problem solving approach in nursing

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Nursing professional development evidence-based practice.

Barbara A. Brunt ; Melanie M. Morris .

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Last Update: March 4, 2023 .

• Introduction

Evidence-based practice is “integrating the best available evidence with the healthcare educator’s expertise and the client’s needs while considering the practice environment. [1] One of the roles of the NPD practitioner in the 2022 edition of the Nursing Scope and Standards of Practice is a champion for scientific inquiry. In this role, the NPD practitioner promotes a spirit of inquiry, the generation and dissemination of new knowledge, and the use of evidence to advance NPD practice, guide clinical practice, and improve the quality of care for the healthcare consumer/partner. Scholarly inquiry is a standard of practice within that role. It is defined as “The nursing professional development (NPD) practitioner integrates scholarship, evidence, and research findings into practice” (p. 104).

There is often confusion between quality improvement, evidence-based practice, and research. A seminal article by Shirey and colleagues. [2]  differentiated these three topics. Evidence-based practice is a systematic problem-solving approach that is evidence-driven and translates new knowledge into clinical, administrative, and educational practice. Institutional Review Board (IRB) approval is usually not required unless outcomes are intended for publication, or the project could potentially expose individuals to harm.

The EBP process, as defined by Melnyk and Fineout-Overholt, includes seven steps:         

• Encouraging and supporting a spirit of inquiry
• Asking questions
• Searching for evidence
• Appraising the evidence
• Integrating evidence into practice
• Evaluating outcomes
• Sharing results

Implementing EBP in practice has been shown to lead to a higher quality of care and better patient outcomes, but nurses encounter many barriers when implementing EBP. NPD practitioners can facilitate the implementation of EBP by ensuring a supportive environment for EBP, providing educational sessions to nurses about the EBP process, being role models, and mentoring nurses.

• Issues of Concern

PICOT Question

The foundation of EBP is developing a PICOT question, which identifies the terms to be used to search for the best evidence to answer a burning clinical question. [3] This framework breaks down the question into keywords. P stands for patient/population; I refers to Intervention; C stands for comparison/control; O stands for the outcome; and T refers to the time frame. When looking at the population, it is important to consider the relevant patients, including age, sex, geographic location, or specific characteristics that would be important to the question.

The intervention examines the management strategy, diagnostic test, or exposure of interest. There may not always be a comparison in the PICOT analysis. If there is, this would be a control or alternative management strategy compared to the intervention. Outcomes should be measurable, as the best evidence comes from rigorous studies with statistically significant findings. The time factor looks at what period should be considered. There are a variety of clinical domains that PICOT questions can evaluate, such as intervention, diagnosis, etiology, prevention, prognosis/prediction, quality of life, or therapy. Writing a good PICOT question for an effective search and making robust, evidence-based recommendations to improve care and outcomes is critical.

The Evidence

While there are multiple ways to evaluate and rank evidence in the literature, one of the most widely used in nursing in the United States uses seven levels. These seven accepted levels of evidence are assigned to studies based on the methodological quality of the design, validity, and application to patient care. In addition, these levels provide the “grade” or strength of the recommendation.

• Level I –  Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs) or evidence-based clinical practice guidelines based on a systematic review of RCTs or three or more RCTs of decent quality with comparable results.
• Level II -  Evidence obtained from at least one well-designed RCT
• Level III – Evidence obtained from well-designed controlled trials without randomization
• Level IV -  Evidence from well-designed case-control or cohort studies        
• Level V - Evidence from a systematic review of descriptive and qualitative studies (meta-syntheses)
• Level VI – Evidence from a single or descriptive or qualitative study              
• Level VII - Evidence from the opinion of authorities and/or reports of expert committees.

Roe-Prior discussed the strength of evidence by comparing it to a murder trial. A suspect’s conviction should require more than the testimony of one witness. If a crowd of people all agree that the suspect was the perpetrator or there was DNA evidence, that evidence is much stronger. Studies without a comparative group, methodologically weak studies, or poorly controlled studies could be likened to one witness. Roe Prior encouraged individuals to also look at non-nursing research findings since research centered on other disciplines, like psychology or education, could be appropriate.

Other frameworks for identifying levels of evidence include The Oxford Centre for Evidence-Based Medicine Levels of Evidence and Burns framework. [4] The Oxford Centre describes five levels with various subparts as listed here:

• 1a           Systematic review of RCTs
• 1b           Individual RCT
• 2a           Systematic review of cohort studies
• 2b           Individual cohort study
• 2c           Outcomes research
• 3a           Systematic review of case-control studies
• 3b           Individual case-control study
• 4             Case series
• 5             Expert opinion

Burns uses three levels to differentiate the strength of the evidence presented:

• I             At least 1 RCT with proper randomization
• II.1         Well-designed cohort or case-control study
• II.2         Time series comparisons or dramatic results from uncontrolled studies
• III           Expert opinions

Roe Prior outlined guidelines for the literature review. [5] Use keywords from the PICOT question to perform simple, then more complex searches in reliable databases, preferably limited to the past five years, although landmark studies can be included. Limit the review to peer-reviewed and research articles and use caution when including only full-text articles, as some key papers may be missed. Check the validity of any online sources and use original research where possible. Remember that textbooks are often obsolete by their publication date, and books are considered secondary sources.

The Cochran Library is comprised of multiple databases where systematic reviews on healthcare topics can be found. Using the Preferred Reporting Items for Systemic Review and Meta-Analysis (PRISMA) Guidelines to evaluate a systemic review or meta-analysis can help the individual ensure the findings are valid and reliable. Findings from the literature review are put into an evidence-based table. There are various formats for these tables, but they all include information about the source, design, sample, summary of findings, and level of evidence for each of the articles included.

The most frequently used EBP models are the Iowa Model, the Advancing Research and Clinical Practice through Close Collaboration (ARCC) Model, the Star Model of Knowledge Transformation, and the John Hopkins Nursing Evidence-based Practice (JHNEBP) Model. The IOWA Model focuses on implementing evidence-based practice changes, and the ARCC model on advancing EBP in systems by using EBP mentors and control and cognitive behavioral therapies. The Star Model provides a framework for approaching EBP, and the John Hopkins Model is a problem-based approach to clinical decision-making accompanied by tools to guide its use.

The Iowa model was revised and updated in 2017 by the Iowa Model Collaborative. [6]  Changes in the healthcare environment, such as a focus on implementation science and emphasis on patient engagement, prompted a reevaluation, revision, and validation of the model. This model differs from other frameworks by linking practice changes within the system. Model changes included an expansion of piloting, implementation, patient engagement, and sustaining change.

Support for the ARCC Model was outlined in an article by Melnyk and colleagues in a study exploring how an evidence-based culture and mentorship predicted EBP implementation, nurse job satisfaction, and intent to stay. [7] This model involves assessing organizational culture and readiness for EBP using EBP mentors who work with clinicians to facilitate the implementation of evidence-based practice.

A concept analysis of feelings of entrapment during the COVID-19 pandemic, using the ACE Star Model, was completed by Lee and Park. The ACE Star model is used to understand the cycle, nature, and characteristics of knowledge used in various aspects of EBP. The model consists of five steps: discovery research, evidence summary, translation to guidelines, practice integration, and process and outcome evaluation.

The JHNEBP Model is a problem-solving approach to clinical decision-making with user-friendly tools to guide individual or group use. It is explicitly designed to meet the needs of the practicing nurse and uses a three-step process called PET: practice question, evidence, and translation. In a study conducted by Speroni and colleagues on using EBP models across the United States, this was the second most frequently used model by the 127 nurse leaders who responded to the questionnaire. [8]

EBP Competence and Implementation

NPD practitioners are instrumental in implementing EBP. Harper and colleagues conducted a national study to examine NPD practitioners’ beliefs and competencies, frequency of implementing EBP, and perceptions of organizational culture and readiness for EBP. [9] The Association for Nursing Professional Development (ANPD) collaborated with the Center for Transdisciplinary Evidence-Based Practice at The Ohio State University to explore the NPD practitioners’ beliefs and experiences with EBP, as well as to explore relationships among NPD practitioner characteristics and healthcare organizational outcomes such as nursing sensitive quality indicator scores and core measures. A total of 253 NPD practitioners from 43 states and the District of Columbia participated in this study. Findings indicated that NPD practitioners need to develop personal competence in EBP, become involved in shared governance, collaborate with others to facilitate the implementation of EBP, and become comfortable with using quality metrics to demonstrate the effectiveness of NPD activities.

The Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare of the Ohio State University developed an Evidence-Based Practice Certificate, which was approved by the Accreditation Board for Specialty Nursing Certification in 2018. There are 24 EBP competencies; 13 for practicing registered nurses and an additional 11 competencies for practicing advanced practice nurses and EBP experts. These competencies are outlined in an article by Melnyk et al. [10]

Although these competencies were initially written for nurses, they apply to other interprofessional team members who have received advanced EBP education. In addition to demonstrating completion of the EBP coursework, applicants must demonstrate current EBP knowledge through content review and successful testing and submit a portfolio to review that shows an EBP practice change project before receiving a certificate.

In 2020, ANPD worked with the Helene Fuld Health Trust National Institute for Evidence-Based Practice in Nursing and Healthcare to develop a curriculum for the Nursing Professional Development EBP Academy. [11] The program consists of live webinars, 26 asynchronous modules, and the completion of an EBP change initiative/project. This Academy curriculum aligns with the EBP Certificate educational requirements.

There are numerous resources available for NPD practitioners on evidence-based practice. There is a peer-reviewed journal published by Sigma Theta Tau International, Worldviews on Evidence-based Nursing, which includes original research with recommendations applicable to use as best practices to improve patient care. ANPD has a year-long evidence-based fellowship consisting of theory and completion of an evidence-based project. The Nursing Professional Development Evidence-Based Practice (EBP) Academy is a 12-month mentored program designed to guide the NPD practitioner through creating PICOT questions, gathering and critically appraising literature, and EBP implementation, evaluation, dissemination, and sustainment. Participation in the EBP Academy enhances the evidence-based competencies of nursing professional development practitioners to enable them to fulfill their role as champions of scientific inquiry and mentor other healthcare professionals in implementing EBP practices.

EBP in Action

One organization evaluated the use of evidence-based practice in clinical practice after nurses attended a formal evidence-based practice course. [12]  Nurses who attended the organization’s EBP course were invited to participate in focus groups to provide additional qualitative data. Data from two focus groups highlighted the impact of the EBP course, areas for further development, and potential barriers to the use of EBP. The nurses indicated that the course changed their way of thinking and enhanced their patient care. They stated there was a need for mentoring and that time was a significant barrier to EBP. That information was used by organizational leadership to help identify areas needing consideration for educational offerings and support mechanisms.

Another large academic medical center evaluated the implementation of an EBP program. [13]  They noted that although their approach to educating professional staff on EBP provided initial benefits, holding the gains over a one-year period was difficult. The “train-the-trainer” model envisioned by the team was not realistic, as the participants did not feel well-versed enough to teach others. They concluded future efforts require attention to participant feedback and the implementation of measures to decrease the barriers to implementing EBP.

There are numerous examples in the literature of individuals/organizations using evidence-based principles to develop programs in a variety of settings. McGarity and colleagues examined frontline nurse leaders oriented with only on-the-job training questioning whether their level of competence is improved with a professional development program. [14] This project used a pre-and post-survey design to evaluate a leadership development curriculum. The intervention was an evidence-based leadership curriculum that consisted of twelve four-hour classes. The fact that all 38 frontline nurse leaders who participated in this project improved their competencies reinforced the need for formal professional development. The outcome of this training program showed that all 38 frontline nurse leaders who attended it were more confident in their skills and improved their competence in leading effective teams, reinforcing the need for education.

Ydrogo and colleagues discussed a multifaceted approach to strengthening nurses’ EBP capabilities in a comprehensive cancer center. [15] They created a program designed to promote a spirit of inquiry, strengthen EBP facilitators, overcome barriers to EBP, and expand nurses’ knowledge of EBP. The program consisted of a blended interactive seminar with leader-directed discussion on promoting a spirit of inquiry, a seven-week course on retrieving, reading, analyzing, and evaluating research papers, and a monthly challenge emailed to staff, posted to the hospital intranet, and included in a weekly nursing newsletter. Both leadership and staff gained increased confidence and a foundation to initiate two research projects and one EBP project shortly after completing the course.

Integrating EBP into an emergency department nurse residency program was the subject of an article by Asselta. [16] In addition to extensive training in the core competencies of emergency nursing, this 6-month program included exemplars in EBP and its positive impact on patient care and/or ED workflow. One of the requirements for this program was for the nurses to participate in developing an EBP project specific to emergency nursing practice. An example of a project comparing intravenous (IV) push medications versus IV piggyback medications was shared. This project demonstrated the advantages of the IV push route of administration, which yielded significant cost savings for the organization.

Pediatric nurses were the focus of a project described by Cline et al. [17] They evaluated nurses’ perceptions of barriers, facilitators, confidence, and attitudes toward research and evidence-based practice. There were 369 nurses who completed the survey during the baseline data collection period, 288 nurses completed the 6-month survey, and 284 nurses completed the 12-month survey. The results indicated that implementation of a curriculum focused on research and EBP may be most successful when implemented with the availability of mentors, in a research-supported environment, with grant funding support for novice researchers, and with an ample amount of time allotted to complete a research study.

Many nurses work in long-term care. Higuchi and colleagues described a study that examined the impact of EBP practice change in ten long-term care (LTC) settings in Canada. [18] Introducing and sustaining practice changes that enhance the quality of care is a significant challenge in LTC facilities. A full-day workshop that included identifying success stories, describing current practice challenges, building a case for change, seizing the moment, and identifying an action plan was presented at each site. Participants completed a questionnaire at the end of the workshop, and all participants were invited to participate in semi-structured interviews five months after the program. The benefits identified in the follow-up interviews were initiating the change process and enhancing team collaboration. This study demonstrated that an interactive workshop had important positive effects on LTC staff.

Clinical nurse educators were the focus of a study conducted by Dagg and colleagues. [19]  Centralization of a new clinical nurse educator (CNE) role created role confusion and poor role outcomes. An evidence-based quality improvement project was completed to integrate the ANPD practice model and transition to the practice fellowship program. An ANPD competency assessment survey tool was selected because it included information specific to the CNE role expectations. The nurse-sensitive indicators selected were fall rates and indwelling urinary catheter rates. Self-assessed competencies and nurse-sensitive quality outcomes of the CNEs were measured before and after the ANPD practice model was integrated into their daily practice. There were only 5 CNEs who completed both the pre-and post-assessment, but results supported that CNEs influenced patient quality outcomes and improved their self-assessed competency.

Phan and Hampton described an evidence-based project focused on promoting civility in the workplace by addressing bullying in new graduate nurses using simulation and cognitive rehearsal. [20]  Nurse bullying (NB) has been a problem for many years, and this can threaten the safety of patients, nurses, and organizations. This study used a mixed-methods, quasi-experimental design.

The NPD Scope and Standards were used to assess, plan, implement, and evaluate the project. In addition to the demographic data collected at baseline, participants completed the Clark Workplace Civility Index (CWCI) at baseline and three times after the intervention (immediately, 2.5 months, and five months). The sample included 36 new graduate nurses (NGNs). The intervention consisted of 2.75 hours of didactic, polling, reflection, simulation role-play, and debriefing. The training was developed virtually on the Zoom platform, and breakout rooms facilitated small group discussions and role-playing. Although there was no statistically significant increase in civility scores, the qualitative data indicated the participants could apply knowledge and skills from the intervention to improve communication, peer relationships, teamwork, patient safety, and care.

• Clinical Significance

Evidence-based practice falls under the champion for scientific inquiry role of the NPD practitioner. According to the NPD scope and standards of practice, the NPD practitioner promotes a spirit of inquiry and assists with generating and disseminating new knowledge. The NPD practitioner also uses evidence to advance the specialty of NPD and guide practice.

The ultimate goal is to promote the quality of care for the healthcare consumer. Competencies for scholarly inquiry include acting as a champion for inquiry, generating new knowledge, and integrating the best available evidence into practice. In addition, the standards include disseminating inquiry findings, including evidence-based practice and quality improvement activities, through educational and professional development activities.

• Enhancing Healthcare Team Outcomes

The healthcare consumer is the ultimate recipient of NPD practice. Therefore, NPD practitioners collaborate with the interprofessional team to ensure quality care, leading to optimal care outcomes and population health. Interprofessional partnerships are critical factors in achieving safe, effective, high-quality care.

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Disclosure: Barbara Brunt declares no relevant financial relationships with ineligible companies.

Disclosure: Melanie Morris declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Brunt BA, Morris MM. Nursing Professional Development Evidence-Based Practice. [Updated 2023 Mar 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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

Ae young kim.

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Correspondence: [email protected] ; Tel.: +82-10-3372-5920; Fax: +82-2-824-7961

Received 2020 Jun 18; Accepted 2020 Jul 5; Issue date 2020 Jul.

Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/ ).

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

Keywords: communication, clinical nurse, perception of professionalism, patient’s condition, structural equation model

1. Introduction

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

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

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

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

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

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

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

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

2. Materials and Methods

2.1. study design.

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

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

Study model.

2.2. Study Participants

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

2.3. Data Collection Method

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

2.4. Research Instruments

2.4.1. communication skills.

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

2.4.2. Problem-Solving Ability

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

2.4.3. Understanding Patients’ Condition

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

2.4.4. Nurse’s Perception of Professionalism

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

2.5. Data Analysis

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

Frequency analysis was conducted to identify the subjects’ demographic and general characteristics.

The reliability of the questionnaire was verified using Cronbach’s α coefficients.

Confirmatory factor analysis (CFA) was performed to verify the convergent validity of the selected measurement tool.

The normality of the data was determined through analyzing the skewness and kurtosis of the measurement variables.

The fitness of the model was verified using structural equation modeling (SEM).

Bootstrapping was utilized to verify the mediating effect in the set study model, as well as the mediating effects of the nurses’ problem-solving ability and understanding of patients’ conditions.

3.1. Demographic Characteristics

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

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

3.2. Technical Metrics of the Measurement Variables

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

All sub-factors of the latent variables secured normality.

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

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

3.3. Correlations between the Measured Variables

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

Correlations between the observed variables.

3.4. Confirmatory Factor Analysis of the Measurement Model

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

Confirmatory factor analysis of the measurement model.

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

3.5. Verification of the Structural Model

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

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

3.6. Influencing Relationships between Variables of the Study Model

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

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

The relationships between the human effects of the measurement model.

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

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

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

3.7. Direct and Indirect Effects of the Variables

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

Mediating effect analysis.

* p < 0.05, *** p < 0.001

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

4. Discussion

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

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

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

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

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

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

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

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

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

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

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

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

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

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

5. Conclusions

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

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

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

Acknowledgments

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

Author Contributions

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

This research received no external funding.

Conflicts of Interest

The authors declare no conflict of interest.

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