Problem-Based Learning in Situ Applied to Students in the Assessment of Nursing Process

Background: Nursing is considered a science in the making that recognizes the nursing process (NP) as the scientific and methodological tool to provide care. The NP is composed of five stages of which the assessment is the first and fundamental to identify the health problems of the people. This research aimed to evaluate a pedagogical didactic strategy that is based on situated constructivism, the Based-Problem Learning (BPL), in order to improve significant learning. Methods: Quantitative research with an explanatory scope, was transversal, and it was applied to 30 students of the first year of the nursing career at the Faculty of Higher Studies Iztacala, National Autonomous University of Mexico. The sample was chosen considering the inclusion criteria. Data were collected using a Likert-type instrument validated in a previous investigation. Results: The average value


Introduction
Nursing process (NP) is an own method of nurse professionals, that explains and describes how to apply the scientific method to healthcare practice. By using this method nurse professionals provide rational, dynamic, and conscious decisions care, also logics to solve problems, priorities definition, and decisions taken to get better ways for health care. The NP originated from the theoretical basis proposed by Florence Nigthingale in the XIX century, it integrates nursing knowledge with epistemological elements such as person, surroundings, health and care, nursing philosophies, models and theories and empirical indicators used in the different steps of nursing process [1]- [7].
Due to its importance and significance NP has been studied from different views, like its teaching and application is a complex process to apply in clinical scenarios [8] [9] [10] [11] [12], where diverse situations occur that impair NP's objectives. Then nursing educational institutions search for the best teaching method [6] [7] [11] [13] [14]; however, no specific teaching method for NP assessment has been studied, even though it is a cornerstone of the process [1] [2] [3] [4] [5].
It was considered that in the teaching-learning process of assessing the main figure is the student, and the teacher acts as a facilitator [12] [15], and it was based on psychological, pedagogical, and philosophical theories of Vygotsky, Díaz Barriga and Sartre, respectively.
It is unquestionably that nurse professionals rely on Vygotsky's theories, they are trained into a social surrounding and share among peers, and guided by other professionals involved in significant activities who apply concepts like zone of proximal development (ZPD) to learn, such as student and teacher situation in a joint action toward defined goals, where the teacher acts a resource available to the student that helps to reach better learning than that self-acquired [16] [17] [18].
Vygotsky's theory focuses on social interaction that surrounds the individual, which leads to knowledge and essential skills for success in a particular culture.
It does not consider the person as an independent explorer making decisive discoveries on his own, but instead sees the person in cognitive development as an activity mediated by society. ZPD is the process in which an expert, when instructing a novice in a situation of learning, responds in a contingent way to the behavior of the latter, so that little by little you know the problem better, with freedom of learning based on the next zone of development [16] [17]. Renkl [22]. The aim of the study was to evaluate a didactic-pedagogic strategy supported in a situated constructivism principle, i.e., an in situ learning method, BPL that will contribute to improving significant learning during the assessment of NP, for a better quality in nursing students learning at FESI-UNAM.

Methods
An exploratory study was conducted to approach reality and obtain information, recognize, locate and define problems that allow refine the method [23]. Quantitative research with an explanatory and transversal scope. Explanatory research accounts reality or its comprehension through scientific theories, elucidate which factor facts-associated determine the observed response, and the accuracy of dependent and independent variables relationships [23]. The current study explained how significant learning occurred in the assessment of nursing step applying the situated teaching, PBL. The study was transversal with one measurement to seek students' learning, and the significant learning progress in estimating NP. The epistemological frame for this study was revised from general and specific aspects, considering the axiological aspect as important and relevant for

Inclusion Criteria
First year nursing students from Facultad de Estudios Superiores Iztacala, Universidad Nacional Autónoma de México. The educational strategy was carried out in first-year students, aiming for an impact on their learning, and it is in this period that they first meet the nursing assessment, and that it would be reinforced throughout the professional training.

Universe Sample
From a universe of 300 nursing students of a public university, a simple of 30 subjects that met inclusion criteria were invited to participate. The sample included 26 women and 4 men.

Information Gathering
A questionnaire of 27 items was the instrument used to evaluate the strategy, with a Likert type scale (Strongly disagree, Disagree, Neither agree nor disagree, Agree, Strongly agree), based in the in situ method Problem-Based Learning PBL, as support and improvement of thinking abilities [18] [25], considering the following items (Table 1): Professor as development zone agent (ZPD) (9 items); Student's performance (7 items); Course organization (11 items).

Procedure
In situ method PBL for teaching and learning during assessment of NP consisted in the following: students were in direct contact with assigned persons, doing physical exploration of human body systems, which is part of the assessment of NP. The strategy was conducted in the classroom, in nurse's laboratory and in the hospital, having the instruments and materials for each session. The process lasted 80 hours along 8 weeks; in the first week the theoretical support of the  [9]. In the fifth week the physical exploration of nervous, tegumentary, musculoskeletal, and cardiovascular systems; during the sixth week the physical exploration of respiratory, digestive, genitourinary, and urinary systems were evaluated. In the seventh week the physical exploration of an external person, and in the eighth week the physical exploration of a person in the hospital were done. The instrument was applied at the end of programming.

Data Analysis
Analysis and processing of the study data were done with the statistical package SPSS, version 20. Results of the instrument evaluating teacher's intervention as a ZPD, student's performance and course organization, considered the highest score as 135 and the lowest score as 27 (Table 2).

Ethics and Legal Aspects
Ethics and legal aspects were based on the principles of the Declaration of Helsinki, point 6 "The right to safeguard the integrity of persons must always be respected. All needed precautions must be adopted to respect intimacy of persons, reduce to a minimum the impact of the study on their physical, mental and personality". An informed consent letter was signed by each informer according to the Nüremberg code and local law [25] [26] [27].

Results
The educational strategy was carried out in several sessions, which required continuous monitoring and counseling by the researcher to maintain control of the implementation, to do that a limited number of participants were chosen. On the other hand, the exploratory research reflected that the rest of the teachers did not know the method in situ, which prevented the implementation of the strategy on their part. The sociodemographic characteristics of the participants are presented in (Table 3).
The Likert's scale obtained average for intervention was 103.4, being 135 the highest value and 83 the lowest value, meaning that it was evaluated as good and  very good. The grade given to the teacher as a ZPD agent was between agree and strongly agree, the highest scored 93% since it provoked challenge in their thinking and favored interaction between classmates ( Figure 1, Table 4).

Discussion
There are a number of definitions for the nursing process; however, in the current study Acosta-Salazar's et al. definition was used [28], in which NP is a "systematic and organized method to manage integral and progressive nursing care, centered in identification and treating the responses to health needs" [28].
Nursing process observed the scientific method steps, which supports the theoretical structure that led to knowledge and acted as a professional guidance. It is a model that underlies the professional nursing care, to engage the scientific knowledge and research, the professional work and it must be present at the beginning of the nursing professional training, accompanied by teachers along the program to reach the objectives, which coincided with the highest score for teachers as agents of ZDP, since they promoted a challenge in students' thinking and favored their interaction. This showed the importance of teachers encouraging innovative pedagogic strategies in the teaching-learning process, to search for significant learning such as PBL. According to Ku   26.-Learning the assessment stage allowed me to give importance to the nursing process as a nurse 10% 90% 27.-The transition between steps of the process was logical and natural 33% 67% Source: data obtained after applying the Likert scale to a nurse group in FESI-UNAM. Figure 1. Total score to evaluate the intervention. Source: data obtained after applying the Likert scale to a nurse group in FESI-UNAM.
the method of in situ learning PBL applied in the strategy showed that 97% and 93% agreed or strongly agreed, translated to the efficacy of the method to support significant learning during NP assessment.
According to Andrade Cepeda NP features highlight that it is an open and flexible method, since it satisfied individual needs, family needs and community needs, it is a cyclic and dynamic process because each step is interrelated, it is centered in the user and satisfies particular needs. It does have a concrete and programmed purpose, and it is interactive so that assumes a relationship between nurse and cared person [5]. By seeking the purpose to give individualized and specific care with a theoretical support, it is used as a basic structure to attend any given health situation along the life of the person; which agrees with the finding that 80% students mentioned that PBL led them to think about their professional acting as nurses and 77% referred that work dynamics generated the need to use analytic and reflexive thinking, supported in significant learning.
Hung and Lin determined that PBL had a strong effect in knowledge acquisition and integration in a quasi-experimental study, and it potentiated motivation and significant learning in nursing students [30]. Among the goals of NP it is highlighted that it stimulated observation ability, professional growth, abilities development, active interaction between nurse and patient. It prevented omissions and repetitions, and promoted a better professional communication, which is coincident with the finding of 73% students mentioned that NP assessment allowed to identify problems and health needs of persons. According to Carpenito there is a growing interest in the diagnostic phase of NP, since nursing care efficacy depended of the ability to identify patient's diagnostics or potential problems; at the same time, the efficacy in identifying problems, intellectual abilities like critical and creative thinking, problem solving and decisions taken, depended of the full evaluation and interpretation of the obtained data in this step [31] [32].
The proposal seeks integration of to know, to do, and to act in nursing students in the assessment of nursing process step, to contribute for significant learning in students [33].
The results obtained in the research may suggest the use of the PBL method to improve the learning of nursing assessment; however, it is necessary to continue doing research in this regard, given the disciplinary importance of the subject in the professional life of the nurse.

Conclusions
Applying the in situ teaching strategy PBL favored significant learning during the assessment step, since students significantly assessed human body systems with a hospitalized patient; the experience contributed to significant learning because students face real scenarios, based on Vygotsky's, Díaz-Barriga's and Sartre's theories.

Limitations of the Study
Teachers did not know the situated teaching in situ PBL method.