• Research article
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  • Published: 07 October 2020

Impact of social problem-solving training on critical thinking and decision making of nursing students

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).


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.

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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).


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.


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.


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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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Soleiman Ahmady

Virtual School of Medical Education and management, Shahid Beheshty University of Medical Sciences, Tehran, Iran

Sara Shahbazi

Community-Oriented Nursing Midwifery Research Center, Shahrekord University of Medical Sciences, Shahrekord, Iran

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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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This study was reviewed and given exempt status by the Institutional Review Board of the research and technology department of Shahrekord University of Medical Sciences (IRB No. 08–2017-109). Before the survey, students completed a research consent form and were assured that their information would remain confidential. After the end of the study, a training course for the control group students was held.

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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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The perceived problem solving ability and values of student nurses and midwives


Problem solving is defined as a response given in an important and difficult situation, where critical thinking is required for a solution. Problem solving skills determine a person's ability to relate productively. This research was to determine the perceived problem solving ability and values of student nurses and midwives. It was planned as a descriptive research project in the University of Kocaeli's, Higher School of Health (Nursing and Midwifery School) in order to find out how students perceive their own problem solving skills, and to examine the relationship between problem solving skills and personal values. The data were collected from 218 students by using a questionnaire to determine the characteristics of the students and the "Problem Solving Inventory" (developed by Heppner and Petersen [Journal of Counseling Psychology 29 (1) (1982) 66]) whose reliability and validity for our country had been tested by Sahin et al. (1993) The scores of the subjects were evaluated and analyzed. Students who describe themselves in accordance with the values of truth (14.2%) and human dignity (19.3%) were also found to evaluate themselves successful in problem solving. Students who expressed that they act systematically (44.5%) and decisively (74.3%) in problem solving were also found to evaluate themselves as successful (47.8%) in problem solving. The results of our study have shown that education in professional ethics should provide the development of professional values (especially of truth and human dignity). Concerning value-laden issues education should help students to reach the desired levels of problem solving skills by allowing them to acquire abilities such as self awareness and being inquisitive.

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Strategies for Problem Solving

Nursing students will be expected to have or develop strong problem-solving skills. Problem solving is centered on your ability to identify critical issues and create or identify solutions. Well-developed problem solving skills is a characteristic of a successful student. Remember, problems are a part of everyday life and your ability to resolve problems will have a positive influence on your future.

6 Steps of Problem Solving

Step 1: Identify and Define the Problem

It is not difficult to overlook the true problem in a situation and focus your attention on issues that are not relevant. This is why it is important that you look at the problem from different perspectives. This provides a broad view of the situation that allows you to weed out factors that are not important and identify the root cause of the problem.

Step 2: Analyze the Problem

Break down the problem to get an understanding of the problem. Determine how the problem developed. Determine the impact of the problem.

Step 3: Develop Solutions

Brainstorm and list all possible solutions that focus on resolving the identified problem. Do not eliminate any possible solutions at this stage.

Step 4: Analyze and Select the Best Solution

List the advantages and disadvantages of each solution before deciding on a course of action. Review the advantages and disadvantages of each possible solution. Determine how the solution will resolve the problem. What are the short-term and long-term disadvantages of each solution? What are the possible short-term and long-term benefits of each solution? Which solution will help you meet your goals?

Step 5: Implement the Solution

Create a plan of action. Decide how you will move forward with your decision by determining the steps you must take to ensure that you move forward with your solution. Now, execute your plan of action.

Step 6: Evaluate the Solution

Monitor your decision. Assess the results of your solution. Are you satisfied with the results? Did your solution resolve the problem? Did it produce a new problem? Do you have to modify your solution to achieve better results? Are you closer to achieving your goal? What have you learned?

University of Rhode Island

Creativity and Problem-Solving Skills in Nursing

Published On:    December 12, 2019

Updated On:    

Nursing is a profession that blends science and art, research and creativity. Though nurses rely on clinical expertise and experience in a variety of situations, those with problem-solving skills are better equipped to serve their patients. By thinking creatively, asking the right questions and considering multiple options, nurses will be able to solve problems much more effectively.

Those who use problem-solving skills see problems not as obstacles but as opportunities to improve their patients' health and well-being . Nurses who have completed an online RN to BSN program understand how to draw upon their creative abilities and critical thinking skills to improve their practice.

Critical Thinking

According to an article from the National Institutes of Health, nurses use critical thinking to evaluate, analyze and synthesize information. They take this information, and their experience, to create a plan of action. Nurses who employ problem-solving skills begin with critical thinking. When there are no clear answers or courses of action, nurses can rely on their creativity to come up with new solutions and make decisions.

Combined with creativity, critical thinking can help nurses solve specific patient problems as well as system-wide challenges. When traditional measures are not effective, creative professionals are able to generate ideas rapidly, be flexible in their approach, act with confidence without direct supervision, and react well under pressure.

Evidence-Based Practice

The world of healthcare is becoming more varied and complex. The new role of nurses requires them to work across disciplines, incorporating more professionals into the care plan of their patients. Nurses who have completed an online RN to BSN program will be well-versed in problem-solving approaches such as evidence-based practice. By incorporating their clinical experience, knowledge and the preferences of the patient, nurses can provide the best care.

Nurses who employ evidence-based practice will see improved patient outcomes for those in their care, according to a Nursing World report. Healthcare providers who stay abreast of the most recent research increase positive outcomes for patients. This means that more patients return home sooner.

Steps to Evidence-Based Practice

The Academy for Medical-Surgical Nurses shows the steps taken by nurses who use evidence-based practice to care for patients. First, they determine the problem and formulate a question. The second step is reviewing the evidence, which helps determine what treatment is most appropriate using existing knowledge. The third is implementation, which means beginning the actual treatment. The fourth step is evaluating the plan by reassessing the patient at pre-determined intervals.

What Does This Look Like in Practice?

A key attribute for any successful healthcare practitioner is the ability to turn obstacles into opportunities for better patient care. In addition, good nurses are those who can learn from past experiences and incorporate those lessons into the care of future patients.

Highly educated nurses who have completed an online RN to BSN program have the skills to make problem-solving a more natural part of their practice. These nurses hold the key to a more responsive healthcare environment and a healthier patient population.

Learn more about the URI online Registered Nurse to Bachelor of Science in Nursing program .

Academy of Medical-Surgical Nurses: Evidence-Based Practice

The Online Journal of Issues in Nursing: The Impact of Evidence-Based Practice in Nursing and the Next Big Ideas

Acta Informatica Medica: Critical Thinking: The Development of an Essential Skill for Nursing Students

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problem solving in nursing definition

Importance Of Problem Solving In Nursing

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Personal Narrative: A Career In Nursing

Nursing, and everything that it entails, cannot be easily described in just one simple word or phrase. It goes beyond the meaning of a profession and the stereotypical definition of treating the ill. Nursing is the “protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations” (American Nurses Association, 2010, p. 1). Therefore, it is a career that requires dedication, passion, critical thinking, and knowledge. It demands commitment and an understanding of its core values and concepts, as well as the nurse’s own personal philosophy and principles.

Multiple Intelligence In Nursing

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Q. how can i solve my back and shoulder problems? also how can i get raid of my eye bugs? A. krando, many thanks i will try those tips you just give me...wish you a wonderful and safe and sound newly year...

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Home » Degrees » RN to MSN » Registered Nurse to Master of Science in Nursing in Administrative Leadership in Nursing » How Leaders Approach Problem-Solving

How Leaders Approach Problem-Solving

No environment is free from problems. But, some require more creative solutions than others.

Healthcare, in particular, presents almost unlimited opportunities for things to go wrong — both in terms of patient care and inter-staff/intra-staff relationships. The problems present within healthcare settings are often a matter of life and death.

It takes effective leadership to keep all issues to a minimum and patient safety remains a priority.

What Makes a Great Leader?

If we think about the great leaders throughout time, they share a few common characteristics. Specific to nurse leaders, Indeed.com lists the following as core qualities for leaders:

Another valuable quality in leadership is being proactive in problem-solving. Good leaders handle issues as they arrive. They are capable of “putting out fires,” and that’s important. Yet, great leaders anticipate problems before they come to a head.

Core Skills Nurse Leaders Need to Possess

While some of the above resonates as more intuitive, emotional intelligence — as opposed to procedural — can be learned. Of course, there are practical skills nurse leaders need to develop as well.

Examples of these skills are healthcare finance and economics. Mastering budgets and efficiently allocating resources is important for nurse leaders. Nurses also need to know how to communicate financial demands to upper administration.

The online Registered Nurse (RN) to Master of Science in Nursing (MSN) in Administrative Leadership program from Northeastern State University (NSU) dedicates a course to heightening nurses’ skills and knowledge surrounding this responsibility.

NSU’s program also includes a course titled Organizational and Systems Management in Nursing. The course description states that nurses will learn about “contemporary influences, theories, principles, and functional strategies related to management/administration and organizational systems at the micro, meso, and macrosystem levels.”

Leadership’s Role in Addressing Lateral and Horizontal Violence (LHV)

While nurse leaders don’t necessarily need to be experts in human resources, it’s a substantial knowledge base. Human resources knowledge is especially relevant given the persistence of lateral and horizontal violence (LHV) within the nursing profession. The World Health Organization (WHO), International Council of Nurses and Public Services International have recognized this issue as a significant global public health priority.

Just how dangerous is LHV to nursing? A study published by Nurse Management describes LHV as: “all acts of meanness, hostility, disruption, discourtesy, backbiting, divisiveness, criticism, lack of unison, verbal or mental abuse, and scapegoating. [These] behaviors taint healthcare organizations; cause irreparable harm to workplace culture; breakdown team communication; and severely impact the quality of the care provided, thereby jeopardizing patient safety.”

With a solid leadership foundation, nurses can handle toxic behaviors that damage the work environment. In doing so, they change the workplace culture and guiding others to follow in their footsteps.

Empowerment Sets Everyone Up for Success

Perhaps the greatest responsibility of a nurse leader is to empower those in their charge. John Quincy Adams said, “If your actions inspire others to dream more, learn more, do more and become more, you are a leader.”

Northeastern State University recognizes empowerment as an essential skill. In the Leadership Development for the Advanced Nursing Professional course, students learn to “effectively manage change, empower others, and influence political processes.”

What Type of Leader Do You Aspire to Be?

It takes much more than “putting in your time” to become an effective leader. Nurses might rise through the ranks based on experience, but are they actually effecting change in the nursing profession? Unless they possess a robust leadership skill set, the answer is likely no. So, what kind of leader do you want to be?

Learn more about Northeastern State University’s online RN to MSN in Administrative Leadership program .

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Relationship Between the Problem-Solving Skills and Empathy Skills of Operating Room Nurses : Journal of Nursing Research

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Relationship Between the Problem-Solving Skills and Empathy Skills of Operating Room Nurses

AY, Fatma 1* ; POLAT, Şehrinaz 2 ; KASHIMI, Tennur 3

1 PhD, RN, Assistant Professor, Faculty of Health Sciences, Department of Midwifery, Istanbul University-Cerrahpaşa, Turkey

2 PhD, RN, Directorate of Nursing Services, Hospital of Faculty of Medicine, Istanbul University, Turkey

3 MS, RN, Director, Operating Room, Hospital of Faculty of Medicine, Istanbul University, Turkey.

Accepted for publication: January 21, 2019

*Address correspondence to: Fatma AY, No.25, Dr. Tevfik Saglam Street, Dr. Zuhuratbaba District, Bakirkoy, Istanbul 34147, Turkey. Tel: +90 212 4141500 ext. 40140; Fax: +90 212 4141515; E-mail: [email protected]

The authors declare no conflicts of interest.

Cite this article as: Ay, F., Polat, Ş., & Kashimi, T. (2019). Relationship between the problem-solving skills and empathy skills of operating room nurses. The Journal of Nursing Research , 28 (2), e75. https://doi.org/10.1097/jnr.0000000000000357

This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY) , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


The use of empathy in problem solving and communication is a focus of nursing practice and is of great significance in raising the quality of patient care.


The purposes of this study are to investigate the relationship between problem solving and empathy among operating room nurses and to explore the factors that relate to these two competencies.


This is a cross-sectional, descriptive study. Study data were gathered using a personal information form, the Interpersonal Problem Solving Inventory, and the Basic Empathy Scale ( N = 80). Descriptive and comparative statistics were employed to evaluate the study data.


Age, marital status, and career length were not found to affect the subscale scores of cognitive empathy ( p > .05). A negative correlation was found between the subscale scores for “diffidence” and “cognitive empathy.” Moreover, the emotional empathy scores of the graduate nurses were higher than those of the master's/doctorate degree nurses to a degree that approached significance ( p = .078). Furthermore, emotional empathy levels were found to decrease as the scores for insistent/persistent approach, lack of self-confidence, and educational level increased ( p < .05). The descriptive characteristics of the participating nurses were found not to affect their problem-solving skills.

Conclusions/Implications for Practice 

Problem solving is a focus of nursing practice and of great importance for raising the quality of patient care. Constructive problem-solving skills affect cognitive empathy skills. Educational level and career length were found to relate negatively and level of self-confidence was found to relate positively with level of cognitive empathy. Finally, lower empathy scores were associated with difficult working conditions in operating rooms, intense stress, and high levels of potential stress-driven conflicts between workers in work settings.


Healthcare institutions are where individuals seek remedies to their health problems. These institutions face problems, which relate to both employees and care recipients. These problems may occur spontaneously and require immediate solution. Moreover, these problems require that the preferred remedies be adapted to address the unique nature of both organizational circumstances and individual requirements. Therefore, it is important that nurses, who are a major component of the healthcare system, have problem-solving skills.

Operating rooms are complex, high-risk environments with intense levels of stress that require rapid judgment making and fast implementation of appropriate decisions to increase patients' chances of survival ( Kanan, 2011 ; Jeon, Lakanmaa, Meretoja, & Leino-Kilpi, 2017 ). Furthermore, aseptic principles may never be compromised, and a high level of coordination and cooperation among team members should be maintained in these areas ( Kanan, 2011 ; Sandelin & Gustafsson, 2015 ). The members of a surgical team may vary in the operating room ( Sandelin & Gustafsson, 2015 ; Sonoda, Onozuka, & Hagihara, 2018 ). Under these difficult conditions, time management and workload are important stress factors for nurses ( Happell et al., 2013 ; Suresh, Matthews, & Coyne, 2013 ). At the same time, operating room nurses are legally responsible for the nature and quality of the healthcare service received by patients before, during, and after their surgical intervention ( Kanan, 2011 ). The American Nurses Association defines a nurse as “the healthcare professional establishing, coordinating and administering the care while applying the nursing process in an aim to meet the identified physiological, psychological, sociocultural and spiritual needs of patients who are potentially at the risk of jeopardized protective reflexes or self-care ability because of surgery or invasive intervention” ( Association of periOperative Registered Nurses, 2015 ).

Problem solving is the most critical aspect of the nursing practice. The fact that nursing requires mental and abstract skills, such as identifying individual needs and finding appropriate remedies, was first stated in 1960s. In 1960s, the nursing theorists Abdellah, Orem, and Levin emphasized the mental aspect of nursing. They argued that the most critical requirement of nurses in the clinical field is the ability to decide on and plan the right action and that nursing care should be founded on a sound knowledge base ( Taşci, 2005 ).

The World Health Organization has stated that “taking measures and applying a problem-solving approach to provide appropriate care is one of the compulsory competencies of nurses” ( Taşci, 2005 ). Thus, enhancing the problem-solving skills of nurses is of great importance in raising the quality of patient care ( Taylor, 2000 ; Yu & Kirk, 2008 ). On the other hand, Bagnal (1981) argued that people with problem-solving skills need to be equipped with personal traits including innovation, clear manifestation of preferences and decisions, having a sense of responsibility, flexible thinking, courage and adventurousness, ability to show distinct ideas, self-confidence, a broad area of interest, acting rationally and objectively, creativity, productivity, and critical perspective (as cited in Çam & Tümkaya, 2008 ).

To provide the best surgical care to a patient, team members must work together effectively ( Sonoda et al., 2018 ). One of the most important factors affecting the quality of healthcare service delivery is effective communication between healthcare professionals and healthcare recipients, with empathy forming the basis for effective communication.

Because of the intrinsic nature of the nursing profession, nurses should have empathy skills. Thus, empathy is the essence of the nursing profession ( Fields et al., 2004 ; Vioulac, Aubree, Massy, & Untas, 2016 ). A review of resources in the literature on problem solving reveals that gathering problem-related data is the first major step toward determining the root causes of a problem. In this respect, empathy is an important skill that helps properly identify a problem. On the basis of the definition of empathy, sensing another person's feelings and thoughts and placing oneself in his or her position or feeling from within his or her frame of reference should work to improve one's problem-solving skills, particularly those skills related to social problem solving ( Taşci, 2005 ; Topçu, Baker, & Aydin, 2010 ; Vioulac et al., 2016 ). It is possible to explain empathic content emotionally as well as cognitively. Emotional empathy (EE) means feeling the emotions of another person and providing the most appropriate response based on his or her emotional state. This is very important in patient–nurse communications. Cognitive empathy (CE) is the ability to recognize the feelings of another without experiencing those feelings yourself ( de Kemp, Overbeek, de Wied, Engels, & Scholte, 2007 ).

Gender, age, level of education, marital status, years of work, duration working at current institution, and problem-solving situations have been shown in the literature not to affect the problem-solving or empathy skills of nurses ( Abaan & Altintoprak, 2005 ; Kelleci & Gölbaşi, 2004 ; Yu & Kirk, 2008 ). Empathy is especially critical to the quality of nursing care and is an essential component of any form of caring relationship. The findings in the literature regarding empathy among nurses are inconsistent ( Yu & Kirk, 2008 ), and no findings in the literature address the relationship between problem-solving skills and empathy skills in operating room nurses.

Today, the healthcare system demands that nurses use their professional knowledge to handle patient problems and needs in flexible and creative ways. Problem solving is a primary focus of the nursing practice and is of great importance to raising the quality of patient care ( Kelleci & Gölbaşi, 2004 ; Yu & Kirk, 2008 ). Enhancing the problem-solving and empathy skills of nurses may be expected to facilitate their identification of the sources of problems encountered during the delivery of healthcare services and their resolution of these problems.

The purposes of this study are to investigate the relationship between problem solving and empathy in operating room nurses and to explore the factors related to these two competencies.

Study Model and Hypotheses

This study is a cross-sectional and descriptive study. The three hypotheses regarding the relationships between the independent variables are as follows:

Study Population and Sample

The study was conducted during the period of May–June 2015 at three hospitals affiliated with Istanbul University. The study population consisted of 121 nurses who were currently working in the operating rooms of these hospitals. The study sample consisted of the 80 nurses who volunteered to participate and answered all of the questions on the inventory.

Data Collection Tool

Study data were gathered using a personal information form, the Interpersonal Problem Solving Inventory (IPSI), and the Basic Empathy Scale.

Personal information form

This questionnaire, created by the researchers, is composed of 10 questions on the age, gender, educational background, organization and department, position, and organizational and professional functions of the respondent.

Interpersonal problem solving inventory

The IPSI, developed and validated by Çam and Tümkaya (2008) , was used in this study. The Cronbach's α internal consistency coefficients of the IPSI subscales were previously evaluated at between .67 and .91. The IPSI includes 50 items, all of which are scored on a 5-point Likert scale, with 1 = strictly inappropriate and 5 = fully appropriate . The lack of self-confidence (LSC) subscale assesses lack of confidence in problem solving. The constructive problem solving (CPS) subscale assesses emotions, thoughts, and behaviors that contribute to the effective and constructive solution of interpersonal problems. The negative approach to the problem subscale assesses intensely the negative emotions and thoughts such as helplessness, pessimism, and disappointment that are experienced when an interpersonal problem is encountered. The abstaining from responsibility subscale assesses failure to take responsibility for solving the problem. The persistent approach (PA) subscale assesses self-assertive/persistent thoughts and behaviors in solving problems encountered in interpersonal relationships. A high score on a subscale indicates a high interpersonal-problem-solving capability for that subscale category ( Çam & Tümkaya, 2008 ). A high score on the negative approach to the problem subscale indicates a higher likelihood of experiencing intense negative feelings and thoughts such as helplessness, pessimism, and sadness when encountering a problem. A high score on CPS indicates that the respondent will show more of the emotions, thoughts, and behaviors that contribute to the problem in an effective and constructive way. A low level of self-confidence indicates that the respondent will exhibit low self-confidence toward effectively resolving a problem. A high score on the abstaining from responsibility subscale indicates a high inclination to assume responsibility to resolve a problem ( Table 1 ). The high level of insistent approach indicates that the participant is more willing to solve problems ( Çam & Tümkaya, 2008 ). In this study, the Cronbach's α reliability coefficients were .901, .899, .763, .679, and .810, respectively.


Basic empathy skill scale

The Basic Empathy Skill Scale was developed by Jolliffe and Farrington (2006) and validated by Topçu et al. (2010) in Turkish. It is a 5-Likert scale (1 = s trictly disagree and 5 = strictly agree ) consisting of 20 items, of which nine measure CE and 11 measure EE. The Cronbach's α coefficients that were calculated for the reliability study range between .76 and .80. The lowest possible scores are 9 and 45 and the highest possible scores are 11 and 55 for the CE and EE subscales, respectively. A high score on the CE subscale indicates that the CE level is high, and a high score on the EE subscale indicates that the EE level is high ( Topçu et al., 2010 ). The two subscales of the Basic Empathy Skill Scale have been found to be highly reliable. The Cronbach's α reliability coefficients in this study were .782 for the CE subscale and .649 for the EE subscale.

Data Collection

The study was conducted between May and June 2015 at three hospitals affiliated with Istanbul University. The researcher explained the study to those nurses who agreed to participate. The questionnaire form was distributed to the participants, the purpose of the investigation was clarified, and permission to use participant data was obtained. The participants completed the questionnaire on their own, and the completed questionnaires were collected afterward. The time required to complete the questionnaire was 15–20 minutes in total.

Evaluation of Data

Number Cruncher Statistical System 2007 (Kaysville, UT, USA) software was used to perform statistical analysis. To compare the quantitative data, in addition to using descriptive statistical methods (mean, standard deviation, median, frequency, ratio, minimum, maximum), the Student t test was used to compare the parameters with the regular distribution in the two groups and the Mann–Whitney U test was used to compare the parameters without normal distribution in the two groups. In addition, a one-way analysis of variance test was used to compare three or more groups with normal distribution, and a Kruskal–Wallis test was used to compare three or more groups without normal distribution. Pearson's correlation analysis and Spearman's correlation analysis were used to evaluate the relationships among the parameters. Finally, linear regression analysis was employed to evaluate multivariate data. Significance was determined by a p value of < .05.

Ethical Considerations

Ethical conformity approval was obtained from the Non-Interventional Clinical Research Ethics Board at Istanbul Medipol University (108400987-165, issued on March 30, 2015). Written consent was obtained from the administrations of the participating hospitals. Furthermore, the informed consent of nurses who volunteered to participate was obtained. Permission to use the abovementioned scales that were used in this study as data collection tools was obtained via e-mail from their original authors.

Eighty nurses (97.5% female, n = 78; 2.5% male, n = 2) were enrolled as participants. The age of participants ranged between 24 and 64 (mean = 37.56 ± 8.12) years, mean years of professional nursing experience was 15.84 ± 8.30, and mean years working in the current hospital was 13.19 ± 8.23. Other descriptive characteristics for the participants are provided in Table 2 .


A comparison of scale subdimension scores revealed a negative and statistically significant correlation at a level of 22.3%. Statistical significance was reached only between the LSC subscale and the CE subscale ( r = −.223, p = .047; Table 3 ). Thus, a higher LSC score was associated with a lower CE score.


Comparisons between participants' descriptive characteristics and subdimension scores on the problem-solving skill scale revealed no significant differences. Thus, demographic characteristics such as age, educational background, and career length were found to have no influence on problem-solving skills ( p > .05; Table 4 ).


Age, marital status, and professional career length were not found to affect the CE and EE subscale scores, with no statistically significant correlations found between the two subscales ( p > .05; Table 4 ). However, the EE scores of undergraduate nurses were found to be higher than those of postgraduate nurses, at a level that approached statistical significance ( p = .078). In addition, the average CE scores of nurses who had worked for 1–10 and 11–20 years were higher than those of nurses who had worked for 21 years or more, at a level that approached statistical significance ( p = .066).

A statistically significant difference was found between mean years working in the current hospital and educational background, respectively, and CE scores ( p = .027 and p = .013; Table 4 ). On the basis of paired comparison analysis, the CE scores of participants with 1–10 years of working experience at their current hospital were higher than those with ≥ 21 years of working experience at their current hospital ( p = .027). Also on the basis of paired comparison analysis, the CE score of participants educated to the undergraduate level was found to be higher at a statistically significant level than those educated to the master's/doctorate degree level ( p = .013).

The comparison of problem-solving skill scores by descriptive characteristics revealed no statistically significant difference between subscale scores and the variables of age, marital status, length of professional and organizational career, or educational background ( p > .05). Thus, the descriptive characteristics of the participants did not affect their problem-solving skills.

Regression Analysis of Risk Factors Affecting Cognitive and Empathy Skills

Variables found after univariate analysis to have significance levels of p < .01 were subsequently modeled and evaluated. A regression analysis was conducted to determine the effect on CE skills of educational level, duration of institutional work, CPS level, and self-insecurity level. The explanatory power of this model was 29.9% ( R 2 = .299), and the model was significant ( p < .001). As a result of the analysis, CPS ( p = .006), educational status of graduate ( p < .001), and working for the current hospital for a period of more than 20 years ( p = .004) were found to have a significant and positive influence on the CE score.

A 1-unit increase in the CPS score was found to increase CE skills by 0.139 points (β = 0.139, 95% CI [0.041, 0.237], p < .01). For education, graduate education was found to decrease the CE score by 4.520 points (β = −4.520, 95% CI [−6.986, −2.054], p < .001). For duration working for the current hospital, working for the same institution for a period exceeding 20 years was found to decrease the CE score by 3.429 points (β = −3.429, 95% CI [−5.756, −1.102], p < .05). In addition, a 1-unit increase in the LSC score was found to decrease the CE score by 0.114 points, which did not achieve statistical significance (β = 0.114, 95% CI [−0.325, 0.096], p > .05).

Regression analysis was used to evaluate the effects of education, PA, and LSC on the risk factors affecting EE. As a result of this evaluation, the explanatory power of the model was determined as 15.3% ( R 2 = .153), which was significant despite the low level ( F = 3.388, p = .001). The effects of PA ( p = .021) and educational status ( p = .015) on the EE score were shown through analysis to be statistically significant ( Table 5 ). A 1-unit increase in PA score was found to increase the EE score by 0.323 points (β = 0.323, 95% CI [0.049, 0.596], p < .05). For education, having a graduate education was found to decrease the EE score by 3.989 points (β = −3.989, 95% CI [−7.193, −0.786], p < .05). Moreover, the LSC score was found to be 0.119 points lower than the EE score. However, this result was not statistically significant (β = −0.193, 95% CI [−0.467, 0.080], p > .05). Dummy variables were used in the regression analysis of sociodemographic characteristics (educational status and years working for the current hospital).


This study found that age, marital status, educational background, years of professional working experience, and years working for the current hospital did not affect the problem-solving skills of the participants. In the literature, the findings of several studies indicate that characteristics such as age, educational background, department of service, and career length do not affect the problem-solving skills of nurses ( Abaan & Altintoprak, 2005 ; Kelleci & Gölbaşi, 2004 ; Yu & Kirk, 2008 ), whereas other studies indicate that these variables do affect these skills ( Ançel, 2006 ; Watt-Watson, Garfinkel, Gallop, Stevens, & Streiner, 2000 ; Yu & Kirk, 2008 ). However, beyond these characteristics, some studies have reported a positive correlation between the problem-solving skills of nurses and their educational level, with this correlation mediated by the physical conditions of the workplace, good relationships with colleagues, and educational background ( Yildiz & Güven, 2009 ). These findings suggest that factors affecting the empathy and problem-solving skills of nurses working in operating rooms differ from known and expected factors.

Operating room nurses deliver dynamic nursing care that requires attention and close observation because of the fast turnover of patients. In addition to the problem-solving skills that they use during the patient care process, these nurses must use or operate a myriad of lifesaving technological devices and equipment ( AbuAlRub, 2004 ; Özgür, Yildirim, & Aktaş, 2008 ). The circumstances in which nurses employ their problem-solving skills are generally near-death critical conditions and emergencies. Furthermore, operating rooms are more isolated than other areas of the hospital, which affects nurses who work in operating rooms and intensive care units ( AbuAlRub, 2004 ; Özgür et al., 2008 ).

Communication is a critical factor that affects the delivery of healthcare services. Communication does not only take place between a service recipient and a provider. To establish a teamwork philosophy between employees, it is essential to build effective communication ( Sandelin & Gustafsson, 2015 ). Empathic communication helps enhance the problem-solving skills of nurses as they work to learn about individual experiences ( Kumcağiz, Yilmaz, Çelik, & Avci, 2011 ). Studies in the literature have found that nurses who are satisfied with their relationships with colleagues, physicians, and supervisors have a high level of problem-solving skills ( Abaan & Altintoprak, 2005 ; Kumcağiz et al., 2011 ) and that higher problem-solving skills are associated with a higher level of individual achievement ( Abaan & Altintoprak, 2005 ; Chan, 2001 ). Another finding of this study is that CPS increases the cognitive emphatic level. This may be attributed to constructive problem-solving skills increasing CE, as these skills are associated with feelings, thoughts, and behaviors that contribute to problem resolution.

A review of the literature on empathy and communication skills revealed, as expected, that these skills increased with level of education ( Kumcağiz et al., 2011 ; Vioulac et al., 2016 ). However, a number of studies have reported no significant correlation between age, marital status, and professional working experience and empathy skills or communication abilities in nurses ( Kumcağiz et al., 2011 ; Yu & Kirk, 2008 ).

EE is assumed to be a more intuitive reaction to emotions. Factors that affect EE are nurses working with small patient groups, frequent contact with patient groups, and long periods spent accompanying or being in close contact with patient groups ( Vioulac et al., 2016 ). Studies in the literature have reported no correlation between the empathy skills of nurses and demographic characteristics ( Vioulac et al., 2016 ). This study supports this finding, with the empathy skills of operating room nurses found to be close to the peak value of the scale.

Studies in the literature reveal a positive correlation between empathy and career length ( Watt-Watson et al., 2000 ; Yu & Kirk, 2008 ) as well as a correlation between increased professional experience and lower empathy ( Yu & Kirk, 2008 ). This study found an association between longer periods working for the same hospital and higher levels of education with lower empathy scores. This may be attributed to the difficult working conditions in operating rooms, intense stress, and high level of potential stress-driven conflicts between employees in work settings.

Stress is a major factor that affects the empathy skills and relationship-building abilities of nurses ( Vioulac et al., 2016 ). Nurses are exposed to a wide variety of stressors such as quality of the service, duration of shifts, workload, time pressures, and limited decision-making authority ( Patrick & Lavery, 2007 ; Shimizutani et al., 2008 ; Vioulac et al., 2016 ). In particular, environments evoking a sense of death (e.g., operating rooms) is another factor known to elevate perceived stress ( Ashker, Penprase, & Salman, 2012 ). High stress may lead to negative consequences such as reduced problem-solving abilities ( Zhao, Lei, He, Gu, & Li, 2015 ). Both having a long nursing career and working in stressful environments such as operating rooms may negatively affect empathy and problem-solving skills. However, this study revealed that working for a long period at the current hospital had no influence on problem-solving skills. The low reliability of the scales means that the variance may be high in other samples that are drawn from the same main sample, with the resultant data thus not reflecting the truth.

Low reliability coefficients reduce the significance and value of the results obtained by increasing the standard error of the data ( Şencan, 2005 ). The Cronbach's α of the EE scale used in the study was between .60 and .80 and is highly trustworthy. However, the Cronbach's α value is close to .60 (i.e., .649). This result may elicit suspicion in regression analysis estimates that are done to determine the variables that affect EE. In the correlation analysis, a statistically significant weak correlation was found only between the LSC subdimension and CE. However, the fact that the subscales of empathy and problem-solving skills are significantly related to the regression models may also be related to the reliability levels of the scales.

According to the results of the regression analysis, all of the variables remaining in Model A affected level of low for the CE ( R 2 = .299). Having constructive problem-solving skills ( p = .006), having a high level of education ( p < .001), and working for the current hospital for over 20 years ( p = .004) were found to be significantly related to CE.

Other variables were found to have no significant effect. According to the results of the regression analysis, all of the remaining variables in Model B accounted for a relatively low portion of the EE ( R 2 = .153). When the t test results for the significance of the regression coefficients were examined, it was determined that PA ( p = .021) and educational status ( p = .015) were significant predictors of EE. Other variables had no significant effect ( Table 5 ). The increase in the level of education of nurses may have increased their cognitive and emotional development. Thus, working in the same hospital for over 20 years was found to increase the levels of CE and EE. This result may be because of greater professional experience and regular experience handling numerous, different problems. In addition, the low explanatory power of the models may also be because of the fact that many other arguments that may affect empathy were not modeled. When constant values are fixed and the value of the independent variables entering the regression formula is zero, constant value is the estimated value of the dependent variable. According to findings of this study, sociodemographic characteristics and problem-solving abilities did not affect empathy level, although the CE value was 31.707 and the EE value was 37.024. Repeating this research in larger and different nurse groups may be useful to verify these research results.


The following results were derived from this study: First, constructive problem-solving skills affect CE skills. EE is adversely affected by the PA and LSC. Second, no correlation was found between the demographic characteristics of nurses and their problem-solving skills. Third, as level of education increases, cognitive and emotional levels of empathy decrease.

Duration of time spent working at one's current healthcare institution and educational level were both found to correlate negatively with the CE score. The higher the educational level and PA and the lower the self-confidence of the participants, the lower their EE levels. Finally, higher constructive problem-solving scores were associated with higher CE skills.


The major limitation of the study is that it was conducted in the affiliated hospitals of one healthcare organization. The study data were obtained from operating room nurses who currently worked in these hospitals and who volunteered to participate. The conditions of nurses who did not participate in the study cannot be ascertained. A second important limitation is that the data reflect the subjective perceptions and statements of the participants. A third important limitation is that participant characteristics such as trust in management, trust in the institution, burnout, and communication skills were not assessed. For this reason, the effects of these variables on problem-solving and empathy skills remain unknown.

Author Contributions

Study conception and design: SP

Data collection: TK

Data analysis and interpretation: FA, SP

Drafting of the article: FA

Critical revision of the article: FA

operating room; critical thinking; surgery; cognitive; emotional


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