Noemí Alcaraz-Moreno,1 Ana María Chávez-Acevedo,1 Ericka Montserrat Sánchez-Betancourt,2 Genoveva Amador-Fierros,1 Rubén Godínez-Gómez1
1Facultad de Enfermería, Universidad de Colima; 2Departamento de Enfermería, Hospital Regional Universitario, Secretaría de Salud del estado de Colima. Colima, México.
Correspondence: Noemí Alcaraz Moreno
Received: October 13th 2014
Judged: January 19th 2015
Accepted: February 26th 2015
Introduction: Nursing Process (NP) is a tool to systematize and evaluate care to the individual, so it is essential that during the learning process of undergraduate nursing students the development of intellectual, technical and relationship skills is promoted to allow the good practice of this tool.
Objective: To analyze the factors that favor or hinder learning and practicing of NP for undergraduate nursing students.
Methods: A mixed approach was conducted in two phases, descriptive quantitative phase included 235 undergraduate nursing students from two educational institutions; a survey for data collection was structured. In the qualitative phase, the work was developed with two focus groups, each group of seven students per school.
Results: More than 50 % of students have knowledge of health promotion, communication and theories and models, among others. They consider that a limitation is the time spent to do it, to know how to use taxonomies made easier for them to develop NP. In this regard, students in the focus groups agree to review that teachers provided tools to perform the nursing process; however, a limitation was teaching methodology and evaluation criteria used by teachers.
Conclusion: Although the results with the two approaches are similar, it should be considered improvements in the educational process in regard to the teaching and assessment.
Keywords: Nursing process; Nursing, Nursing education, Learning
The importance of the nursing process (NP) as a tool for the systematization and evaluation of individualized care to the individual, and the demands of the necessary requirements for learning and application (such as cognitive, technical, and interpersonal skills),1 are issues that require us, as trainers of future nursing professionals, to have our graduates competent in the application of this tool. However, we constantly hear comments from students saying that it is difficult to learn and more so to implement NP. This is consistent with scientific studies, in which we realize that learning NP is not only hard work for undergraduate students, it is also hard for those on the specialist level,2 and what’s more, also for those who are already professionals.3
The difficulties that nurses have in the design and implementation have been documented.4-6 In the practical context, nurses see this process as a way to do and not as a way of thinking to act, that is, in its dual intellectual and behavioral component (MC Castrillon quoted by Zabala, 2005).1 This situation affects the understanding and application by students, finding no empirical referent to integrate that knowledge; just as it happens with the wide diversity of views among teachers for teaching, testing, and operation within specific subjects of nursing.1
Because of this we think it important to note that to achieve any learning, there are influential factors of one’s own or external to the person, which in this research we classify as intrinsic and extrinsic factors. In the intrinsic category you have the motivation of the person, their learning goals, their communication skills, the development of critical thinking skills, interests, emotions, and their level of anxiety.7,8 As for the extrinsic type, you have the methodology used by teachers, social factors, institutional factors, and social and cultural context.7-9
In addition to the above factors, a knowledge is necessary of basic sciences related to the health field, and nursing science. Among the technical skills necessary are those concerning the development of basic and specific nursing procedures, and other practices that involve teamwork and coordination among health professionals, as well as developing the ability to think critically in the clinical area, critical and clinical reasoning, interpersonal skills and attitudes. Examples of behaviors that reinforce interpersonal relationships are openness, acceptance and open-mindedness, honesty, having initiative and responsibility, being humble, showing respect, being confident and prepared, showing genuine interest, accepting manifestations of positive and negative feelings, being clear and direct, and showing a sense of humor and positive attitude, among others.10
Based on the above considerations, we decided to analyze the factors that help or hinder the learning and implementation of NP in undergraduate students in the state of Colima.
To achieve our goal we conducted a study of mixed type, that is, we used the methodology of both quantitative and qualitative research. To integrate 100 % of students trained in the undergraduate level in the state of Colima, we worked in two institutions: the Facultad de Enfermería de la Universidad de Colima and the Instituto Tecomense Benito Juárez García. The universe consisted of 339 students, and a sample of 289, as 50 students who had no theoretical or practical experience in NP were excluded. Furthermore, 54 surveys were eliminated because of errors in filling. The dependent variable was determined as the set of factors that help or hinder learning NP, and it was defined as: agents intrinsic and extrinsic to the student acting for or against the acquisition of knowledge, skills and attitudes to learn and apply NP.
For the process of gathering information from the quantitative phase, an instrument consisting of four sections was developed. The first included general data about the participant; the second comprised the knowledge required for the nursing process, of which four answer choices were taken: none, low, sufficient, and optimal; the third was associated with critical thinking skills, of which the student marked which ones they had and were then asked to rank them; the fourth section was for the student to identify factors associated with learning and applying the processes of nursing care. For this, the two response options were: It helps me, or It hinders me.
It is important to note that the instrument was not validated; however, it was built from NP frames of reference: critical thinking and meaningful learning. A pilot test was also conducted, which involved the collaboration of 15 participants (interns and graduates of the Facultad de Enfermería de la Universidad de Colima). After this process, necessary adjustments were made to the instrument, and its application proceeded.
After obtaining quantitative data, methodological triangulation was conducted of the dependent variable related to the factors that help or hinder NP learning and implementation, i.e., qualitative methodology was used to get a subjective view of the "how" and the "why" of these factors. This allowed students to carry out a thorough analysis and discussion of the issues considered as limiting the learning and implementation of NP.
To collect data, we resorted to the strategy of focus groups (FG), of which one was formed at each participating school. The selection of the participating students was made based on the results of the quantitative stage; seven students from the Universidad de Colima (FG1) and seven from the Instituto Tecomense Benito Juárez García (FG2) were chosen. For the development of this strategy, a guide was developed that contained open discussion questions and trigger or facilitator questions. The application of the instrument was carried out on November 21st and 23rd 2012 on the premises of each of the educational institutions involved, and each lasted an hour and a half. Each of the members of both focus groups was asked for verbal informed consent.
Within the context in which each of the focus groups developed, we note that the environment of FG1 initially felt tense, though this situation did not affect member participation, as each unveiled their different points of view. In most of the questions, the students agreed on what the rest of their teammates commented, regardless of the semester to which they belonged. This led to debate, which encouraged all respondents provide their views.
Regarding FG2, the atmosphere was quiet, and students seemed fearful and silent. Sometimes they had difficulty understanding the questions; however, with the intervention of the moderator understanding was established, and participation and discussion of the topics addressed was encouraged.
The dialogues obtained from both FG were transcribed to be interpreted and analyzed by researchers. For this work we are guided by the recommendations made by Chavez-Mendez (2007). As a result of this process three analytical categories were generated, which were described and sketched through a map or diagram.11
Of the 235 students who formed the study population, 199 belonged to the Facultad de Enfermería de la Universidad de Colima and 36 to the Instituto de Estudios Superiores Tecomense Benito Juarez. The average age was 20.5 ± 1.7 years.
Regarding the essential knowledge mentioned by students to acquire learning and apply NP, it was found that over 50 % of them said they had enough knowledge in subjects or areas as health promotion, nursing process, communication, basic nursing processes, and public health, in addition to knowledge about critical thinking, culture-ethics-legal, research, models and theories of nursing and mental health, most of which were deemed sufficient. Subjects or areas in which they said they had little knowledge were pharmacology, epidemiology, anatomy, physiology and pathology.
The critical thinking skills that students believe they have, included: being respectful, which was described as greatly strengthened; positive attitude, which was considered strengthened; showing interest, which was seen as regularly strengthened; showing security, seen as little strengthened; and demonstrating initiative and openness, skills that were rated poorly strengthened.
With regard to facilitating factors for learning and the implementation of NP, students said the following in descending order: knowing how to use the NANDA, NIC, NOC taxonomies; communication skills; critical thinking skills; knowledge of the stages of NP; demonstrating motivation and interest; the attitude of the teachers of clinical practice, and forms and tools used to produce NP (Figure 1).
Figure 1. Factors that facilitate learning and implementation of NP. Source: data collection instrument. NP = nursing process
Figure 2. Factors that limit learning and implementation of NP. Source: data collection instrument. NP = nursing process
Factors that were considered limiting included: the time required to apply NP; the time allotted to practice; the methodology used by the teacher to teach NP; knowledge in areas of basic sciences; diversity of criteria used by teachers for teaching NP, and the unwillingness of the student to apply NP (Figure 2).
As products of the analysis of the focus groups, 33 codes were identified, which were integrated into five families, from which emerged three categories: the first one related to the subjective view of NP by the students, the second with attitudes and skills developed by students from NP, and the third with the factors that facilitate or limit the implementation of NP.
The first category addresses the meaning of NP for students, in addition to the tools they considered important to its development. For the informants, NP is a useful tool in nursing, they agree that it is useful to ground actions in it, while at the same time it contains all the stages of the scientific method, which promotes the initiative to nursing research. This can be identified by the following comments:
It is a tool to support our interventions towards the patient (FG1. CH6. Seventh semester).
It is a very good tool. It makes you be a kind of scientist. It has all the steps for the scientific process (FG1. CH2. Fifth semester).
It is a tool with several aspects; it promotes research initiative (FG1. CH3. Third semester).
In addition to being considered essential knowledge for nursing, informants noted that NP is important for the understanding of diseases and possible treatments to use. However, they did not only focus their comments on the biological part of the person, but had a holistic view of NP, as they mentioned that this allows them to keep the nurse-patient relationship direct, while helping getting to know the person and the ways in which they can become closer.
It is about the knowledge of disease and possible treatments (FG2. CH6. Fifth semester).
It is useful for having a more direct patient-nurse relationship and thus knowing how we can reach that patient (FG2. CH7. Fourth semester).
A nurse has to be dynamic, not just based on the disease, [they have to] see the problem from the lifestyle that the patient has, for us to help (FG2. CH4. Fifth semester).
Through the comments made by students regarding NP, they see it as a tool to generate bonds of relationship between them and patients; therefore, we can determine that students are aware of the importance of NP in their education.
For knowledge that informants considered essential for the development of NP, many mentioned the subjects of anatomy, physiology, pharmacology and semiotics, considering them as essential to understand and implement NP. This means that for them it is essential to have a vast knowledge of the basic sciences, as evidenced by the following comments:
[You have to have] All knowledge of anatomy and physiology and physical examination (FG1. CH5. Fifth semester).
Apart from anatomy, physiology and physical examination, I would add pharmacology; you must add initiative and show security (FG1. CH6. Seventh semester).
However, they did not only refer to the basic medical sciences, but also indicated as important knowledge of nursing science and supporting science, such as psychology, sociology, and others:
The physical examination, using taxonomies correctly, plus all the rest are important, such as pharmacology (FG1. CH6. Seventh semester).
Knowing the characteristics of ages in our patients, having psychology, social work skills, anatomy, physiology, and culture (FG1. CH3. Third semester).
Knowing the disease, sociology, defining characteristics, and knowing the theory and books (FG2. CH4. Fifth semester).
Even though students perceive the need for knowledge of basic sciences, they added importance to aspects of professional ethics, values, and culture as well as a holistic view of the person from their individuality, which is demonstrated in the following testimony:
You have to know how to approach the patient and [for us to] develop the ability to communicate with them (FG1. CH5. Fifth semester).
Informants value the importance of both knowledge and a comprehensive view of the person for the proper implementation of NP.
Therefore, we can say that students of both institutions clearly see the importance of NP as their working tool as future professionals, as the meaning attributed to it is similar to that expressed by Alfaro, who notes that NP is a dynamic and systematized tool to provide nursing care, the axis of all approaches to nursing that promote humanistic care, focusing on objectives (results), and efficacy.10 It also encourages nurses to continuously review what they do and consider how they can improve it.
Regarding the second category, our informants consider it important that as students they have some general skills to develop NP, which will help them to enrich their knowledge sometimes with the help of teachers, and thus strengthen their actions in nursing:
It helps me search and dig deeper and enrich my knowledge (FG1. CH1. Fifth semester).
They strengthen me because when they question you or tell you where you are wrong, that makes you investigate (FG1. CH1. Fifth semester).
Similarly, they mention the importance of critical thinking, which according to comments allows them to better understand data from observations of the patient. In addition, they ensure that such thinking is strengthened with work experience
In observing we must be objective and subjective, because we won’t just see the physical side of the patient, we will see it all (FG2. CH7. Fourth semester).
I believe that everybody keeps acquiring critical thinking in practice and their experiences (FG2. CH4. Fifth semester).
We could sense that students identify some of the critical thinking skills developed from NP; however, it seems that they do not perceive this ability as a tool for strengthening reflection, or critical and clinical judgment, which can be an obstacle for them as professionals. According to Kurland, broadly speaking, critical thinking is related to reason, intellectual honesty, and open-mindedness as opposed to intellectual laziness, the emotional, and narrow-mindedness. In short, critical thinking is self-driven, self-disciplined, self-regulating and self-correcting.12 It is worth mentioning that it is important for students to manage to question their own learning from their experiences both in clinical practice and in the classroom.
In the third category the factors are described that students considered facilitators or constraints to the development and implementation of NP, even when these aspects are derived from its methodology and teaching. Comments are diverse and have connotations in the experience of each informant. Among the facilitators mentioned were the use of standardized formats, i.e. formats that teachers give them and where students are guided to perform this process, in addition to a manual that provides them with information related to NP.
Something that makes [the implementation of NP] easier for me is the manual they give us. It tells you step by step and you know which table is for each thing (FG1. CH2. Fifth semester).
Something that makes it easier is formats that are already standardized (FG1. CH5. Fifth semester).
In analyzing the factors identified by the informants, one can see that they center their opinions solely on standardized formats as an important tool to develop NP.
Among the factors that respondents said hindered the use of taxonomies, are the time allotted for processing, the diversity of evaluation criteria, teaching methodology used by teachers, lack of knowledge of the student in the basic sciences and their abilities to use taxonomies.
The main limitation is the time of delivery (FG1. CH2. Fifth semester).
They also note that the teaching methodology that teachers use, and the system for evaluating NP, is not homogeneous, that is, each teacher applies their own criteria to evaluate:
There is a need for coordination between teachers for assessment (FG1. CH1. Fifth semester).
Teachers ask you where you got the information (FG1. CH4. Third semester).
... but to when you hand it in, it is not encouraging because of the variety of ways the teacher grades (FG1. CH3. Third semester).
In addition, students believe that teaching strategies that teachers use in areas essential for obtaining the theoretical basis of NP do not provide sufficient knowledge, and they relate it to the level of qualification of teachers and the theoretical-practical relationship.
The classes are very routine and all teachers use the same slide template. And reading them is what makes the class very boring (FG1. CH7. Third semester).
The core subjects have to have an agreement with regard to clinical subjects (FG1. CH4. Third semester).
When you have a doctor as the tutor in the Problem-Based Learning class it’s because they do not like to see nursing interventions, which for us is one of the most important things (FG1. CH6. Seventh semester).
Therefore, students think they should have other subjects or knowledge of other disciplines such as support for the development and implementation of NP:
... there should be other classes, such as psychology, social work, hydrotherapy, massage therapy. This would help us a lot (FG1. CH1. Fifth semester).
It is important to note that while students believe that there are several factors that limit the development and implementation of NP, these factors do not prevent seeing the importance of this tool, which is considered essential for patient support.
It is essential to nursing but not always motivating to do it (FG1. CH.5. Fifth semester).
It motivates me to have a little knowledge of the patient (FG1. CH7. Third semester).
I feel motivated to do NP, because you know your patient and it makes you investigate further (FG1. CH3. Third semester).
The welfare of the patient, which you can help along (FG2. CH5. Fourth semester).
If we analyze the factors that students reported as facilitators and constraints, we can see that the first is related to the tools that teachers provide students for the development of NP; however, at the same time they saw as limiting the teaching methodology and assessment criteria used by teachers (Figure 3).
Figure 3. Linear scheme of results (representing categories). NP = nursing process, PBL = problem-based learning
By comparing the results obtained in our study with others, we find that Franco Corona et al. documented that all teachers know, teach, and apply NP; they also referred to the importance of teaching and application in clinical practice. Meanwhile, regarding the meaning, there is a tendency of teachers to recognize this process as a scientific method and an important instrument in acting as a nursing professional.13 This is similar to our study, in that according to the factors reported as facilitators to the learning and implementation of NP, one of them is the positive attitude of teachers in clinical practice, which is important because we believe that such behavior may be related to their knowledge and conviction about this indispensable tool for providing care. Likewise we concur with Zabala-Rodriguez, who said that 75% of the teachers often encouraged linking fields of knowledge, and that their attitude inspired confidence for learning NP.1
Agama Sarabia et al. showed that one of the most highly evaluated factors was the dimension of interpersonal relations.14 they found similarity with one of the factors of our study, which was communication skills, considered an intrinsic factor facilitating learning and application of NP. Even though they don’t have the same term, it is thought that there is a relationship between the two factors, since communication is understood as a "continuous and dynamic process being two people, to form a series of events and in constant interaction; considering important aspects such as perception, beliefs and values, social and cultural factors, among others ."15
González Sara concluded that diagnostic reasoning tools and care plan were among the resources that facilitate teaching in NP students who are joining clinical practice.16,17 This is similar to that expressed by the students participating in our study, since one of the extrinsic facilitating factors was formats and instruments to develop NP.
Guerra Cabrera et al. reported that difficulties in its implementation and monitoring are related to insufficient training of students in this area of knowledge of the discipline.2 These results agreed with our study in that students’ knowledge in basic sciences (such as pharmacology, epidemiology, anatomy, physiology and pathology) are factors that limit the learning process, as these are scarce. However, there are differences in that over 50% of our students mentioned that they had sufficient knowledge in essential subjects for learning NP. Moreover, these latter results are similar to those of Pecina Leyva, who mentions that 65% of students have sufficient knowledge of NP. This same study found that teachers do help in learning this tool in the hospital area, but the limitations for application are excess of patients and lack of time.3 These latter two aspects coincide with our results, since one of the limiting factors is the time required to develop and implement NP.
Hernandez-Silva et al. showed that 89.7% of participants in their study believe that the lack of unification of teachers in the teaching of NP is not related to the lack of knowledge and application of this methodology,4 contrary to the opinion of 63.8% of participants in our study, who believe that the diversity of criteria used by the teacher is an extrinsic factor that limits learning and implementation of NP.
Even when students identify critical thinking skills as essential, at the time of thinking about them, they did not identify their scope for the knowledge and the implementation of NP.
The use of both research approaches yielded the same results regarding factors that undergraduates of both educational institutions considered as factors that help or hinder learning and the implementation of NP.
According to the results, the greater percentage of factors limiting learning and implementation of NP are extrinsic, i.e. those relating to education (methodologies, criteria, time, etc.); therefore, it is imperative that we teachers conduct a reflection on how to facilitate the transmission and understanding of our main working tool as nursing professionals.
Limitations of the study
As mentioned in the Methods section, one limitation of the study is the lack of validity testing of the instrument used in the quantitative phase, which we tried to compensate with the implementation of the pilot and review in pairs by NP experts.
Theoretical implications and research methodologies
The study results led us to reflect on the importance of promoting certain thinking skills in students, such as critical thinking and clinical reasoning, since even when students identify the importance of these skills, they do not seem to have incorporated them into theoretical and practical knowledge.
Another aspect that is relevant to point out is the use of methodological triangulation to achieve a full and profound vision of the phenomena studied. Our research is another example of the use of both methods of research supplementing each other, so as nursing professionals we can continue to expand our paradigms to generate theoretical and conceptual frameworks that contribute effectively to the development of nursing science.