Abstract
Aim
This study aims to examine the nursing diagnosis skills of students who took the case-based online nursing processes course during the COVID-19 pandemic.
Methods
The study followed a descriptive and cross-sectional design. The participants were first-year students (n = 148) enrolled in the nursing principles course in the spring semester of the 2020–2021 academic year in the nursing department of a university. The course on nursing processes was delivered online due to the COVID-19 pandemic. At the end of the course, students who volunteered to participate in the study developed nursing diagnoses for the cases assigned to them. The data were collected from the students using two forms and were evaluated using a form developed by the researchers. The data were analyzed with numeric and percentage calculations.
Findings
Although 56.8% of the students stated that they had difficulty making nursing diagnoses, 56.8% of them thought online education was not useful. The most commonly made diagnoses by the students who participated in the study included hyperthermia (66.2%), ineffective breathing pattern (54.7%), risk of falling (39.9%), fatigue (34.5%), and anxiety (33.8%). It was also found that students were able to identify objective data more easily as diagnosis criteria, whereas they were not able to identify abstract concepts.
Conclusions
It was seen that the students who participated in the study had low levels of nursing diagnoses. Based on the findings, it is recommended that different teaching methods be employed in the online nursing processes course, and these methods be evaluated in terms of their effects on students’ learning outcomes.
Implications for nursing practices
The online nursing process course should be made more efficient. First-year nursing students are not yet ready to identify nursing diagnoses in terms of knowledge and skills.
INTRODUCTION
The essence and scientific basis of nurses is established through a nursing process implemented in a systematic and planned way (Tadzong-Awasum & Adelphine, 2021). The World Health Organization (WHO) recommends that the nursing process method be used in order for nurses to be able to fulfill the professional roles and responsibilities expected from them on a scientific basis (WHO, 2009)
Professional knowledge and skills used in the nursing process should be taught during undergraduate education of nurses (Potter et al., 2020). The nursing process is taught through in-class theoretical courses and sample case analyses in nursing schools at the undergraduate level and is put into practice following several nursing models and theories. Similar to the curricula of all practice-based disciplines, theoretical knowledge and clinical experience are inseparable and complement each other in nursing education (Tiwaken et al., 2015).
However, the global pandemic experienced for a while was identified as COVID-19 by the WHO on March 11, 2020, and interpersonal interaction was restricted in many countries, causing a transition to online education from face-to-face education (WHO, 2020). In this regard, the effect of online education on nursing students’ educational outputs and objectives has become a topic of great interest (Brooks et al., 2020; Sahu, 2020).
BACKGROUND
Although the literature includes studies that were conducted previously and focused on distance nursing education, no study has been found concerning the effect of online education on the nursing diagnosis skills of students during the pandemic. One study carried out during this period concluded that web-based distance education made more contribution to students’ theoretical knowledge than their practical skills (Keskin & Özer Kaya, 2020).
The case-based practice that replaced clinical practices during the pandemic has been reported to be considerably important for nursing students’ learning the knowledge and skills concerning patient care and improving their critical thinking skills (Jiang et al., 2021). Another study conducted before the pandemic found that the online case-based nursing processes course enhanced students’ patient care skills and their skills of coping with challenges in real clinical settings (Barisone et al., 2019). On the other hand, it is possible to find studies from different countries reporting that distance education in nursing has made no positive contribution to cognitive learning and student satisfaction (Dwyer & Searle, 2009; Horiuch et al., 2009).
Although the number of studies on students’ feelings and opinions about the COVID-19 pandemic and online education is gradually increasing, it was seen that the literature lacks information on the targeted tangible outcomes for nursing education. Similarly, no study has been found concerning students’ ability to learn the nursing processes course online and to put it into practice. The present study aimed to examine the nursing diagnosis skills of students who receive online education.
METHODS
Design and sample
This descriptive and cross-sectional study was conducted to examine the nursing diagnosis skills of nursing students who received online education during the COVID-19 pandemic. The study was carried out in the Faculty of Health Sciences of a university located in the south of Turkey in the spring semester of the 2020–2021 academic year. First-year students were included in the study. The reason for including first-year nursing students in the study was that these students received entirely online education due to the pandemic and did not have any experience of clinical practice during this period.
Students who attended the sessions on the nursing process and agreed to participate were included in the study. The total number of first-year students in the nursing department was 206. Although 30 students did not attend the theoretical and practical classes of the course, 28 students refused to participate. As a result, the study was conducted with 148 students who attended all the theoretical and practical classes of the course and agreed to participate in the study.
Settings
At the university where the study was carried out, online education was delivered via Microsoft Teams. Within the scope of the nursing principles course, the nursing process was taught online to students in the second semester of the first year (2021 April) through theoretical (6 hours) and practical (12 hours) classes. In the theoretical scope of the course, all the steps of the nursing process were explained in detail following the NANDA-I taxonomy (Herdman & Kamitsuru, 2014) and the Roper, Logan, and Tierney model (Roper et al., 1996). The practical scope included discussions over sample cases prepared by the researchers. Once the course was completed, the students were informed about the study, and students who agreed to participate were included in the study. A sample case was sent to the students through Microsoft Teams, where the course was delivered. The students were asked to identify nursing diagnoses and diagnostic criteria as well as classify these diagnoses according to the Roper, Logan, and Tierney model. The students were given one week to upload the Word document they would prepare on the system.
Data collection tools
The data were collected online over Microsoft Teams. Data collection was performed using “The Personal Information Form” including students’ descriptive characteristics and “The Nursing Diagnosis Form.”
The Personal Information Form
The form developed in line with the literature (Basit & Korkmaz, 2021; Bdair, 2021; Singh et al., 2021) consisted of eight questions asking about demographic data such as the student's age and gender, device used for attending the course, preference to attend the course, usefulness of the course, time allocated for identifying nursing diagnoses, difficulties faced when identifying nursing diagnoses, and the resources used.
The Nursing Diagnosis Form
This form included a sample case and 12 activities (creating and maintaining a safe environment, communication, breathing, eating and drinking, eliminating, personal cleansing and dressing, controlling body temperature, mobilizing, working and playing, expressing sexuality, sleeping and resting, dying) developed according to the Roper, Logan, and Tierney model. The sample case was taken from the book titled Fundamentals of Nursing, Human Health and Function, which does not include a nursing process developed for the case (Craven & Hirnle, 2015).
The Nursing Diagnosis and Diagnosis Criteria Evaluation Form
The form was developed in accordance with the NANDA- I taxonomy (Herdman & Kamitsuru, 2014) and with reference to the Roper, Logan, and Tierney model (Roper et al., 1996) by the researchers and was sent to students. It was used by the researchers during data analysis to achieve standardization in evaluation.
The students were asked to make 12 nursing diagnoses in total for the case prepared, including creating and maintaining a safe environment (pain–infection risk–risk of falling–ineffective coping), communication (anxiety), breathing (ineffective airway clearance, ineffective breathing pattern), eating and drinking (lack of self-care in eating and drinking), controlling body temperature (hyperthermia), and sleeping and resting (sleeplessness, fatigue, and discomfort).
The Nursing Diagnosis Form filled out by the students was compared with The Nursing Diagnosis and Diagnosis Criteria Evaluation Form. The nursing diagnoses and diagnosis criteria under the 12 activities developed according to the Roper, Logan, and Tierney model were recorded as “correct” if they matched each other in both forms, “incorrect” if they did not match, and as “absent” if no statement was provided.
Ethical considerations
The study was approved by the university's Institutional Review Board (Ethical permission number: 22.01.2021-107). Ethical guidelines regarding plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, and redundancy were observed by the author. Institutional permission was obtained from the health sciences faculty where the research was performed. Verbal consent was obtained from the participants before data collection. The students were explained that the nursing diagnoses they would make would not be graded and there would be no change in the behaviors and attitudes toward them.
Data analysis
In line with the aim of the study, the collected data were evaluated on the Statistical Package For Social Science (SPSS) 21.0 program. Descriptive data of the students, nursing diagnoses provided by the students, diagnosis criteria, and diagnosis classification according to the Roper, Logan, and Tierney model were analyzed using numbers and percentages. The statistical significance was accepted at the P < 0.05 level.
RESULTS
The mean age of the students who participated in the study was 20.10 ± 1.48, whereas 81.1% were female and 18.9% male. 53.4% of the students attended the nursing processes course on a computer. 94.6% expressed that the course should be delivered face to face. The online nursing processes course was found sufficient by 4.7% of the students, partly sufficient by 38.5%, and insufficient by 56.8%. 56.8% of the students stated they had difficulty in developing nursing diagnoses. The time spent making a nursing diagnosis by the students was found a maximum of one day (35.1%), two–three days (43.2%), four–five days (20.3%), and one week (1.4%). In this process, the students used course notes (66.2%), scientific books other than course notes (70.3%), the internet (80.4%), and scientific publications (25.2%) (Table 1).
Students’ demographic data and knowledge of the nursing processes course.
Some students marked more than one choice in these questions.
The most frequent diagnoses developed by the students in the study were hyperthermia (66.2%), ineffective breathing pattern (54.7%), risk of falling (39.9%), fatigue (34.5%), anxiety (33.8%), ineffective airway cleansing (27.7%), pain (27.7%), and infection risk (27%).
Under the activity of creating and maintaining a safe environment, 27.7% of the students were able to make pain diagnosis, 20.9% identified the descriptive characteristics of this diagnosis, and 5.4% could name associated factors with the diagnosis. Although 39.9% of the students could identify risk of falling diagnosis, whereas the ratio of the students who were able to write the risk factors of the diagnosis occurred was 2.7%. Infection risk diagnosis was developed by 27.7% of the students, whereas no students were able to write the risk factors of the diagnosis correctly. The ratio of identifying ineffective coping diagnosis was 5.4%, and the factors related to the descriptive characteristics of the diagnosis were identified by 2.7% of the students.
As for the communication activity, the ratios of diagnosis of anxiety, descriptive characteristics of the diagnosis, and identifying the related factors were 33.8%, 27.7%, and 18.2%, respectively.
Under the breathing activity title in the study, 27.7% of the students were able to diagnose ineffective airway clearance, 41.2% identified the descriptive characteristics of the diagnosis, and 20.9% could find the related factors. Ineffective breathing pattern diagnosis was made by 54.7%, descriptive characteristics of the diagnosis by 48.6%, and related factors by 23.0% of the students.
Concerning the eating and drinking activity, lack of self-care in eating and drinking was identified by 2.7%, descriptive characteristics by 27.7%, and related factors by 23.6% of the students.
Under the controlling body temperature activity, hypothermia was diagnosed by 66.2%, descriptive characteristics by 47.3%, and related factors by 10.3% of the students.
Under the sleeping and resting activity title, the study concluded that sleeplessness was diagnosed by 11.5%, descriptive characteristics by 58.8%, and related factors by 34.5% of the students. Another diagnosis under the sleeping and resting activity title, fatigue was identified by 34.5% of the students, descriptive characteristics of this diagnosis by 8.8%, and factors related to the diagnosis by 8.8%. Diagnosis of discomfort included in the same activity title was made by only one student, who was, however, unable to identify the criteria related to this diagnosis (Table 2).
Students’ nursing diagnoses and determining diagnosis criteria according to the Roper, Logan, and Tierney model.
DISCUSSION
Online education, which has come into our lives with the pandemic, has caused rapid changes in nursing education. Although the methods and techniques that are intended to use arouse excitement, suspension of face-to-face education and clinical practices has caused nursing instructors and students to encounter many challenges (Aggarwal et al., 2020).
A majority of the students who participated in the study expressed that online education was not effective or productive and that they had difficulty in developing diagnoses. In addition, students think the nursing processes course should be delivered face to face. This finding indicates that students are not satisfied with the online course. In similar studies conducted with nursing students (Diab & Elgahsh, 2020; Keskin & Özer, 2020), web-based education was reported to be less effective than face-to-face education, which is parallel to our study findings. No matter how successfully the theoretical information was taught in the course, students were able to put into practice through online case discussions only. At this point, they could not perform patient observations in real clinic settings. Similarly, in the related literature, nursing students expressed that the theoretical information was sufficient, yet they had difficulty in putting this information into practice in the clinic (Tadzong-Awasum & Adelphine, 2021). Despite all these negative opinions, online education has also been reported to be beneficial, particularly for students who have different studying routines and lifestyles (Billings & Halstead, 2019), to provide students with an opportunity for cooperative learning and to be effective in developing deeper learning approaches (Haslam, 2020).
The study found that most students had trouble in developing nursing diagnoses. This is thought to result from the fact that students were not able to have as much face-to-face communication with the instructors as they do in real clinical settings. The literature states that active participation, learner's feelings, technological devices used for learning, family support, educator support, and communication all play an important role in achieving success in online education (Jowsey et al., 2020). Another study suggests that techniques that boost interaction, such as case studies, group discussions, and debates, should be employed in order to prevent students from isolating themselves and to increase their motivation in online education (Wu et al., 2020).
The study also found that students used scientific publications in developing nursing diagnoses at a considerably low level. This is an expected result considering the richness and availability of internet resources and students’ ability to use technology. Also, in addition to reading course books and attending workshops and seminars, students can improve their self-learning skills through such methods as surfing websites, reading e-books, and watching educational materials on YouTube (Obied & Gad, 2017).
The study concluded that the association of the diagnoses with diagnosis criteria occurred at a low level. The students were seen to associate diagnosis criteria consisting of objective data such as temperature, inability to sleep, coughing, and irritability with related diagnoses (hyperthermia, sleeplessness, disordered breathing patterns, and anxiety) more easily. Although it was underlined that the presence of at least three descriptive characteristics was to be matched up with the nursing diagnosis as suggested by the literature (Wilkinson et al., 2018), the study failed to reach the expected results. This finding may reveal that first-year students, who have just started critical thinking acquisition, are only at the beginning of the learning process and they have not yet developed the required skills to use the correct resources.
The risk diagnoses expected from the students were identified at a considerable rate in the study. A similar study in the literature concluded that online case-based nursing process education had positive effects on students’ ability to differentiate a real diagnosis, a possible diagnosis, and a risk diagnosis from each other and highlighted its contribution to the accurate expression of risk diagnoses (Basit & Korkmaz, 2021).
It was seen in the study that the students’ skills in identifying nursing diagnoses and associated factors were not at the expected level. According to the literature (Garcia et al., 2018), the fact that students are distant from the instructors may affect achievement negatively. Inability to receive help or ineffective seeking for help could adversely affect learning (Chowdhury & Halder, 2019). Therefore, instructors should assess when their students need help, what type of help is needed, and how they ask for help and should encourage them to ask for help. These are also included among the new roles of educators in distance education (Park et al., 2022).
Limitations
The results are limited only to the sample of the study and cannot be generalized. Although the current NANDA-I diagnosis book was available in the literature at the time the study was conducted, the NANDA- I taxonomy book (Herdman & Kamitsuru, 2014) was used as all the participating students had it as a resource.
CONCLUSION
During the pandemic, which was experienced as a period of extraordinary conditions, online delivery of the nursing processes course remained insufficient in teaching diagnosis skills to students, which also negatively affected student satisfaction. In this respect, the limitations and disadvantages of the case-based online nursing processes course should be looked into and improved to be more productive for students in the future.
Moreover, it is recommended that experimental studies be conducted on the issue to contribute evidence-based information to the literature. It is also believed that nursing education should be made up-to-date, evidence-based, student-centered, and accessible by everyone with the advanced technology in the future.
AUTHOR CONTRIBUTIONS
All of the authors contributed to the design of the work, drafting the work, and revising it critically for important intellectual content, final approval of the version to be published, and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy.
CONFLICTS OF INTEREST STATEMENT
No conflict of interest has been declared by the authors.
FUNDING INFORMATION
No external or intramural funding was received.
ETHICS STATEMENT
Ethical permissions were obtained for the study.
