Development and Practical Application of a Relationship

Diagram-creation Tool Centering on Automatic Creation

Functionality

Norio Ishii

, Yuri Suzuki

and Saori Sakuma

Aichi Kiwami College of Nursing, 5-4-1 Jogan-dori, Ichinomiya, Aichi, Japan

College of Engineering, Chubu University, 1200 Matsumoto-cho, Kasugai, Aichi, Japan

School of Nursing, Seirei Christopher University, 3453 Mikatahara-cho, Kita-ku, Hamamatsu, Shizuoka, Japan

Keywords: Nursing Education, Learning Support Tool, Relationship Diagram, Automatic Creation.

Abstract: In nursing education, learning the effects of relationship diagrams drawn by students is useful in

understanding patients and the entire nursing process. However, drawing these diagrams is time consuming,

and the diagram creation process is strenuous for students. In this study, we have developed a relationship-

diagram creation tool that further reduces the difficulty of node organization. In particular, we have

developed a tool that implements an automatic drawing function in which the tool, rather than the student,

organizes information in the diagram. We conducted lectures on methods to use the tool at a nursing college

as well as a questionnaire survey to evaluate its efficacy. On the basis of these results, we confirmed the

improvements in the tool’s usability and efficacy.

1 INTRODUCTION

The creation of relationship diagrams is important in

the nursing process. Relationship diagrams are

“concept maps” or “concept networks” that logically

use arrows to depict the causes of illness, organic

changes, functional changes, symptoms, and

decreasing lifestyle activity to understand a patient.

Relationship diagrams are used in basic nursing

education to organize and integrate related

information and present an overall image of a

patient. They are important in determining the

course the nursing process takes (Akinsanya and

Williams, 2004; Hsu and Hsieh, 2005).

Earlier research has reported the use of

relationship diagrams in nursing education to

reinforce logical thinking and understanding

(Sugisaki and Ogawa, 2006; Yakushijin et al., 2006).

This study has noted that consolidating information

improves learning and critical thinking abilities.

However, it has been pointed out that the placement

of nodes and lines in relationship diagrams make

them difficult to draw and revise (Sugisaki and

Ogawa, 2006). This suggests that, for students, the

creation of relationship diagrams is a complex and

difficult activity that requires an understanding of

the patient, an ability to follow the nursing process,

and critical thinking capabilities.

As the earlier study suggested, creating

relationship diagrams has merits, such as (1)

promoting understanding of the patient as a whole

and (2) improving logical and critical thinking

capabilities. The current study focuses on (1) and

aims to construct a learning environment for

beginners to support the understanding of the patient

as a whole.

Earlier studies tested a number of methods to

increase the effectiveness of relationship diagrams

as a learning tool, as described in (1), by avoiding

confusing the students with detailed rules, including

giving students rules for drawing diagrams that

distinguish between actual and potential conditions

and depicting different elements of information with

different colors (All and Havens, 1997; Schuster,

2002; Toyoshima et al., 2005). These practical

studies can be seen as a research approach that

supports students by proposing effective rules for

drawing relationship diagrams, which have not had

clear and established drawing rules.

In contrast, the authors have performed research

based on the development of a learning support tool

for creating relationship diagrams and constructing a

394

Ishii N., Suzuki Y. and Sakuma S..

Development and Practical Application of a Relationship Diagram-creation Tool Centering on Automatic Creation Functionality.

DOI: 10.5220/0004944903940401

In Proceedings of the 6th International Conference on Computer Supported Education (CSEDU-2014), pages 394-401

ISBN: 978-989-758-021-5

 2014 SCITEPRESS (Science and Technology Publications, Lda.)

Figure 1: Relationship-diagram creation tool.

learning environment that reduces the previously

mentioned student difficulties. In previous research,

we developed a computer-based tool for simple

creation of relationship diagrams using Microsoft

Excel VBA and introduced this program into the

classroom in an attempt to reduce the burden of

diagram creation (Ishii and Sakuma, 2011). Using

this tool allowed students to easily create and

organize relationship diagram nodes and links. In

practical use, the tool received positive evaluations

from students in terms of creating and editing

diagrams. However, no difference was seen in the

amount of time required to create a diagram with the

tool and the time to create a diagram by hand. We

inferred that this was because the time spent by

students on editing tool-generated diagrams was

greater than that spent on hand-drawn diagrams

since the tool allowed students to easily rearrange

nodes.

In this study, we have developed a relationship

diagram-creation tool that further reduces the burden

of node organization. Specifically, we developed a

tool that implements an automatic drawing function

in which the tool rather than the student organizes

information in a diagram. We then deployed this

program in a classroom. In addition, we made

improvements to the tool based on student

evaluations, and we investigated the effects of the

improvements by introducing the program in the

classroom once again during the following academic

year.

2 A RELATIONSHIP

DIAGRAM-CREATION TOOL

2.1 Development Environment

We developed the tool in the Java development

language under the Windows operating system.

During development, we used three libraries:

Processing, which is specialized for graphics

functions; Apache POI, which reads and writes files

in formats for Microsoft applications such as Excel

and Word; and JFreeChart, which allows creation

graphs from Java applications.

2.2 Tool Functions

In this study, we developed a relationship diagram-

creation tool with three functions: an automatic

drawing function, a creation process replay function,

and an evaluation support function (Figure 1).

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2.2.1 Automatic Drawing Function

The tool automatically creates diagrams based on

information entered by the student. We call this the

automatic drawing function. The diagrams are

composed of nodes and links, and nodes are

hierarchically organized from left to right.

Relationship diagrams are generally composed in a

radial shape; however, based on interviews with

nursing instructors, we have adopted a hierarchical

composition, which was assessed as easy to read.

To create a node, the user selects the “create

element” tab from the lower part of the tool. After

inputting the target information for the new element,

the user selects element properties and connecting

element numbers (a node number pointing to a

higher level in the hierarchy) from the menu. This

automatically creates a new node in a color based on

its properties and places the node in the diagram.

The node is also automatically assigned a number in

order of creation. There are six element properties:

(1) physical attributes (height, weight, ailments,

etc.), (2) social background elements (family

composition, household environment, etc.), (3)

psychological state elements (mental state, mental

issues, etc.), (4) expectations (future expectations

regarding the patient), (5) nursing obstacles (critical

issues concerning nursing), and (6) nursing

intervention (nursing activity for the subject patient).

To edit node information, the user selects the

“edit element” tab, and then selects the number of

the node they wish to edit from the pulldown menu.

Current information is shown in the content field of

the element. Current information can be edited.

When the OK button is pressed, these changes are

reflected in the diagram. Nodes can be deleted by

selecting the “delete node” tab and selecting the

number of the node to be deleted from the pulldown

menu. However, to preserve links, only nodes with

no lower level nodes can be deleted.

Links between nodes are automatically

generated, and normal links are indicated by solid

arrows. Prediction links are indicated by dotted

arrows. To add a link between nodes, the user

chooses the “edit connections” tab and enters edit

mode to select the number of nodes to be connected

from the pulldown menu. The added link is shown

with a red arrow. To delete a node, after selecting

deletion mode, the user must then choose the

number of the node to be deleted in a similar

fashion.

Finally, as nodes and links are created

automatically, the student cannot change their

placement; however, by selecting the “change

connection distance” tab, the users can adjust the

spacing between nodes.

2.2.2 Creation Process Replay Function

The tool automatically logs the creation process of

the relationship diagram and can recreate this

process step by step after creation. This is called the

creation process replay function. The creation

process replay includes the deletion as well as

addition of elements and connections. This function

allows students and instructors to confirm a

student’s creation process.

2.2.3 Evaluation Support Function

After the creation of a relationship diagram, this tool

can display an evaluation sheet that shows the

number of links and nodes of each type in a table as

well as the proportion of nodes of each type as a

graph. This is called the evaluation support function.

Evaluation sheets are output in a Microsoft Excel-

compatible format.

3 INTRODUCING THE TOOL

IN THE CLASSROOM

3.1 Course and Object of Study

In this study, we introduced the developed

relationship diagram-creation tool into a classroom.

The target course was “The Nursing Process,” a first

year open lecture at a short-term nursing school. One

of the course’s fifteen total classes focuses on the

creation of relationship diagrams. There were 88

first-year short-term nursing college (school of

nursing) students in the class.

3.2 Class Design

The class content was composed of three steps:

introduction of the tool, creation of relationship

diagrams, and evaluation and improvement of

diagrams.

In the first step, students received a basic

explanation of the fundamentals of the tool.

Specifically, students received an explanation

regarding the creation, revision, and deletion of

nodes as well as the addition of nodes and

adjustment of spacing between nodes. The procedure

for saving files was also explained.

In the second step, students were divided into

groups of two to three and created one full image

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Table 1: Evaluation items.

relationship diagram based on a given case

(symptoms associated with stroke, physical changes

associated with aging, and the effects of these

symptoms on daily life). Because the students are

beginners at creating diagrams, we distributed a data

file in which one portion related to the illness was

created in advance. Students completed a

relationship diagram by adding information to the

distributed diagram.

In the third step, students used the evaluation

sheet provided by the tool to assess the created

relationship diagram. Students then added

supplementary information and revised incorrect

information. Finally, students reviewed the creation

process using the creation process replay function.

After the diagram creation process finished, students

assessed the tool following the same process used in

earlier research (Ishii and Sakuma, 2011). More

specifically, a system usability scale (Brooke, 1996)

(10 items, 5-rank evaluation) was used to assess

usability. Evaluation items based on points that the

students considered difficult in earlier research were

also used (10 items, 4-rank evaluation) to assess

efficiency. The evaluation items are shown in Table

3.3 Student Evaluation of the Tool

In our evaluation of the tool, we first compared

evaluations received from students in this study with

those obtained in earlier research (Ishii and Sakuma,

2011) regarding the previous relationship diagram

tool. As explained in Section 1, the tool in this

research varied from the previously developed tool

as follows: (1) nodes were automatically created by

entering information but students manually

organized the diagram; (2) similar to nodes, links

were also manually organized by the students; and

(3) the creation process replay functionality and

evaluation support functionality were not

implemented. In addition, creation of the

relationship diagram was performed over two

classes in previous studies, whereas in this study, the

relationship diagram was created in a single class

period.

3.3.1 Usability Evaluation

Figure 2 shows usability evaluations for the previous

and proposed tools. The system usability scale

utilized in this study included inverted evaluation

items. In Figure 2, positive evaluations are

represented with higher values.

Figure 2 shows that the evaluations were higher

for the proposed tool than the previous tool for all 10

evaluation items. A non-corresponding t-test

performed for the average difference in total

usability points between the previous and proposed

tools confirmed that the proposed tool obtained a

significantly higher average point total (33.9) than

the previous tool’s average (31.1) (t(146)=3.572,

p<.01). However, the average point values were less

than 3.0 for items 4, 9, and 10 in the evaluations of

the proposed tool.

3.3.2 Efficiency Evaluation

Figure 3 shows efficiency evaluation results for the

proposed and previous tools. A non-corresponding t-

test performed for the average difference for items 1

to 10 confirmed that the proposed tool obtained a

significantly lower average than the previous tool’s

No. Usability Efficiency

1 I think that I would like to use this tool frequently. It didn't take long.

2 I found the tool unnecessarily comp lex. It was p ossible to draw diagrams easily .

3 I thought the tool was easy to use. It was p ossible to draw diagrams neatly .

I think that I would need the sup p ort of a technical p erson

to be able to use this tool.

It was p ossible to draw diagrams in detail.

5 I found the various functions in this tool were well integrated. It was easy to erase nodes or links.

6 I thought there was too much inconsistency in this tool. It was easy to revise diagrams.

I would imagine that most peop le would learn to use this tool

very quickly.

It was easy to rearrange nodes or links.

8 I found the tool very cumbersome to use.

It was useful to classify information

by kinds of color or line.

9 I felt very confident using the tool. It was easy to organiz e informat ion.

I needed to learn a lot of things before I could get going with

this tool.

It was easy to consider relationship .

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average for item 7 (t(146)=2.377, p<.05). While the

proposed tool received higher point totals in most

evaluation categories, we did not find a significant

difference.

Figure 2: Result of usability evaluations using the previous

and proposed tools.

3.4 Evaluations of Student Created

Relationship Diagrams

To show the effect of the proposed tool on learning,

we evaluated the relationship diagrams created by

students and conducted student evaluations of the

tool. This study established evaluation items for (1)

the number of nodes for each type and (2) the

number of links (excluding the crossing links

mentioned below), which express the amount of

information in the diagram, and (3) the number of

crossing links (links that cross node levels; we

observed activity when links were added to

previously created nodes), which are used as an

evaluation item in representative earlier research

(Novak and Gowin, 1984). The subjects of analysis

were relationship diagrams (14 from the previous

tool, 30 from the proposed tool) created by

consenting student groups.

Table 2 shows the results of analyzing the

relationship diagrams created in experiments using

the previous and proposed tools. Each item is

represented by a number; however, this excludes

data included in data files provided at the beginning

of diagram creation. A non-corresponding t-test

performed for the average difference for each

evaluation item confirmed that diagrams created by

the proposed tool had significantly more expectation

nodes (t(42)=2.330, p<.05) and crossing links.

Figure 3: Result of efficiency evaluations using the

previous and proposed tools.

Table 2: Results of analyzing the relationship diagrams

using the previous and proposed tools.

(t(42)=3.865, p<.01) compared with those created by

the previous tool. We also found that the relationship

diagrams created with the previous tool had a

significantly larger number of nodes regarding social

background elements (t(42)=4.505, p<.01).

3.5 Discussion

Usability evaluations of the tool confirmed that the

proposed tool received higher overall evaluations

than the previously developed tool. This suggests

that the control methods and interface developed in

this study were easy for the students to understand.

No significant difference between the previous

and proposed tool was seen in evaluation of tool

efficiency. Low evaluation of the proposed tool’s

ability to change the organization was due to the

specifications of the proposed tool; students could

not reorganize the diagram. As no difference was

seen in other items, we hypothesize that this

specification did not have a large overall effect on

relationship diagram creation.

Evaluation items Previous tool Proposed tool

Phy sical attributes 4.7 5.2

Social background elements 1.6 0.3

Psy chological state elements 2.9 3.7

Expectations 1.1 2.2

Nursing obstacles 1.7 1.3

Nursing intervention 2.8 3.0

Links 15.7 14.8

Crossing links 2.9 6.8

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Analysis of the relationship diagrams created by

students confirmed that the number of prediction

nodes and crossing links increased with the proposed

tool. This suggests that students actively investigated

the possibility of future occurrences based on the

provided information as well as the relationships

among the information. Diagram creation required

two class periods with the previous tool, whereas the

proposed tool used only one. This indicates the

efficiency of the proposed tool.

Future improvements could include

strengthening support functions for promoting link

creation and diagram nodes. In particular, the results

showed that few social background elements were

created by the proposed tool. In future, we aim to

add additional functions to promote entry of such

elements.

4 IMPROVING THE

RELATIONSHIP

DIAGRAM-CREATION TOOL

4.1 Adding Functions to the Tool

To increase the efficiency of the relationship

diagram-creation tool introduced to the classroom in

Section 3, we have implemented the following

additional functions: an initial information entry

function and a nursing problem extraction function.

4.1.1 Initial Information Entry Function

The initial information entry function supports

activity at the beginning of the relationship diagram

creation process. Students enter basic information

regarding the patient using a template displayed in

list format (age, sex, family composition,

occupation, medical history, and disease name). This

data is saved as an initial information file. By

importing the initial information file through the tool

menu, a relationship diagram based on all the

information is displayed.

This function is expected to promote the creation

of social background elements and physical

attributes related to the target patient. We also

expect this function to increase productivity of

student data entry during the initial creation of the

relationship diagram, reducing both data omissions

and time required to create a diagram.

4.1.2 Nursing Problem Extraction Function

The nursing problem extraction function supports

evaluations after creation of the relationship

diagram. As stated in Section 2.2.3, we implemented

an evaluation support function that provided

quantitative information related to the relationship

diagram. However, evaluating the content of the

created relationship diagram was difficult with this

function. Thus, we implemented the nursing issue

extraction function to assess the content of the

relationship map effectively. By selecting this

function, links are extracted from the initial

information nodes to the nursing issue (crucial issues

in nursing) nodes and displayed in another window

(for example, “76-year-old woman > stroke >

incontinence > damp skin > bedsores).

This function is expected to make it easy for

students to conduct an evaluation by reviewing their

thought process through a large quantity of

information, which can promote understanding of

the subject.

4.2 Introducing the Improved Tool into

the Classroom

We introduced the improved tool in a class to assess

the effects of the improvements. As with the

experiment described in Section 3.1, we used one

class period of “The Nursing Process,” a first-year

open lecture at a short-term nursing university.

There were 82 first-year short-term nursing college

(school of nursing) students in the class.

The class design was approximately the same as

the previous class, with the following changes. (1)

We added an explanation of the initial information

entry function at the first step. (2) In the second step,

students created a relationship diagram using the

initial information entry function (students were

given a printed sheet of information rather than a

data file). (3) In the third step, the relationship

diagrams were assessed using the nursing issue

extraction function in addition to the evaluation

sheet and creation process replay function. After the

class, tool evaluation was performed using the same

questionnaire. 66 students were targets of this

analysis.

4.3 Student Evaluations of the

Improved Tool

In Section 3, we assessed the tool through

comparison with the previously developed tool. Here

we compare student evaluations of the proposed tool

before and after implementing the improvements

described in Sections 4.1.1 and 4.1.2.

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Figure 4: Result of usability evaluations of the tool before

and after improvement.

4.4 Student Evaluations of the

Improved Tool

In Section 3, we assessed the tool through

comparison with the previously developed tool. Here

we compare student evaluations of the proposed tool

before and after implementing the improvements

described in Sections 4.1.1 and 4.1.2.

4.4.1 Usability Evaluation

Figure 4 shows the usability evaluations of the tool

as points before and after improvement. Figure 4

shows that the evaluations of the tool after

improvement were higher in every item except 5. A

non-corresponding t-test performed for the average

difference in total points of usability for the tool

before (33.9) and after improvement (36.6) showed

that the improved tool received significantly higher

average point totals (t(135)=2.855, p<.01). Items 4,

9, and 10, which received evaluations with average

point scores below 3.0 prior to improvement, rose

above 3.0 after the improvements were

implemented.

4.4.2 Efficiency Evaluation

Figure 5 shows efficiency evaluation results of the

tool before and after improvement. A non-

corresponding t-test performed for the average

difference in points for each evaluation item

confirmed that the improved tool received

significantly higher evaluations in items 1

(t(144)=2.365, p<.05), 2 (t(144)=3.706, p<.01),

and10 (t(133)=2.882, p<.01). No evaluations were

significantly lower after improving the tool.

Figure 5: Result of efficiency evaluations of the tool

before and after improvement.

4.5 Evaluation of the Relationship

Diagrams Created by Students

As with the relationship diagrams created with the

proposed and previous tools, we assessed the

diagrams created before and after improvement of

the proposed tool. The subjects of analysis were

relationship diagrams (30 with the unimproved tool,

20 with the improved tool) created by consenting

student groups.

Table 3 shows the results of analyzing the

relationship diagrams created using the tool before

and after improvement. As in Table 2, the numerical

values exclude information included in the data file.

A non-corresponding t-test performed for the

average difference in points for each item confirmed

that diagrams created with the improved tool

contained significantly higher nodes containing

physical attributes (t(48)=3.751, p<.01) and social

background elements (t(48)=2.317, p<.05). In

contrast, we found that psychological state elements

were significantly more numerous in the relationship

diagrams created with the tool prior to improvement

(t(48)=2.911, p<.01).

4.6 Discussion

Usability evaluations confirmed that the improved

tool received higher overall evaluations than the tool

prior to improvement. This suggests that the

additional functions improved usability even further

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when creating new relationship diagrams and

assessing the created diagrams.

Table 3: Results of analyzing the relationship diagrams

using the tool before and after improvement.

In addition, efficiency evaluations of the tool

showed improvement in three evaluation items; in

particular, 1, which considered creating diagrams,

improved. The reason for this is thought to be that

by adding the initial information entry function, it

was possible to reduce the time required for students

to enter information. In addition, 10, which

considered the ease of thinking about relationships,

also improved. This suggests that the nursing issue

extraction function was effective in making

relationships easier to grasp.

Analysis of the relationship diagrams created by

the students confirmed that physical attributes and

social background elements increased in the

improved tool. This is thought to be because the

improved tool reflects the results of continuing

creation while the student focuses on social

background elements, such as occupation and family

composition, and physical attributes, such as

medical history, through the initial information entry

function implemented in the tool. We hypothesize

that the reduction in psychological state elements

was due to the absence of psychological state

elements in the initial information.

In this study, during creation of the initial

information we selected the basic information that

we wanted students to enter in the relationship

diagram. If the selected information had a strong

effect on the content of the relationship diagram, we

considered that it should include information that

would serve to develop opportunities for further

consideration; for example, problems during

hospitalization and psychological state elements,

such as what the patient does not want to do. In

future, we aim to investigate this point through

practical experiments.

5 CONCLUSIONS

The relationship diagram-creation tool developed in

this study received more positive evaluation than

tools developed in earlier research. We have also

examined the effects of further improving the tool.

While this study conducted an analysis of the

relationship diagrams created by the students, future

research is aimed at performing detailed analysis of

the creation process and experimentally

investigating the effect of each function

implemented to facilitate addition of knowledge

obtained in the current study. Based on the results of

this analysis, we hope to improve the tool further

and create a more effective learning environment.

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Evaluation items

Before

improvement

After

improvement

Phy sical attributes 5.2 8.8

Social background elements 0.3 0.9

Psy chological state element s 3.7 2.3

Expectations 2.2 1.7

Nursing obstacles 1.3 0.7

Nursing intervention 3.0 3.5

Links 14.8 15.7

Crossing links 6.8 7.6

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