Nursing students ’ experiences regarding nursing process : a qualitative study

Introduction A major purpose in medical sciences training, in addition to growth of competency and professional capabilities, is to develop decision-making skills, problem solving and self-efficacy.1 The courses in the nursing field include two parts: theoretical training and practical training (in order to obtain clinical skills). In fact, the final purpose of this course is nothing but fostering the ability to provide basic care and properly implement the nursing process.2 The nursing process is systematically solving problems for nursing care.3 This model helps clinical decision-making through assessing patients’ needs4 and is applicable in all care systems.5 This organized method concentrates on existing and potential problems.6 In the nursing method, students make clinical decisions through systematic investigation.4 Therefore, the nursing process is a framework for planning and implementing care for patients and families.7 Following routine patterns will reduce self-esteem and self-confidence in patients’ care, and this will decrease motivation.8 According to the results obtained from studies on the nursing process, it is considered the most effective method for planning and care.9 There are different opinions about the advantages and disadvantages of the nursing process. Some consider it a limitation to critical thinking and others believe that it increases the ability for clinical decision-making.10,11 Since studies have revealed that the nursing process has potential problems and considering that our knowledge is limited in this regard, and because our care culture and social situation is different and qualitative studies are helpful for clarifying these differences, the researchers decided to utilize qualitative research for this study. Nowadays, the nursing process is widely used in training students in offering care services. But the researchers’ experiences in clinical teaching shows that the students are faced with numerous challenges in application of the nursing process. Since the qualitative research is able to investigate the phenomenon of study deeply, the researcher decided to do qualitative research with the purpose of nursing students’ experiences of the nursing process.


Introduction
A major purpose in medical sciences training, in addition to growth of competency and professional capabilities, is to develop decision-making skills, problem solving and self-efficacy. 1 The courses in the nursing field include two parts: theoretical training and practical training (in order to obtain clinical skills).In fact, the final purpose of this course is nothing but fostering the ability to provide basic care and properly implement the nursing process. 2 The nursing process is systematically solving problems for nursing care. 3This model helps clinical decision-making through assessing patients' needs 4 and is applicable in all care systems. 5This organized method concentrates on existing and potential problems. 6n the nursing method, students make clinical decisions through systematic investigation. 4Therefore, the nursing process is a framework for planning and implementing care for patients and families. 7Following routine patterns will reduce self-esteem and self-confidence in patients' care, and this will decrease motivation. 8According to the results obtained from studies on the nursing process, it is considered the most effective method for planning and care. 9There are different opinions about the advantages and disadvantages of the nursing process.Some consider it a limitation to critical thinking and others believe that it increases the ability for clinical decision-making. 10,11Since studies have revealed that the nursing process has potential problems and considering that our knowledge is limited in this regard, and because our care culture and social situation is different and qualitative studies are helpful for clarifying these differences, the researchers decided to utilize qualitative research for this study.Nowadays, the nursing process is widely used in training students in offering care services.But the researchers' experiences in clinical teaching shows that the students are faced with numerous challenges in application of the nursing process.Since the qualitative research is able to investigate the phenomenon of study deeply, the researcher decided to do qualitative research with the purpose of nursing students' experiences of the nursing process.

Materials and Methods
This qualitative study was done through the contractual content analysis method.Qualitative content analysis is usually used for studies that are designed for describing a phenomenon.It is appropriate when theories or existing articles about a phenomenon are limited. 12he participants included 9 nursing students studying in their sixth semester.The content analysis in this study was inductive.This process included open coding, classification and abstraction. 13In this study, the participants were interviewed after obtaining a consent letter.Individual interviews were done in the hospital.The participants were informed about the researcher's goals and reasons for doing the research.Participants were approached face-toface.Nobody refused to participate in the research.Each interview lasted 35 minutes.The interview started with the open question of "please tell your experiences with the nursing process, " and it continued with probing questions.Sampling and data collection continued until saturation was which occurred after 9 interviews.Having listened to the tape several times, the researcher deeply investigated the data to find a general point of view toward interviews.All interviews were duplicated word by word.Words that were key concepts were made bold.Thus, key concepts and codes were extracted from important paragraphs and and they were classified based on their similarities and differences.Finally, the categories were combined based on their relationship to major categories. 11Sampling, data collection and interviews continued until the researcher found out that saturation had occurred.Saturation means that the participants have not proposed any new issue and the information is repetitive.Interviews and data analysis were done simultaneously.In the present study, the researcher studied the data in depth after listening to the tapes in order to find general perception about interviews.All interviews were copied word by word in order to bold the words carrying the main concepts, and in this manner the codes were extracted.The concepts and codes were grouped based on their similarities and differences, and, finally, the subcategories were merged according to their relationship and decreased in number.The following measures were taken in order to increase data validity.The researcher had long visits and interviews with participants and she constantly read the interviews to obtain accurate and stable data.In order to revise peers' comments, the colleagues' complementary suggestions and comments for confirming and correcting codes and extracted categories were used.In order to revise participants' information, some interviews were reviewed in order to evaluate the consensus on codes among researchers and participants.

Results
The participants ranged from 21-23 years old and included 5 female students and 4 male students.Two data coders coded the data based on categories identified in advance.The Microsoft OneNote software was used to manage the data.Participants provided feedback on the findings.Based on data analysis obtained with students' experiences, 3 categories were specified (Table 1) decrease of performance, decreased critical thinking and students' dissatisfaction.These categories were divided into subcategories.The decrease of performance category was divided into the following three subcategories: decrease of a sense of dependence, decrease of motivation and decrease of performance.The decreased critical thinking category was divided into the three subcategories of routineness, decrease of creativity and copying, and the students' dissatisfaction categories was divided into the two subcategories of similarity of weak and strong students and ambiguity of nursing measures assessment.Decrease of performance was based on data analysis, and the three subcategories of decrease of a sense of dependence, decrease of motivation and decrease of performance were determined.Regarding this a student said: "The nursing process has turned into a kind of red tape, we just write something on papers to get rid of our assigned tasks and we give them to professors.We have no dependence and it's very rigid, the professor corrects them and gives them back, at last we don't find out why we have written them…" (Third male student).Another student stated: "The nursing process has turned into a habit; we have practiced it since the beginning of training until now that we are in our third semester.It's tiring and men are less interested in doing it and we have no motivation for that, what's the use of it?"(First male student).One of the students said: "The nursing process has decreased our performance and we don't like it; our professors emphasize it too much, and half of our training is spent on it, which is only on paper…" (Fifth female student).

Decreased critical thinking
Based on data analysis, the decreased critical thinking subcategories including routineness, decrease of creativity and copying were specified.Regarding this a student said: "The nursing process is a routine task that our professors ask us to do it when we enter a ward." Another student said: "Whenever we are told to do the nursing process, we copy from other students to get a We don't work with the patient.It's not practical" (Second female student).One of the students said: "We copy from Brunner's book and we don't practically use it.It's just because our professor emphasizes it.It is a routine task for us" (Forth female student).

Students' dissatisfaction
Based on data analysis, the categories of students' dissatisfaction were specified in the two subcategories of similarity of weak and strong students and ambiguity of nursing measures assessment.As one student said: "We all use a book or we copy from others' papers in the dormitory.Finally, the professor gives the same mark to everyone with just minor differences" (Forth male student).Another student stated: "In addition to the routineness of the process, there is no innovation.We study the book and copy the nursing process.Finally, our mark is the same as others.The professor gives the papers back, but we practically don't use the process" (Second female student).One of the students stated: "The assessment of most of the nursing measures that we write in process is on papers, and this is difficult for us to write the required assessment for problems without knowing the results" (Fifth female students).Another student stated: "I don't know whether we correctly use the process or not, whether the process has been defined clearly for us or not.The process is boring and everyone complains about it" (Third male student).

Discussion
Based on data analysis obtained from students' experiences, the major categories of decrease of performance, decreased critical thinking and students' dissatisfaction were specified.Most students stated that using the nursing process decreases the sense of dependence due to monotony, and this in turn causes routineness and finally results in a decrease of motivation and performance in nursing students.According to the results of our study, for students the nursing process involves bureaucracy and copying from books.In confirmation of our findings, Hicks-Moore stated that the cliché framework of the nursing process prevented students from critical thinking and led them toward copying from references. 14ost students stated that the nursing process is just copying to get rid of the assigned tasks and this routineness decreases their creativity and innovation.Ebadi and colleagues stated that the skill of critical thinking is the basis of correct decisions, which decreases expenses and increases quality of care. 15Also, findings of Sarhangi and colleagues showed that in educating nursing students, methods should be employed that give rise to significant and deep learning. 16ccording to our results, students are not satisfied with the present method because nursing measures are not assessed clearly.According to the findings of Aein and Frouzandeh, nursing students are dissatisfied with implementing the nursing process. 17Findings of Habibzadeh et al indicated that nursing education based on evidence will promote the required skills for the nursing process because it encourages creativity. 18It should also be noted that the present study represents that the nursing process will not increase critical thinking and creativity in itself.Takahashi and colleagues stated that lack of knowledge is one of the obstacles for not implementing the nursing process.They also emphasized that practical and theoretical education during bachelor's level will help in implementation of the nursing process. 19However, Akbari and Shamsi stated that authorities in the Ministry of Health should provide nurses with required trainings for the nursing process. 20We should acknowledge that the current complex care system is not meeting nurses and students' needs and it is necessary to use alternate methods in nursing care and education.

Conclusion
According to the results of our study, the nursing process in students involves bureaucracy and copying from books.The results of our study revealed that using the nursing process will decrease critical thinking, decrease creativity and increase students' dissatisfaction.Since delivering high-quality care requires significant and deep learning, therefore, obtaining critical thinking skills requires applying new methods in nursing education.Our data provides a rich, detailed picture about nursing students' feelings and experiences with the nursing process.Of course, because few participants were studied it is not possible to generalize our results to the population.Considering this matter, it is necessary for nursing professors to use alternate methods that increase critical thinking in nursing education; however, further studies are required to address this issue

Ethical approval
It should be mentioned that the present study is confidential, names of participants are not mentioned and moral considerations have been observed.