’ understanding of patients’ conditions and nurse’s perception of professionalism, the value of the standardization factor was 0.56, and the CR value was 2.14, indicating that nurses’ understanding of patients’ conditions has a statistically significant effect.

There are some limitations to this study. First, as we only examined nurses at secondary and tertiary university hospitals, our findings may not be generalizable to all clinical nurses. Replication studies examining a range of levels of medical institutions and associated workers are necessary. Second, the structural relationship between problem-solving ability and the nurse’s perception of professionalism turned out to be insignificant or mediated. Subsequent studies on the various approaches to revisit this structural relationship should be performed. Third, theories should be systematically developed to establish the values of the nursing profession, and additional studies are necessary to explore other variables.

Acknowledgments

We would like to thank the staff nurses who participated in the survey and took the time to complete the initial assessment.

Author Contributions

Conceptualization, A.Y.K. and I.O.S.; methodology, A.Y.K.; software, I.O.S.; validation, A.Y.K. and I.O.S.; formal analysis, A.Y.K. and I.O.S.; investigation, A.Y.K.; resources, A.Y.K.; data curation, A.Y.K.; writing—original draft preparation, A.Y.K.; writing—review and editing, A.Y.K. and I.O.S.; visualization, A.Y.K. and I.O.S.; supervision, I.O.S.; project administration, I.O.S. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Conflicts of Interest

The authors declare no conflict of interest.