Optimal utilization of knowledge enables students to effectively assess patients. Therefore, recognizing the relationship between student knowledge and assessment skills is important when discussing instructional tools that augment assessment skills. However, studies of assessment skills in relation to knowledge are scant despite abundant research on assessment education. Standardized patients or the Objective Structured Clinical Examination are used for assessment education in the USA and Japan [4] [5] . These instructional tools focus on student behavior and ways of thinking. Whether a sufficient number of studies have investigated knowledge used for assessment is difficult to demonstrate.

Yula, H. and Walsh, M.B. [6] state that using the nursing process will facilitate the application of vast amounts of knowledge to clinical situations in an organized form.

When students learn about the logical thinking of the nursing process, they should apparently have a wide knowledge of nursing, and acquire a method to apply such knowledge.

Many cognitive psychology research findings related to problem-solving processes have been reported. Working memory is effective in assessment education [7] . In addition, the Learning Theory underlies the notion that how nursing students learn affects the Conceptual Frame [8] . Therefore, we focused on cognitive psychology to devise an educational learning method associated with assessment.

Cognitive psychologies recognize that a concept held by a person can be represented as a node in a network with the properties of the concept represented as labeled relational links from that node to other concept nodes [9] . When one concept is activated in a problem-solving situation, activation spreads to other nodes linked in the network and this promotes the use of knowledge for problem-solving. Chi, M.T., Feltovich, P.J. and Glaser, R. compared networks of concepts and the knowledge of physics experts and novices [10] . They viewed the network of the experts as representing internal schemata, with category names as access labels for the appropriate schemata. The schemata of the experts contained a great deal of procedural knowledge, with explicit conditions for applicability. Novice schemata can be characterized as containing sufficient declarative knowledge but lacking abstract solution methods [10] .

The representation of knowledge not only improves the applicability of knowledge to problem-solving but also relates to the process of acquiring new knowledge [11] . Baddeley, A.D. viewed the process of acquiring new knowledge as a working memory model and proposed the cognitive processing system, “working memory” that facilitates the retention of new concepts in long-term memory [12] . Cognitive processing in working memory is assumed to be associations of new and extant concepts or knowledge in long-term memory, while referring to long-term memory when a new concept is introduced [11] . The structure and application of knowledge are supposedly augmented by conscious memorization, namely, the storage of new information while remaining conscious of the scene in which the information will be applied. In terms of nursing, the following can be considered. Learning new knowledge while remaining conscious of how to apply it to assessments in a clinical scene augments knowledge structure and application in the clinical scene.

Ichikawa, S. suggested “cognitive counseling” as a practical technique for linking cognitive theory and education [13] . A cognitive counselor is an individual learning consultant who handles problems and/or concerns with learning and instructs individuals in learning strategies with which to solve their own problems. Cognitive counseling comprises diagnostic guidance to identify learning-associated problems and gives instruction that includes graphical and figurative explanations, virtual teaching and instructive induction. The suggested merit of using a graphic is that it can clearly convey a concept and the structure of the content to be handled. Cognitive counseling focuses on “supporting independence” so that individuals can acquire skills to actively learn.

From the above, we considered acquiring medical knowledge in association with a clinical scene and graphically augmented structural knowledge with explicit conditions for applicability. Therefore, we attempted to teach a learning strategy using “concept maps”. Furthermore, intervention was aimed at teaching students to understand learning strategies and actively apply them.

The survey and instructional intervention consisted of pre-tests, individual instructional interventions, self-study by participants, and post-tests. The study proceeded between February and April 2015.

The purpose and ethical considerations of the present study were described to 78 second-year undergraduate nursing students. Among them, 55 provided written, informed consent to participate voluntarily in this study, which started before a clinical practicum that included a clinical assessment.

Participants performed two tasks based on information derived from actual diabetic patients because they had already learned about diabetes in their student curriculum. Furthermore, many opportunities for a clinical scene are likely to arise because of the high prevalence of diabetes.

Nineteen and 36 participants were randomly assigned to receive instruction (intervention group) or not (non-intervention group).

The students were directed to study the pathophysiology, diagnosis, treatment, diet therapy and nursing considerations regarding diabetes. The assignment was for one A3 size handout, but participants could add content and pages as needed. The period of self-study was the two months of spring break to eliminate the influence of other lectures. The intervention group was directed to apply self-study after receiving instructional intervention, and the other group was directed to do self-study using their current learning method.

The instructional intervention aimed to have participants learn the strategy to acquire knowledge associated with clinical scenes based on actual patients with lung cancer or liver cirrhosis. The intervention group created concept maps regarding the pathophysiology and nursing of diseases, and we taught a learning strategy to understand the relationships between concepts and the assumption of clinical assessment. Lung cancer and liver cirrhosis were selected because the symptoms are diverse and the status of the patient must be comprehensively captured based on knowledge. Nine and 10 students assessed patients with lung cancer and liver cirrhosis, respectively. Participants individually engaged in five 40- to 90-minute interventions. The procedure for educational intervention is described below.

Participants created concept maps and assessed an actual diabetic patient. The amount of time spent in self-learning and the learning strategies applied were investigated using free description.

This study was approved by the Ethics Committee at Hirosaki University (No. 2014-085).

The mean amounts of time that the intervention and non-intervention groups spent studying by themselves were 4.5 ± 2.8 vs. 2.7 ± 1.4 hours, respectively (minimum and maximum, 0.3 and 12.5 hours). The results of t-tests showed that the intervention group spent significantly more time studying by themselves than the non-intervention-group (p < 0.01). The results of χ² tests showed that 17 (89.5%) and 2 (10.5%) participants in the intervention group applied understanding and non-understanding types of self-learning strategies, respectively,

Categories as below. Information described in case description; Care information. Highly relevant information not described in case description. Nursing problems and factors.

whereas only 5 (18.5%) in the non-intervention group applied understanding-type strategies (p < 0.001). In the intervention group 15 (79.0%) students described concept maps, whereas no one in the non-intervention group described concept maps.

The results of analysis of variance in mean structural knowledge scores found no pre-test differences between the intervention and non-intervention groups, but the intervention group scored significantly higher in the post-test (p < 0.001) (Figure 1).

We evaluated assessment skills using the checklist, calculated average scores for each assessment category, then compared the mean pre- and post-test scores (Figure 2).

The results of the analysis of variance of the intervention/non-intervention × pre-test/post-test × assessment category revealed that these three categories tended to interact. Multiple comparisons using the Ryan method identified significant differences between intervention/non-intervention and pre/post regarding “nursing problems and factors”. Post-test scores for the intervention group were significantly higher than those in pre-tests (p < 0.001) and also significantly higher than post-test scores of the non-intervention group (p < 0.01).

On the other hand, pre- and post-test scores for assessing nursing problems and factors in the non-intervention group did not significantly differ (Figure 2). Pre-test scores for “patient information” were significantly higher for the non-intervention group (p < 0.05), but post-test scores did not significantly differ (Figure 2).

Understanding associations regarding diabetes appeared to increase in the intervention group based on the finding that structured knowledge increased only in this group in the post-test. Our educational intervention seemed to have influenced strategies to self-study diabetes, although the students had not yet finished learning about diabetes. We considered that learning medical knowledge in relation to a clinical scene encouraged structural knowledge, with explicit

conditions for applicability. Appropriate application of knowledge enabled the students to effectively assess patients. Also, such thinking takes place in working memory. Advanced skills are required to simultaneously process multiple pieces of new information, although the processing capacity of working memory varies among individuals. To process large amounts of information, problem-solving using diagrams reduces the amount of thinking effort required [15] . Ito T., et al. [16] indicated that one validity of a diagram in the thinking process of problem-solving is “Entirety”. That is, entire relationships among pieces of information are easier to grasp from a diagram. Furthermore, creating a diagram has more effect on thinking than simply thinking using an already prepared diagram because describing self-made diagrams not only promotes thinking by externally maintaining thought processes, but also renders the thinking process more objective, which in turn promotes further thinking [17] . Learning strategies described by a student based on self-made diagrams indicates that understanding the relationships among pieces of knowledge augments understanding of their relevance from the viewpoint of entirety.

This learning strategy has the feature of meaningful learning. Facts gained from rote learning may lack cohesiveness. However, putting information together in meaningful ways improves information retention and understanding [8] . The intervention group seemed to have learned the effect of meaningful learning during the educational intervention using meaningful learning strategies. The self-learning strategies for diabetes applied by the non-intervention group focused on gaining information by means such as “reading a textbook” or “searching the Internet”. However, the intervention group focused on understanding important information derived from data in concept maps that they created or summarizing important information in notes as well as connecting information with the actual status of the clinical patients. Therefore, knowledge of diabetes was considered to be structured because the relationships between pieces of information were understood.

Regulating and integrating a regimen into one’s daily life is important for chronic disease patients [18] . The presented patient could not self-manage a therapeutic dietary regimen because of low concern, whereas he self-managed a therapeutic medication regimen relatively well. Therefore, comprehensively considering the problem by seeing self-management ability and attitude regarding treatment not only from the aspect of dietary, but also medication therapy is important for this patient. The ability to identify the status of the patient and to identify nursing problems was significantly higher in the intervention group in the post-test, indicating that the educational intervention influenced the ability of the students to identify nursing problems. Participants in the intervention group apparently had better comprehension of the overall status of the patient by describing a concept map with the feature of Entirety. Therefore, the intervention group comprehensively identified the patient’s status not only from the aspect of inadequate diet therapy self-management, but also from the aspect of well-managed medication therapy. On the other hand, the non-intervention group seemed unable to identify a relationship between self-managed diet and medication therapy because their comprehension of the overall status of the patient was insufficient, even though they could determine that self-management of diet therapy was insufficient.

With respect to the ability to collect information, which is the first step in an assessment, both groups could identify cue information from the statements presented by the patient. Students were randomly assigned to either group, but patient information scores for the intervention group were significantly lower than those in the non-intervention group at pre-test. However, since there was no significant difference between the intervention and non-intervention groups at post-test, it seems that the intervention also affected how information was collected.

However, the ability to recall information that was not described and applied was low.

Benner, P. [19] described a five-step process of skill acquisition. Beginners have had no experience of the situations in which they are expected to perform. They are taught about situations in terms of objective attributes and measurable parameters of a patient’s condition that can be recognized without situational experience. At that point, the rule-governed behavior typical of a novice is extremely limited and inflexible. Second-year students before a clinical practicum seemed to have difficulty in recalling knowledge related to the situation and refer to existing knowledge and seemed to have difficulties with applying it to collect information. In actual nursing situations, students need to select and collect information to evaluate the health of a specific patient from vast amounts of patient-related data. Therefore, the ability to recall and apply the information needed to assess patient health status is required.

Further studies are needed to determine educational methods related to the development of skills for collecting knowledge-based information.

The present findings indicated that educational intervention could improve the ability to identify nursing problems using structured knowledge with explicit conditions for applicability, although we did not teach the assessment strategies. Structured knowledge with explicit conditions for applicability and learning a way to apply such knowledge to assess a patient before a clinical practicum seemed to promote the effective development of the nursing process.

Therefore, this educational method might help to augment assessment skills.

Further studies are needed regarding educational methods related to developing assessment skills. Questions that might be addressed include how to educate students about thinking strategies to identify nursing problems and about how to apply knowledge to information collection.