ABSTRACT
Globally, the quality of health care relates closely with
the quality of nursing care. The nursing process is widely adopted as an
evidenced-based tool that guides the practice and delivery of quality nursing
care. To improve its use, a number of studies have been conducted into the
extent of use of the nursing process and its associated challenges in several
countries. In Ghana, however, the extent of use of the nursing process, as well
as, barriers associated with its use have not been thoroughly examined. This
study sought to assess the extent of use of the nursing process, as well as,
barriers associated with its use at the Tamale Teaching Hospital. A
cross-sectional survey of 286 registered nurses and midwives, chosen by
stratified random sampling technique, was undertaken using a self-completing
questionnaire. Data analysis was done using IBM SPSS version 23. Statistical
tools used were Frequencies, Kruskal-Wallis H Test of association and Multiple
Logistic Regression. Most participants were highly knowledgeable in the nursing
process (71.0%), while usage of the nursing process was low (32.3%). Major
barriers of the nursing process were stressful work environment (96.8%),
absence of nursing process policy (94.7%), lack of further nursing process
training (91.5%), inadequate supply of consumables (81.2%), and lack of nursing
process clinical skills (42.9%). Age, educational level and years of experience
were significantly associated with the use of the nursing process. Nursing
process policy and supply of consumables/stationery were found to be
significant predictors of the use of the nursing process. The hospital should,
therefore, develop a nursing process policy, supply adequate quantities of
consumables and conduct periodic clinical re-training of nurses on the nursing
process.
CHAPTER ONE
INTRODUCTION
This chapter introduces and gives a background to the nursing
process, its importance and the barriers to its utilisation. The chapter also
presents the research problem, the purpose of the study, the objectives and
research question, the significance of the study, limitations and delimitations
of the study, operational definition of terms, as well as how the entire thesis
has been organised. The study aims to assess the extent of use and barriers
associated with the use of the nursing process at the Tamale Teaching Hospital.
The nursing process is a systematic five-step tool that
guides the sequence of clinical reasoning and action by nurses (Dal Sasso et
al., 2013). It enables nurses to assess, diagnose, plan, implement and evaluate
nursing care activities, and to modify their performance according to patient
recovery needs. The nursing process has therefore transformed nursing from
being dependent on traditional and ritualistic care to a more rigorous and
evidence-based profession that contributes significantly to the quality of
health care services that improve patient outcomes.
Nursing regulatory bodies around the world, including Ghana,
demand the use of the nursing process in the provision of nursing care. Despite
this demand, studies have shown varied levels of use of the nursing process in
the clinical setting, with low levels of usage documented in some countries,
especially in Africa.
Background to the Study
Nursing is said to be both an art and a science, and the
application of the nursing process comprises the blending of the two, which has
proven to be valuable in changing nursing practice as well as patient outcomes
(Afolayan, Donald, Baldwin, Onasoga, & Babafemi, 2013). Nursing practice is
said to have been rooted in traditions and ritualistic care, with nurses
falling into a daily routine to the neglect of patients' psychological,
spiritual, emotional and social needs (Daaleman, Usher, Williams, Rawlings,
& Hanson, 2008; and Wolf, 2012). The disregard for patient’s input into
their care and inflexible behaviour toward patients are among the
characteristics of this daily routine care (Ebrahimi, Torabizadeh, Mohammadi,
& Valizadeh, 2012).
Over the past decades, however, questions have emerged as to
why nurses do what they do, with nurses being challenged to show evidence that
nursing practices are effective (Wolf, 2012). Additionally, concerns over accurate
documentation of nursing care have grown in response to the need for the
nursing profession to develop a knowledge base in its quest of turning into a
true profession. In response to these demands for best practices in providing
nursing care, the nursing process was established from the Deliberative Nursing
Process Theory by Ida Jean Orlando in 1961 (Sellers, 1991). Orlando (1990) had
argued that a process goes on between a nurse and a patient when they interact
because of a distress expressed by the patient.
This process (nursing process) is the central core of nursing
practice and comprises the basic framework a nurse uses to render nursing care
to patients. Orlando further stresses that it is not enough for the nurse to do
what she thinks is best for the patient. Therefore, planning care and carrying
out interventions without assessing or interacting with the
patient is not professional (I. J. Orlando, 1990).
According to the American Nurses Association [ANA] (2010),
the nursing process is a systematic problem-solving process, made up of five
interrelated steps (assessment, nursing diagnosis, planning, implementation,
and evaluation) that registered nurses use to guide the delivery of holistic,
patient-focused care. The process enhances the critical thinking capability of
nurses through the collection, analysis and interpretation of data to make
clinical judgments, set patient care goals, establish priorities, select
appropriate interventions, implement these interventions, and evaluate patient
outcomes to determine if the plan has been effective in solving patients
problems or otherwise (Müller-Staub, Lavin, Needham, & Van Achterberg,
2006). The nursing process again enables nursing staff to evaluate their
efficiency and effectiveness, and to modify their performance according to
patient recovery results (Dal Sasso et al., 2013).
Assessment, which is the first step of the nursing process,
involves the collection, verification, organisation, interpretation, and
documentation of data (ANA, 2010). Nursing diagnosis is the second step and it
involves a process of data analysis using diagnostic reasoning (a form of
clinical judgment) in which judgments, decisions, and conclusions are made
about the meaning of the data collected to determine whether or not nursing
intervention is indicated (ANA, 2010). Planning, which is the third step,
involves prioritising, establishing expected outcomes, determining nursing
interventions and recording the plan of care (DeLaune & Ladner, 2002).
Implementation is the fourth step of the nursing process
where nurses provide direct and indirect nursing care interventions to patients
for achieving the goals and outcomes of nursing care set under the planning
phase (ANA, 2010). Evaluation is the fifth step of the process. Once all
nursing intervention actions have taken place, the nurse completes an
evaluation to determine whether the goals for patient wellness have been met
(ANA, 2010; Craven & Hirnle, 2008). The nursing process, therefore,
provides an organised framework to guide and standardise nursing practices
(Edet, Mgbekem, & Edet, 2013) as well as improve patient outcomes (Afolayan
et al., 2013; Haapoja, 2014).
The healthcare industry in Africa is gradually becoming
consumer-driven. Ofi and Sowunmi (2012) report that Nigerian nurses are now
faced with a changing health industry that values patient outcomes and
performance measurements. Similarly, in Ghana, patients are reported to be
cognisant of their rights, and by inference, the standard of care to expect
from a nurse (GACC, 2014). Patients are beginning to demand quality care and
seek legal redress when this demand is not met (Peacefmonline.com, 2015).
The quality of nursing care is closely related to effectiveness
of healthcare systems (Mason & Attree, 1997). In order to achieve this
effectiveness, there is a need to pay attention to measures that ensure quality
nursing care. There is, therefore, the need to establish a culture that
encourages the use of the nursing process to provide nursing care in every care
setting (Pokorski, Moraes, Chiarelli, Costanzi, & Rabelo, 2009).
In several countries today, it is a legal and policy
requirement that registered nurses should use the nursing process for rendering
patient care and care documentation (Axelsson, Björvell, Mattiasson, &
Randers, 2006; Haapoja, 2014; Habte, 2015). Similarly, the Nursing and
Midwifery Council and the Ministry of Health of Ghana demands that the nursing process
be used by registered nurses/midwives as a tool to meet the total health needs
of patients, families and communities (Ministry of Health Ghana [MOH], 2005;
Nursing and Midwifery Council of Ghana [NMCGH], 2007)
Notwithstanding the professional standards and quality care
the nursing process seeks to ensure, it has been established that nurses in
some countries, especially in Africa, poorly utilise the nursing process in
patient care (Afolayan et al., 2013; Aseratiie, 2011; Edet et al., 2013; Hagos,
Alemseged, Balcha, Berhe, & Aregay, 2014; Laryea, 1994). Afolayan et al.
(2013) for instance, evaluated the utilisation of the nursing process and
patient outcome at a Neuro-Psychiatric Hospital in Nigeria and found that, even
though nurses at the hospital had good theoretical knowledge of the nursing
process, they did not apply it in the care of their patients. Inadequate
clinical knowledge, inadequate staff, work overload, management's inability to
provide the needed materials among others were cited as factors that hindered
its use in the hospital. The study also found that there was a strong positive
correlation between application of the nursing process and patients’ recovery.
Therefore, the study concludes that the lack of application of the nursing process
by nurses can impair patients’ recovery and outcome.
Edet et al. (2013) in a descriptive cross-sectional study to
examine professional nurses’ perception and use of the nursing process at the
University of Calabar Teaching Hospital in Nigeria found that nurses with
higher education were 17 times more likely to perceive fewer barriers compared
to nurses with only basic nursing and midwifery qualifications.
In a cross-sectional study of selected government hospitals
in Ethiopia to assess factors affecting implementation of the nursing process
among nurses in these hospitals, Aseratiie (2011) found that close to half of
the respondents (47.9%) did not utilise the nursing process during patient
care, with as low as 16.1% of respondents being highly knowledgeable in the
nursing process. Nurses with good knowledge in the nursing process were 38.913
times more likely to implement nursing process than those with less knowledge.
The study also found that nurses working in a stressful working environment
were 2.8 times less likely to implement the nursing process, while nurses
working in units where resources were available for nursing care were 2.25
times more likely to implement nursing process than nurses working in
facilities without the necessary resources were.
Similarly, in a study of factors affecting the application of
the nursing process in Ethiopia, Hagos et al. (2014) found that a majority of
the respondents (90%) had poor knowledge of the nursing process, with all of
the respondents indicating that they did not use the nursing process when they
provide care to their patients. Educational level was found to have a
statistically significant association with knowledge of nurses on the nursing
process, with first-degree nurses being very knowledgeable about the nursing
process than diploma-level nurses.
In Ghana, Laryea (1994) studied the barriers to the
implementation of the nursing process and discovered that the knowledge of the
nursing process among respondents was high. However, the majority of
respondents lacked the clinical skills in data collection, nursing diagnosis
and objectives setting, which are necessary components of the assessment,
diagnosis and planning phases of the nursing process. The nursing process being time-consuming
and failure of management to motivate nurses as well as the lack of resources
and supplies were also cited among factors that hindered the application of the
nursing process.
It is evident from the reviewed studies that, most of the
studies were conducted outside Ghana and focused mainly on the benefits,
barriers and facilitators to the use of the nursing process. The field of the
nursing process in Ghana thus remains largely unexplored. There is, therefore,
the need to undertake further studies into the state of the nursing process in
Ghana.
Problem Statement
The extent of use of the nursing process in patient care in
Ghana, as well as barriers and challenges associated with its use have not been
thoroughly examined. Very little is known about the extent and barriers and
challenges associated with the use of the nursing process in the Tamale
Teaching Hospital (TTH). The Nursing and Midwifery Council of Ghana virtually
acknowledged this when they indicated that they did not have any published or
unpublished studies and technical reports on the extent of use the nursing
process in the country (Nursing and Midwifery Council of Ghana, personal
communication December 16, 2016) (Appendix G and Appendix H).
Additionally, the lack of application of the nursing process
for patient care has been cited by some nursing units of the hospital as a
problem faced in nursing care delivery (Tamale Teaching Hospital [TTH Nursing
Directorate], 2014). There is, therefore, the need to undertake a study into
the extent and barriers associated with the use of the nursing process in the
hospital.
Purpose of the Study
The Nursing and Midwifery Council and the Ministry of Health
of Ghana demand the utilisation of the nursing process as a tool in providing
care to patients, their families and communities by registered nurses and
registered midwives (MOH, 2005; NMCGH, 2007). Additionally, the Nursing
Directorate of the hospital has a vision of being a centre of excellence for
the delivery of tertiary nursing and midwifery care services, nursing education
and nursing research, at all levels to improve the quality of life of clients
and clients’ families (TTH Nursing Directorate, 2015). There is therefore a
need to encourage the use of the nursing process which has been shown to
improve nursing care quality and patient outcomes (Afolayan et al., 2013;
Haapoja, 2014).
To meet the demands of the Nursing and Midwifery Council and
the Ministry of Health of Ghana, and to achieve the vision of the Nursing
Directorate of the hospital, it is important to determine what exists in terms
of the extent of use as well as challenges associated with the use of the
nursing process for patient care in the hospital.
The study is expected to provide empirical evidence on what
exists in terms of the use and challenges associated with the use of the
nursing process in the hospital, resulting in recommendations to nurses,
midwives and management of the hospital. These recommendations will be targeted
at enhancing the use of the nursing process to enhance the quality of nursing
care, promote nursing clinical education and nursing research in the hospital,
and to meet the standards demanded by the Nursing and Midwifery Council and the
Ministry of Health of Ghana.
Objectives of Study
The main aim of this study was to assess the extent of use,
as well as, barriers and challenge associated with the use of the nursing
process for patient care at the Tamale Teaching Hospital.
Specific objectives
Specifically, the study sought to:
Assess the knowledge level of nurses of Tamale Teaching
Hospital on the nursing process.
Assess the extent of use of the nursing process for patient
care at the hospital.
Identify factors that serve as barriers and challenges to the
use of the nursing process in the hospital.
Determine if there are any significant associations between
participants’ demographic characteristics and utilisation of the nursing
process in the hospital.
Determine if there are any significant associations between
the barriers and challenges, and the utilisation of the nursing process in the
hospital.
Research Questions
The following research questions underpinned the study:
What is the knowledge level of nurses at the Tamale Teaching
Hospital on the nursing process?
What is the extent of use the nursing process for patient
care in the hospital?
Which factors serve as barriers and challenges to the use of
nursing process in the hospital?
Are there any significant associations between participants’
demographic characteristics and the use of the nursing process in the hospital?
Are there any significant associations between the barriers
and challenges, and the use of the nursing process in the hospital?
Significance of the Study
Findings of this study are expected to be of great benefit to
the following groups of people and institutions:
Nurses/Midwives: The findings of this study are expected to
reveal to registered nurses and midwives of Tamale Teaching Hospital empirical
evidence regarding their use of the nursing process in patient care. The
findings are also expected to help registered nurses and midwives strive to
meet the standards expected of them by the Nursing and Midwifery Council and
the Ministry of Health of Ghana, and to improve the clinical use and training
of registered nurses and midwives on the nursing process.
Tamale Teaching Hospital/Nurse managers: Given the vision of
the Nursing Directorate of Tamale Teaching Hospital, and the fact that quality
nursing services impact the quality of health care, it is important that
strategies are developed to deal with challenges to the use or establishment
and sustenance of the use of the nursing process in the clinical setting.
Findings of this study, therefore, give empirical evidence to hospital and
nurse managers on the extent of use as well as challenges associated with the
use of the nursing process. Additionally, based on the recommendations of this
study, the managers can put in measures that can help deal with the identified
challenges to improve the quality of nursing care and patient outcomes through the
application of the nursing process.
Nursing and Midwifery Council /Ministry of Health of Ghana: Findings
of this study will also present these institutions with empirical evidence on
the extent of use of the nursing process, and a basis for policy
revision/formulation. The review of the course content of clinical training of
registered nurses and midwives will benefit from the findings from this study,
as findings may reveal clinical competency shortfalls in the nurses and midwives
that are being produced by the current training system.
Nurse researchers: The findings of this study will serve as a
basis and a reference material for future research into the field of the
nursing process in Ghana, Africa and the world at large.
Delimitation of the Study
The study was limited to only registered nurses and
registered midwives (RGN, RM and RMN) fully employed and working in the Tamale
Teaching Hospital. These nurses and midwives were included in the study because
the nursing process is part of their training curricula. Additionally, the
Nursing and Midwifery Council and the Ministry of Health of Ghana, places a
demand on them to use the nursing process as a tool for meeting the total
health needs of patients, families and communities. Enrolled nurses, enrolled
midwives, certificate midwives and community health nurses were excluded from
the study. The nursing process does not form part of the training curricula of
these groups of nurses and midwives, and no demand is placed on them to use it
in patient care.
The study also examined at the extent of use of the nursing
process in the Tamale Teaching Hospital as well as barriers to the utilisation
of the nursing process. The barriers examined included those related to nursing
process knowledge level, clinical nursing process skill, views/attitude towards
the nursing process, and the self-motivation to use the nursing process. Others
include the presence of stressful work environment, inadequate staffing and
high workload, burden with non-nursing activities, absence of nursing process
policy, lack of managerial support for the use of the nursing process, lack of
monitoring and supervision by nurse managers, lack of further training on the
use of the nursing process, inadequate supply of consumables/stationery, as
well as, the length of patients stay in the ward.
Limitations of the Study
The study was conducted at the Tamale Teaching Hospital and
hence the findings could be peculiar to only the Tamale Teaching Hospital.
Hence, findings may not be generalizable to others hospitals. Being a nurse at
the hospital, the researcher could have had an influence on the responses of
participants due to social desirability bias. However, this was avoided as much
as possible through self-completion of the questionnaire by participants
without the need for the presence of the researcher or field assistant.
Additionally, a retrospective evaluation of the use of the
nursing process as evidenced in patient records over a number of years in all
the teaching hospitals in Ghana would have been ideal. However, the limited
time for this study as well as the financial implication of such a study could
not allow for that. Furthermore, the study employed a cross-sectional survey
design and hence in-depth meanings, further clarification and
explanation of answers could not be sought from participants.
Operational Definition of Terms
Nurse: A person who has undergone a three or four-year
prescribed programme of study in registered general nursing, registered
midwifery or registered mental nursing in a Nursing Training
College/University, and has been licenced to practice in Ghana by the Nursing
and Midwifery Council of Ghana.
Nursing Process: A systematic five-step method of rendering
individualised nursing care through assessment, diagnosis, planning,
implementation and evaluation.
Knowledge level about the nursing process: This refers to a
nurse or midwife’s theoretical knowledge level about the nursing process. The
nursing process knowledge level of participants was measured and categorised
based the classification used by Assefa (2014). Highly knowledgeable
participants were those who answered 6 or 7 of items number 10 to 16 under
section B of the questionnaire correctly. Moderately knowledgeable participants
were those who answered 5 or 4 of the items correctly, and poorly knowledgeable
participants were those who got 3 or less of the 7 items correctly.
Utilisation of the nursing process: This refers to the
application or use of the nursing process in the provision of daily nursing
care to patients. It was measured by participants’ affirmative response to
questionnaire items 18 – 21. Affirmative responses to items 18 and 19 indicate
that participants made use of the nursing process during patient care, while
negative responses shows that they were not making use of the nursing process.
Barriers: These refer to the factors that make it difficult
or hinder the use of the nursing process for patient care by nurses and
midwives. For purposes of this study, these include knowledge and skill
factors, institutional-related factors and attitude/self-motivational factors.
Knowledge and skill factors refer to the nursing process
theoretical knowledge level and clinical nursing process skills. Knowledge
level was measured by the number of correct responses to items on the knowledge
measurement, while item 25 measured the possession of clinical nursing process
skills by participants. Poor knowledge of the nursing process and negative
response to item 25 shows the presence of challenges related to nursing process
knowledge and clinical skills.
Institutional-related factors refer to factors in the purview
of an institution whose presence or absence has a negative impact on the
utilisation of the nursing process. These include inadequate staffing,
stressful work environment, high workload, burden with non-nursing activities,
absence of nursing process policy, lack of managerial support, absence of
nursing process monitoring and supervision, lack of opportunity for further
training on the nursing process, inadequate supply of consumables/stationery as
well as the length of patient stay on the ward. The presence of these barriers
was measured by negative response to items 21, 22 and items 24 – 33.
Attitudinal/self-motivational factors refer to the
views/attitude, as well as, the self-motivation to engage in the use of the
nursing process during patient care. Affirmative responses to items 34 – 36,
and negative responses to items 37 and 38 the presence of these barriers (poor
attitude and lack of self-motivation) towards the use the nursing process
respectively.
Organisation of the Study
This study is organised into five chapters. Chapter One deals
with the introduction to the study, which captures the background of the study,
the problem statement, the purpose of the study, research objectives and
questions, significance of the study, delimitations, limitations as well as
definition of terms. Chapter Two presents the review of relevant up-to-date
theoretical and empirical literature on the topic, including the
theoretical/conceptual framework that guided the study.
Chapter Three presents the research methodology, which
includes research design, study population and setting, data collection
instrument, sampling and data collection procedures as well as data management
and analysis. It also deals with issues of ethical considerations and
clearance. Results of the study and discussion of key findings are presented in
Chapter Four. Chapter Five presents the summary, conclusions, recommendations
of the study, as well as suggestions for future studies.
Chapter Summary
This chapter presented the background to the study via a
brief presentation on the origin and motivation behind the establishment of the
nursing process. The problem statement and the purpose of the study were also
presented. Studies have not thoroughly examined the field of the nursing
process in Ghana despite the apparent low levels of use of the nursing process
in patient care in Africa.
Also presented in the chapter are the research objectives and
the research questions to be answered by the study. This study seeks to assess
the extent of use and barriers associated with the use of the nursing process
at the Tamale Teaching Hospital. The findings of the study are
expected to provide empirical evidence on what exist in terms of the use and
challenges associated with the use of the nursing process in the hospital,
resulting in recommendations targeted at enhancing its use in the hospital. The
findings are also expected to be of significance to nurses and midwives, the
Tamale Teaching Hospital, the Nursing and Midwifery Council of Ghana, the
Ministry of Health of Ghana, and Nurse Researchers.
The chapter also presented the delimitations, limitations,
operational definition of terms and the organisation of the study. The study is
limited to only registered nurses and registered midwives working in the Tamale
Teaching Hospital. It has been organised into 5 chapters.
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