Evaluating the Relationship between Nurses’ Problem-Solving Skills and Automatic Thoughts

Aim: This study aimed to evaluate the relationship between nurses’ problem-solving skills and automatic thoughts. Methods: This study was conducted as descriptive, cross-sectional, and correlational study between August and December 2016. The sample of the study comprised 112 nurses working at a training and research hospital. The Problem Solving Inventory, the Automatic Thoughts Questionnaire, and a sociodemographic form prepared by the researchers were used to gather the data. The data were analyzed using Statistical Package for Social Science (SPSS) 20.0. Results: It was found that problem-solving, approach-avoidance, and personal control skills of nurse managers were higher than those of clinical nurses (p<.05). The nurses who thought that nursing was not an appropriate profession for themselves and said that they were not satisfied with their profession had higher levels of automatic thought (p<.01). There was a positive and significant low correlation between the scores obtained by the nurses from the Problem Solving Inventory and Automatic Thoughts Questionnaire (rs=0.259, p<.01). Conclusion: This study showed that nurses’ problem-solving skills were affected by working in the position of manager and by automatic thoughts about their profession. It is thought that practices to increase nurses’ problem-solving skills and to reduce their automatic thoughts about their professions will be beneficial.


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Evaluating the Relationship between Nurses' Problem-Solving Skills and Automatic Thoughts roblem solving is a complex process that includes a series of cognitive, emotional and behavioral activities and is used for solving the problems that may be encountered throughout life. Nurses face a large number of work-related problems during the day and need problem solving skills to make decisions about nursing interventions. (1,2) It is necessary to improve nurses' problem solving skills in order to provide an efficient nurse care and preserve nurses' mental health, which is closely associated with problem solving skills. (3,4) A previous study revealed that problem solving skills of clinical and nurse managers were at medium and high levels. (5)(6)(7)(8) Nurses are involved in every stage of patient care and they are expected to deal with various crises within the scope of problem solving process. Some other studies have revealed that problem solving skills are effective for nurses in coping with negative emotions and thoughts, finding healthy solutions and enhancing the quality of care. (5,6,9) Automatic thoughts stem from the beliefs of people about themselves, such as the ones that are of interest to rationalemotive behavior therapy and other cognitive-behavioral therapies. (10) Automatic thoughts are almost always stated as negative automatic thoughts. (11,12) It is indicated that automatic thoughts, which are shaped by a person's negative perceptions towards themselves, future and the world, are the most significant factors that reveal despair and anxiety. (13) Automatic thoughts do not follow a certain logical order in goal-oriented approach or problem solving. (14) Every individual can experience automatic thoughts. (15) It is stated that individuals with automatic thoughts experience difficulty in developing alternative solutions to problems (16) However, clinical settings need creative and professional nurses who are capable of effectively solving great patient problems. (17) In this respect, it is thought that investigating the relationship between problem solving skills and automatic thoughts of nurses will provide helpful insights to nurse managers and educators on how to support nurses and nurse students.
In literature, there are a high number of studies (18)(19)(20)(21)(22) that evaluate problem solving skills of nursing students; however, there are only a few ones evaluating clinical nurses in this regard. (6,7) Besides, there is no study examining both the problem solving skills and automatic thoughts of clinical nurses. With regard to this information, determining problem solving skills and automatic thoughts of nurses and establishing the relationship between these variables would help nurses to provide a qualified patient care in clinics and to preserve their psychosocial health by presenting solutions.

Aim
The aim of this study is to examine problem solving skills and automatic thoughts of nurses.
For this purpose, we sought answers for the following research questions: • What are the levels of problem solving skills and automatic thoughts in clinical nurses?
• Which personal and occupational factors affect problem solving skills and automatic thoughts in clinical nurses?
• Is there a relationship between problem solving skills and automatic thoughts in clinical nurses?

Methods Design
A descriptive, cross-sectional, and correlational design was used in this study.

Sample and Setting
This study was conducted with nurses working at a training and research hospital serving as part of a university between August and December 2016. Population of the study included 311 nurses working at this hospital. In this study, sampling method was not used. The sample group consisted of nurses from every clinic who provided voluntary consent to participate in the study. Additional sample determination was not carried out. As a result, the sample of the study consisted of 112 nurses.

Data Collection
The data of the study was collected using three tools; the sociodemographic form prepared by the researchers upon the literature review, (18,19,23,24) The Problem Solving Inventory (PSI), and The Automatic Thoughts Questionnaire (ATQ). The data collection forms were delivered collectively to the units where the nurses were working. The nurses filled out the forms at any time suitable for them independently of the researcher. The researchers daily followed up the forms completed by the nurses and then gathered them. The data collection process lasted for averagely 10 minutes for each participant.
Sociodemographic Form: This form includes 15 questions regarding demographic characteristics like "age, gender, educational level, marital status" and occupational characteristics like "clinic worked, working hours as a nurse, type of working, position at the clinic, working status (permanent or contracted), willingness on choosing the profession, thinking whether or not this profession is suitable for themselves, income status and existence of a chronic disease".
Problem Solving Inventory (PSI): Developed by Heppner and Petersen (25) (1982), the PSI was used for measuring problem solving skills.The PSI aims to evaluate people's thoughts about problem solving behaviors and approaches and how they evaluate themselves about their problem solving skills. Adapted into Turkish by Sahin and Heppner (26) (26,27) In this study, Cronbach's alpha internal consistency coefficient for total scale score was .84.

Automatic Thoughts Questionnaire (ATQ): Automatic
Thoughts Questionnaire aims to measure the frequency of a person's negative evaluations about themselves. Being developed by Hollon and Kendall (21) (1980), ATQ is a likert scale with 30 items which are scored between 1 and 5. Score interval of the scale is between 30-150. Total score obtained from the scale shows that automatic thinking occurs frequently in the individual. In the reliability studies conducted in Turkey, Cronbach's alpha internal consistency coefficient was found as .93 in the study by Sahin and Sahin (29) (1992) and 0.95 in the study by Aydın and Aydın (28) (1990). In this study, Cronbach's alpha internal consistency coefficient obtained from a sample including 112 nurses was found as .93.

Ethical Considerations
A written consent from Amasya University General Secretary of Public Hospital Union and an ethics committee approval from Amasya University Health Sciences Ethics Committee were obtained (Consent number: 30640013-044). The participants were informed about the content of the study and the nurses willing to participate were included in the study.

Statistical Analysis
The data of the study were evaluated using Statistical Package for the Social Sciences (SPSS) 20 (IBM Corporation, New York). Compatibility of the data to normal distribution was measured by using Shapiro Wilk and Kolmogorov Smirnov tests. The results revealed that the data were not normally distributed (p<.05). Descriptive statistical tests, median, minimummaximum (min-max) points, Mann Whitney U test, Kruskal-Wallis analysis of variance, Spearman correlation analysis, and Cronbach's alpha were used for the analysis of the data. Statistical significance was accepted as p<.05. Table 1 shows the nurses' median and min-max scores of PSI, PSI subscale, and ATQ. It was found that total median and minmax score obtained by the nurses from the PSI was 86 (Min 47-Max 120) and their total median and min-max score of the ATQ was 47 (min 30-max 108). With reference to median and min-max score of the PSI subscale, it was detected that median and min-max score of CPSS was 24 (min 11-max 46), median and min-max score of AA was 44 (min 22-max 73). Median and min-max score of PC was 19 (min 11-max 31).   When the nurses were evaluated according to their duties in the service (clinical nurse or nurse manager), this evaluation revealed that there was a significant difference between their PSI, AA, and PC median scores (p<.05). It was also determined that the nurse managers had higher problem solving skills than clinical nurses and they felt AA and PC against problems. Additionally, there was no significant difference in ATQ in terms of being a clinical nurse or nurse manager.

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Evaluating the Relationship between Nurses' Problem-Solving Skills and Automatic Thoughts profession. It was found that 54.5% of the nurses were partially satisfied with their working conditions, 70.5% had chosen the profession voluntarily, and 50.0% regarded the nursing profession as a suitable profession for themselves. No significant difference was found between the status of expressing satisfaction with the nursing profession and PSI and its subscales (p>.05).
A significant difference was found between the ATQ median scores of nurses and the status of saying that they were satisfied with their professions (p<.05). The ATQ scores of the nurses saying that they were satisfied with their professions were higher. Additionally, it was also determined that nurses thinking that nursing profession is not suitable for themselves had significantly higher ATQ median scores than those who thought the profession is suitable or partially suitable for themselves (p<.01). No significant difference was found between PSI median scores of the nurses thinking that nursing profession is suitable for themselves (p>.05).
The relationship between PSI, ATQ, and their subscale scores of the nurses were analyzed by using Pearson Correlation Coefficient as shown in Table 5. A low-level positive correlation was found between PSI and ATQ scores of the nurses (rs=0.259, p<.01).

Discussion
PSI and ATQ levels of the nurses and the relationship between them were investigated in this study. Problem solving ability is a very important factor in professional nursing practice. In this study, it was determined, that problem solving skills and automatic thoughts were not affected by the nurses' age, gender, marital status, educational levels, and opinions about the profession. Similar to the results of this study, the study by Basar et al., (30) revealed no correlation between marital status, gender, educational status, working unit and problem solving ability. These results suggested that personality traits of individuals, upbringing, and life experiences may be more determinative for problem solving skills.
Professional nursing role is based on communication and decision making for both nurse managers and clinical nurses. Problem situations are an important part of the practice of administrative nurse managers and clinical nurses. (31) Being more skilled on problem solving is attributed to nurse managers. However, as clinical nurses and nurse managers may replace each other according to functioning of the clinic, problem solving skills are among the skills clinical nurses should also

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Evaluating the Relationship between Nurses' Problem-Solving Skills and Automatic Thoughts have. (22) Additionally, this study indicated that nurse managers had higher problem solving skills than clinical nurses when the nurses were evaluated according to their duties during the service. In contrast to the results of this study, Basar et al., (30) did not find any significant difference between problem solving skills of nurse managers and clinical nurses. In another study, there was no significant differences in problem solving skills of the nurse managers, and also it was stated that the nurses who did not have management responsibilities trusted to their problem solving skills more and defined themselves as people willing to handle problems. (8) The related studies have shown the opposite by suggesting that nurses with management responsibilities have lower problem solving skills. (7) However, another study revealed that clinical nurse managers had better problem solving skills. (5) There are contradictory results on this matter; however, it is thought that being a nurse manager after a long term of employment as a nurse can be related to nurse managers' better problem solving skills since higher education and a certain level of professional experience are required for management positions.
In the PSI subscales, it was found that there was a difference between the AA and PC levels of clinical nurses and nurse managers, but there was no difference between their CPSS. The fact that there was no significant difference in CPSS subscale in the study suggested that the beliefs of clinical nurses and nurse managers towards problem solving were similar. PC subscale represents a case of providing alternative solutions to a problem encountered and maintaining personal control in problematic situations. (27) A significant difference was also found in this study in favor of the nurse manager in AA and PC subscales. This result may be due to the fact that nurse managers were more likely to encounter problems, to produce alternative solutions to problems, and to provide high levels of personal control in problematic situations. Nurses must possess a positive self-image and professional identity in order to provide optimal professional care for patients. (31) When ATQ scores of the nurses were evaluated, it was found that the nurses who said they were not satisfied with their professions had higher ATQ scores. In the literature, it is reported that automatic thoughts in nurses are based on the stress related to their professions. (32) According to the results obtained in this study, it is understood that there is a relationship between emergence of automatic thoughts and nurses' being not satisfied with their professions and finding the profession not suitable for themselves. Recognizing stressful situations that cause arousal of automatic thoughts and replacing them with realistic thoughts are necessary to empower the individual in the face of problems. (33) It is thought that automatic thoughts will decrease as the nurses acquire positive thoughts about their professions.
There was a low positive significant correlation between PSI and ATQ mean scores. This result might be interpreted as PSI decreasing with increased automatic thoughts. This correlation was also detected in other similar studies with different samples. (34,35) In another related study, it was found that automatic thoughts were hindering the development of problem solving skills. (35) Reduction of automatic thoughts in terms of professional development of nursing is thought to have a positive effect on problem solving skills of nurses.

Conclusion
Nurses' problem solving skills and automatic thoughts were examined and the relationship between them was determined in this study. According to the study results, nurse managers are more likely to have problem solving skills, to provide alternative solutions to a problem encountered, and to maintain personal control in problematic situations. Automatic thoughts were lower in nurses who said that they were satisfied with their profession and that the nursing profession is appropriate for themselves. In addition, problem solving skills of the nurses were adversely affected by automatic thoughts.
This study was a single-center study. In order to increase the power of the results to represent the study population, larger sampled and multicentered studies should be conducted. Studies for understanding and specifying the factors that cause nurses to be not satisfied with their professions and to feel not suitable for their profession can provide valuable information.
In addition, it is recommended to make meetings that provide nurse managers to share their experiences and knowledge on effective problem solving skills with clinical nurses.

The Limitations of the Study
This study has several limitations. In this study, the rate of the nurses in target group was 36%, which was low. The power of the data to represent all the nurses in the hospital seems limited. Also, the total number of patients in the busy hospital where data were collected may affect the result of the present study and may be different from other hospitals which is less busy or has less number of patients. So, the results of the present study may not reflect the PSI and ATQ levels of nurses working in other hospitals accepting fewer patients.