Factors Affecting Implementation of Nursing Process Among Nurses Working in Governmental Hospitals, Oromia Region, Ethiopia, 2016: Cross Sectional Study

Background: Nursing process used in clinical practice worldwide to deliver quality individualized care to patients and lack of its application can reduce the quality of care. Nursing Process is a systematic problem-solving approach used to identify, prevent and treat actual or potential health problems and promote wellness. It has five stepsassessment, diagnosis, planning, implementation, and evaluation. Applying nursing process requires understanding of factors affecting its implementation from the perspective of nurses. Nursing process implementation could be highly influenced by different factors that can lead to poor quality of nursing care, disorganization of the service, conflicting roles, medication error, poor diseases prognosis, readmission, dissatisfaction with the care provided, and increased mortality. These problems are manageable if a nurse can properly implement nursing process. Objective: The main aim of this study was to assess factors affecting implementation of nursing process among nurses in governmental hospitals of Arsi Zone. Materials and Methods: A cross-sectional study was used to conduct on governmental hospitals in Arsi Zone from DecemberJune 2016. Both quantitative and qualitative methods were used. All governmental hospitals in Arsi Zone was used since they were convenient for the study. Numbers of the participants were small, so all those who full fill inclusion criteria were participant in the study. Tools were given to nurse out of the study to check for its validity and adjustment was made according to the feedback obtained before actual data collection. Data was collected using self-administered questionnaire and in-depth interview. Data was analyzed using SPSS 21.0 version. Result: Findings revealed that organizational factors have the highest predictive value in the use of nursing process, followed by practice related factors. Conclusion and Recommendation: The result concluded that the organizational factors have the most important influence on the use of nursing process. It is recommended that the organization should fulfill needed materials which are necessary to provide nursing care. This will enhance nurses’ ability to use nursing process to improve the quality of patient’s care.


Introduction
Nursing process is one of the standardized nursing cares in which professional nurses are accountable and responsible. If professional nurses implement nursing process in standardized way, quality of nursing will be increased.
The nursing process is an organized and systematic process of giving goal oriented and humanistic nursing care that is both effective and efficient. It is consisting of five sequential and interrelated steps-Assessment, Diagnosis, Planning, Implementation, and Evaluation. Nursing Process is based on the assumption that professional nursing practice is interpersonal in nature. [1] The nursing process is based on a nursing theory developed by Ida Jean Orlando. She developed this theory in the late 1950's as she observed nurses in action. All nursing personnel take part in the nursing process. The RN has the primary responsibility however. [2] Implementation of the nursing process as identified in this Nursing Standard should allow for the delivery of quality nursing care within a systematic, goal-directed framework and a reasonable assurance that the individual's course along the health/illness continuum is predictable and progressive. [3] By providing quality care, safe and free of risk, it is understood that nurses make a nursing diagnosis assessment, elaborate the clinical evolution in every work shift, provide complex care demanding specific skills and knowledge, and manage technological equipment. [4] The nurse practitioner's role involves responsibility for meeting the health care and nursing needs of individual patients, their families and significant others. This dominant role of nurses could be achieved by the proper application of the nursing process. [5] Effective implementation of the nursing process leads to improved quality of care and stimulates the construction of theoretical and scientific knowledge based on the best clinical practice. [6] So this study attempts to find out factors that affect the implementation of the nursing process.

Methods and Materials
Health Institution based quantitative and qualitative study was conducted in three governmental hospitals of Arsi Zone Oromia reign from December to June 2016. A total of 111 BSc nurses were included in the study.
To select study participants', for quantitative study all BSc nurses in Arsi zone hospitals that were going to be included in the study was taken from the respective coordinator of nursing unit and head nurse. Data was collected from all who were fulfilling the inclusion criteria. Purposive sampling method was used for qualitative method.
For data collection structured questionnaire was used. Data was collected by self-administered questionnaire. Before the actual data collection, data collectors had two days training about the aim of the study and the content of the instrument.
There are two types of questionnaire for quantitative and qualitative. For quantitative method of data collection structured questionnaire was used. It includes five main parts about nurses 'socio demographics, organizational, knowledge of nursing process, attitude and skill of nurses. For qualitative aspect of the study, open-ended questions were prepared to guide an in-depth interview.
The questionnaire was pre tested for the relevance of dependent and independent variables to avoid any confusion during actual data collection period. The principal investigator was checked 5 (5%) nurses' response one week prior to the actual data collection period in Adama Medical college hospital, Adma.
Correlation analysis was used to see the association of independent with the dependent variable. Finally, the results were interpreted as statistically significant association if p<0.05 and 95% of CI, and some of the results was compared with results of other studies available. Data from an in-depth interview was transcribed by arranging the record according to forwarded questions.
Letter of ethical clearance was obtained before the beginning of data collection from Arsi University College of health sciences research Publication office (RPO). Permission letter was provided to selected hospitals for proceeding data collection.

Socio-demographic Characteristics of the Study Population
Out of 82 sampled respondents were participate in the quantitative study during the study period a total of 43 (52.4%) were females and 39 (47.6%) were males. Fortify five (54.9%) of the respondents were in the age range from 25-29 years, 13 (42.2%) were in 20-24 years, 10 (12.2%) were 30-34years and 6 (7.3%) were 35-39 years. Regarding Work experience twenty-seven (32.9%) of respondents had 5-9 years of work experience. (Table 1) According to the current study, 56 (68.3%) of respondents were implemented nursing process in their hospital. Among the respondent, 47 (57.3%) of them known as there were support from administration to implementation of nursing process and regarding the resource for implementation of nursing process 50 (61.0%) were not adequate. According to respondents nurse patient ratio 41 (50.0%) and time allocation 40 (48.8%) to implement the nursing process was not matches. Regarding appreciating feedback available 42 (51.2%) for the nursing process implementation was low. Sixty nine (84.1%) were working over time with low payment 54 (65.9%). (See table 2 below). Regarding the knowledge assessment of nurses few of respondents 16 (19.5%) have answered the correct for nursing theorists who was developed nursing process and majority of them 66 (80.5%) have wrongly answered. Sixty one (74.4%) have answered correctly what the nurse should do one at the first step of nursing process and the rest of them 21 (25.6%) have wrongly answered. More than half of respondents 41 (50%) answered human response towards physiological disturbance is the focus of Gordon approach which is the correct answer whereas the remaining 41 (50%) have wrongly answered. Fifty six 56 (68.3%) of respondents have correctly answered as nursing diagnosis for a problem to be manifested in the future is potential nursing diagnosis while the remaining 26 (31.7%) have wrongly answered. Fifty one (62.2%) respondents have chosen the correct answer that the major difference between nursing diagnosis and medical diagnosis is the focus of nursing diagnosis towards human response than the disease process while 31 (37.8%) of them answered wrongly. Twenty one (25.6%) of respondents have chosen the correct answer that was, data base of the patient could not be recorded in the planning phase of nursing process where as the remaining 61 (74.4%) of respondents have wrongly answered. Forty three 43 (52.4%) of respondents correctly answered that implementing the proposed interventions in the planning phase is the expected activity to be performed in the implementation phase of nursing process and 39 (47.6%) have wrongly answered. (Table 3). As it is shown in the table below 16 (19.5%) of respondents were highly knowledgeable and 39 (47.6%) were moderately knowledgeable while 27 (32.9%) had poor knowledge.  Regarding the ability to follow the steps of nursing process during provision of care (as shown in table 6) thirty seven (45.1%) of the respondents were use always while 23 (28.0%) used sometime. Fifty (61.0%) always ability to developed nursing diagnosis from assessment while 22 (26.8%) able develop sometime. fifty (69.5%) always able to safely administer medicine and other therapies. Forty nine (59.8%) respondents have practiced always the principles of health and safety, including moving and handling, infection control; essential first aid and emergency first aid and emergency procedures very much where as 19 (23.2%) were practiced it Sometimes. Association of implementation of nursing process Regarding association of implementation of nursing process with selected variables with correlation analyses as shown in table 7 there is no association with socio-demographic characteristics. There is association of implementation of nursing process with some of the organizational factors. Hospital administration support has correlation, for implementation of nursing process (r=. 494**,.000 Correlation is significant at the 0.01 level (2-tailed)). Nurse patient ratio has association (r=.366**.001; Correlation is significant at the 0.01 level (2-tailed).) Time sufficient, feedback available, adequacy of school practice and adequacy of training from instructor was significantly associated with implementation of nursing process r=.378**,. 236*,. 236*,. 227*,. 354**) respectively. ( Table 7) Regarding association of implementation of nursing process with factors related to knowledge and attitude; there is no association. But one of the practice related factor; the ability to follow the steps of nursing process has an association with implementation of nursing process. (r=.047). The data collected from interviewees was summarized thematically by identifying the core ideas they have responded. The whole information is summarized into three themes.
Organizational Factors Most of interviewees have described that hospital's environment was not suitable for implementation of nursing process. Hospitals were not able to afford supplies needed for caring. For example, nursing process formats were not available. The available format was not the correct format to register all the components of nursing process. Low nurse to patient ratio was the other problem that participants were described. Nurses were obligated to care for many patients beyond their capacity. In the contrary they were not obligated to record their activities in a formal way. Simply they were allowed to perform their activities following the instruction of physicians. Higher officials were not informed the role of nurses and the benefit of nursing process on the patients 'outcome. They were only working for the successful accomplishment of medical services leaving nursing services apart. Low salary and duty payments created negligence among most of nurse to enforce nursing process. Knowledge Most of the respondents agreed that knowledge is a determinant factor that could influence implementation of nursing process. Some respondents believed that nurses have obtained adequate amount of knowledge for caring their patients. But as nurses stayed for long time without implementing nursing process their knowledge might be depreciated.
Attitude and skills Most of the respondents described that nurses were not committed to implement nursing process. There were several reasons that make nurses to become negligent about their responsibility. The first reason was their experience. From their experience they were recording their activities and fighting for the betterment of nursing but nothing was changed rather the value of nursing was declining. The second reason was absence of recognition for the highly devoted nurses. They were advocating for the patient from the beginning history of nursing in Ethiopia yet they were not considered as they could contribute anything for the health of the country. The third reason was poor payment.
The nursing process is a widely accepted method and has been suggested as a scientific method to guide procedures and qualify nursing care. In Ethiopia, quality of health care was poor and to improve the quality of health service, application of nursing process may contribute a lot. [9] Regarding resources related factors, this study revealed that 50 (61.0%) of nurses agreed upon several resources' barriers, which included inadequate staff in the unit, lack of specified nursing care document and education budget, insufficient equipment and absence of supplies and materials. These results were in line with the previous studies. Another most challenging factor was nurses to patient's ratio in which one nurse giving care for more patients in their hospital. Half 41 (50%) of the respondent said that the nurse to patient ratio was not optimal to apply the nursing process; whereas only 37 (45.1) said that the allocated time was sufficient. There is lack of time to apply the nursing process. Forty 40 (48.8%) of the respondents believes that as there is shortage of time to implement nursing process.
Forty two (51%) of the respondents said that there is no available appreciating feedback for the nursing process implementation. Majority of the nurses 69 (84.1%) worked over time with payment 54 (65.9%) which was not enough payment 54 (65.9%). This is with lower than research conducted in Addis Abeba city hospitals which is Only 9 (5.7%) of the respondents were satisfied with the over time payment where as 148 (94.3%) were not satisfied with the payment. [7] Sixteen 16 (19.5%) of respondents were highly knowledgeable and 39 (47.6%) were moderately knowledgeable while 27 (32.9%) had not knowledgeable. These results were almost in line with study conducted at College of Medicine and Health Sciences, Arbaminch University, Arbaminch, Ethiopia in which 23.34% of respondents were highly knowledgeable and 44.9% were moderately knowledgeable while 31.63% had not knowledgeable. [5] According to both the qualitative and quantitative findings nurses of the study sites have positive attitude towards the nursing process. A survey on the attitudes of nurses toward the nursing record revealed that Nursing process enables to provide quality nursing care to pts. Thirty seven (45.1%) of respondents reported that they followed the nursing process in the provision of care to their clients. This is lower than research conducted in Bale zone hospitals which was 52.1%of respondents reported that they followed the nursing process in the provision of care to their clients. (15) Fifty seven (69.5%) respondents were safely administer medicine and other therapies very much but 6 (7.3%) were not at all administered. This is somewhat similar with research conducted in Addis Abeba which was 57.8% respondents were safely administer medicine and other therapies very much but 1.6%) were not at all administered. [7] This study showed that organizational factor influence the implementation of nursing process more than other variables. One of the biggest problems currently facing the nursing profession is that of implementing the nursing process was lack of equipment's, formats for formulating nursing care plan and lack of administration supports were identified. Practice factor ranks the second highest predictive value in the use of nursing process but currently, many institutions do not use nursing process for the care of their clients. Lack of application of the nursing process as a standard of care can reduce job satisfaction, incorrect evaluation, reduction in the quality of care, neglecting of some of the authorities to this field, devaluation of this profession by nurses themselves and their excessive dependency to the physicians, indisputable obedience, doing routine activities without thinking, conducting one dimensional care, reduce in patients independence and costing heavy expenses due to doing repeated acts.
It is well known that nursing process implementation is very essential to maintain nursing as profession. The following measures should be taken to minimize the burdensome of factors affecting implementation of nursing process. In order to achieve quality health care service, quality nursing care is the key element and to fill this demand application of the nursing process have a significant role, but in practice application of the nursing process is not well developed. Based on these facts the principal investigator would like to give the following recommendations: 1. Hospitals should provide the appropriate supply of instruments for nursing care. 2. Hospital managements including the medical directors should be enlightened on the benefits of the process in terms of patients' outcome. This will enhance regular supply of the needed materials for the practice of the nursing process and motivate the staff nurses. 3. Hospital officials should get the right information about nursing. 4. Health facilities must provide in-service education or periodical training to update the knowledge of nursing process. 5. There should be regular supervision of nurses by head nurse / matron 6. Change the training/practice system to make nursing a well recognized profession by the society and professionals themselves.