Real-world problem-solving skills are considered essential by employers of college graduates (American Association of Colleges & Universities [AAC&U], 2015; Bok, 2017; Hora et al., 2016). As a part of the accreditation process of the Southern Association of Colleges and Schools Commission on Colleges (SACSCOC), institutions are required to assess student learning needs and develop a five-year Quality Enhancement Plan (QEP).
In 2016, our state university launched a campus-wide QEP initiative we call "We Solve It!" to strengthen the real-world problem-solving skills of our students. We intentionally engage students in the process of problem-solving as follows: discover (define problem), design (design a solution), deliver (communicate the solution to stakeholders), and reflect (identify ways to improve for future setting). QEP theoretical underpinnings are in alignment with Tanner's model of clinical judgment in nursing. Tanner (2006) describes clinical judgment as a complex process involving numerous factors, such as the client-specific situation and the nurse's reasoning patterns. To effectively care for a client in a complex clinical scenario, the nurse cognitively goes through each of the four processes of Tanner's model: noticing, interpreting, responding, and reflecting.
As with the Tanner model, QEP begins with a problem and progresses through a series of steps to reach a solution. Each model ends with reflection. To incorporate problem-based activities, five nurse faculty facilitated learning activities that included QEP's processes into the assignments. This article discusses the problem-based approaches in nursing education implemented at our state university and discusses the effects on student learning.
BACKGROUND
Quality Enhancement Program and Tanner's processes are in alignment as both delineate the complex cognitive skills required to resolve difficult problems or situations. Problem-solving skills are essential in nursing practice. As nurses are repeatedly challenged by unexpected problems that affect patient care and patient outcomes, problem-solving should be at the core of effective nursing education activities (Institute for Safe Medication Practices, 2019; Shahbazi et al., 2018). However, "educators and clinical facilitators have recognized that newly qualified nurses do not meet the expectations for entry-level clinical judgment[horizontal ellipsis][and educators] are held accountable for finding adequate learning experiences as preparation for such practice demands" (van Graan et al., 2016, p. 280).
Real-world classroom and clinical activities are needed to help nurses navigate complex work and global environments, but facilitating positive change for students requires that faculty receive training and support. Our school of nursing adopted the "We Solve It!" rubric developed by the AAC&U and modified it for our QEP initiative. The rubric provides a common point of reference in assessing students' learning across disciplines and is used to assess both the process and product of problem-solving. The process is measured by the reflection report (We Solve It! report) students complete at the end of the problem-solving experience in their courses. The standardized rubric and reflection form allow for the measurement of student learning across campus and provide a consistent language across disciplines. Reflection on the process of problem-solving is intended to foster students' metacognition about the process.
INTEGRATING QEP IN NURSING COURSES
We integrated the QEP into three RN-BSN online courses and two traditional BSN courses. Our Professional Development RN-BSN online course starts with students identifying a problem in the work setting, then moving through the steps to solve the problem. Often, the problems students select are not solvable in the short time frame of the course. Because of their complexity, students are asked to outline the proper steps needed to solve the problem, such as changing policy and discussing solutions at staff meetings. The main benefit from this assignment is to practice the steps and enhance future problem-solving skills.
In our Selected Topics in Professional Nursing online course, students identify a time they witnessed or were involved in incivility in the workplace. The purpose is to assist students in identifying and appropriately addressing incivility in their work environments. Based on current literature, each student prepares a PowerPoint presentation including the definition of incivility, types of uncivil behavior, effects in the work environment, a personal example of incivility, and strategies and solutions to address the problem. After evaluating the pros and cons of each proposed solution, students select the best solution for their personal examples. Completed presentations are posted to the course discussion board for peers to review.
In our Senior Project online course, students select a quality improvement issue in the clinical setting. The purpose is to allow students to identify a real health care issue and research evidence-based solutions to solve the problem and improve the quality of care in the clinical setting. Students use a fishbone diagram to identify what has caused the particular event to occur, research evidence-based practice solutions for their quality improvement issue, select solutions, and identify pros and cons for each solution. The students then determine what changes can be made that will result in an improvement. They create a narrated PowerPoint presentation of their findings for their classmates to review.
In a traditional face-to-face senior-level course, students identify a problem of interest they encountered in their pediatric clinical rotation at the hospital. They are then asked to research evidence-based practice and use results found in peer-reviewed journals to provide a potential solution to the problem. The next task is to compose a summary of the problem with an evidence-based solution using situation, background, assessment, and recommendation (SBAR) communication, plus a brief reflection. Students present their problem, analysis, and solution in SBAR format to their peers. In a junior-level hybrid health assessment course, students identify a scenario from their clinical experiences that requires a call to the health care provider. They write out what they would say to the provider using the SBAR communication technique.
EVALUATION
Using the We Solve It! rubric, faculty assessed their students' performance on the problem-solving process as well as the effectiveness and creativity of their solutions. We assessed a total of 172 students (85 percent female, n = 147) representing several ethnic groups (white, 59 percent; black, 31 percent; other groups, n = 15). Most students were undergraduates (89 percent). Their overall performance was measured on the rubric as follows: 0 = does not meet minimal level performance, 1 = minimal, 2 = developing, 3 = competent,4 = accomplished.
Students in BSN courses showed relatively high scores on the problem-solving process. However, scores for overall effectiveness and creativity were below competent; overall scores also showed the evaluation of solutions to be less than competent, indicating this area may benefit from more attention to the design of teaching strategies. The sample size was not proportionately distributed, and no inferences were made regarding student performance on problem-solving and ethnic background or gender. No significant difference was observed between undergraduate and postbaccalaureate students.
The BSN senior students also take the Critical Thinking Assessment Test (CAT), developed and scored by Tennessee Technological University. This is a 50-minute face-to-face test consisting of 15 items that capture a more accurate picture of nursing students' competencies in problem-solving and other dimensions, such as creativity, critical thinking, and communication. The CAT data provide additional insight into how faculty teach and how students develop problem-solving skills. The results are used for course assessment and improvement of student learning (Tennessee Tech, 2019).
CAT results showed that BSN seniors perform well on separating relevant from irrelevant information and using basic mathematical skills when solving a real-world problem. The finding suggests that students may benefit from more focused instruction on identifying additional information needed to evaluate a hypothesis, using and applying relevant information to evaluate a problem, and identifying suitable solutions for a real-world problem by using relevant information.
CONCLUSION
With the findings from the We Solve It! rubric and the CAT, faculty have gained insight into multiple ways of defining problems and assessing how students solve problems. Our collective insight allows us to create better alignment across courses and improve student learning at the program level. Refined problem-solving skills are essential competencies for nurses, enabling them to provide safe and effective nursing care when working in increasingly complex health care environments. The problem-solving assignments in the learning environment allow students to demonstrate an enhanced ability to creatively solve real-world problems, promoting lifelong, self-generated learning devoted to improving patient outcomes (Ancel, 2016).
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