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Вестник РУДН. Серия: МЕДИЦИНА 2022;26(1):79-87
RUDN Journal of MEDICINE. ISSN 2313-0245 (Print). ISSN 2313-0261 (Online) http://journals.rudn.ru/medicine
ОРГАНИЗАЦИЯ ЗДРАВООХРАНЕНИЯ И ОБЩЕСТВЕННОЕ ЗДОРОВЬЕ
HEALTH POLICY AND PUBLIC HEALTH
DOI 10.22363/2313-0245-2022-26-1-79-87
RESEARCH ARTICLE НАУЧНАЯ СТАТЬЯ
Nursing process application in Nepal teaching hospital
Katel Kalpana О
Gandaki Medical College Teaching Hospital and Research Center, Pokhara, Nepal E3 katelkalpana@gmail.com
Abstract. Relevance. Nursing process is a scientific method of organizing and providing nursing care. Due to imbalance of nurse patient ratio, application of nursing process in actual clinical setting is very limited which reduces the quality nursing care. Despite the importance of application of nursing process, there is no standard nursing process protocol available in the hospital where study was carried out. The governments set a standard nurse patient ratio in Nepal, UK and USA is 1:10, 1:8, and 1:5 respectively. However, global statistic has been revealed due to improper nurse patient ratio which cannot implement the nursing process for patient caring which are being for leading cause of mortality of patient in hospitals. Aim of the study. The study was conducted to assess the application of the nursing process among nurses working in teaching hospital. Additionally, this study explores the association between status of application of nursing process and selected variables. Materials and Methods. Based on a descriptive cross-sectional study design. A simple random sampling technique was applied for nurses working in tertiary hospital of Chitwan, Nepal. The data was collected using structured questionnaire among 182 nurses. The statistical analysis tool chi-square was used to find out the association and logistic bivariate to find out the odds ratio. Results and Discussion. The result indicates that only 23.1 % of nurses have moderate level of application of nursing process. Majority of nurses did not follow standard ways of nursing process. This study also explored the influencing variable for barriers related to nurses and profession. Age (p=0.001), professional qualification (p=0.001) and learning approach (p=0.022) were the significant influencing variable for barriers related to nurses whereas practical skill (p= <0.001), cooperation among nurses (p=0.008) and difficulty in diagnosis characteristic (p=0.010) were the barrier related to profession. Conclusion. It was concluded that the majority of nurses working in teaching hospital of Nepal did not follow the standard ways of nursing process so that barriers for the application of nursing process are identified. The overall ratio of nurses to patients in the teaching hospital is 1:16, that is in the lower range than the standards set by the government. Therefore, special attention must be paid to adherence to a standardized nursing process protocol for quality medical care.
Key words: application, nurses, barriers, nursing process
Author contributions. Katel K.—concept, collection and processing of material, analysis of the data obtained, interpretation of the data and approval of final manuscript.
© Katel K., 2022
—^—| This work is licensed under a Creative Commons Attribution 4.0 International License I^^hs^h https://creativecommons.org/licenses/by/4.0/
Received 07.11.2021. Accepted 17.01.2022.
Conflict of interest statement. The author declares no conflict of interest.
Acknowledgement. I would like to thank all the study subjects who kindly cooperate in providing required information even during the research period.
For citation: Katel K. Nursing process application in Nepal teaching hospital. RUDN Journal of Medicine. 2022;26(1):79-87. doi: 10.22363/2313-0245-2022-26-1-79-87
Introduction
Nursing is the profession which concern with protection, promotion and optimization of health and abilities, prevention of illness and injury; alleviation of suffering through the diagnosis and treatment of human response; and advocacy in health care for individuals, families, communities and population [1]. The discipline of nursing is synonymous with the nursing process. It is an organized, systematic approach used by nurses to meet the individualized health care needs of their patients. Nursing Process is the use of clinical judgment in the provision of care to the enable people to improve their health, to cope with health and their problems, and to achieve the possible quality of healthy life, whatever their disease or disability, until death [2].
Lydia Hall, first referred to nursing as a «process» on journal article in 1955. The nursing process was widely used from early 1970s [3]. The nursing process is referred as a series of steps: assessment, planning and evaluation [4]. The study described nursing process as a principle of an effective interaction with the patient that lead to effective interventions and most likely to positive outcomes [4]. Only the single effort of the nurse side was not sufficient for the patients. Orlando emphasized on creating the good environment for mutual understanding with the patient. Since, every patient and nurse are individual and it is understandable that persons taking part in interaction might perceive the situations in a very different way.
Currently nursing process is widely accepted as a scientific method to guide procedures and quality nursing care. The process consists of systematic and dynamic way to deliver nursing care operating through five interrelated steps: assessment, diagnosis, planning, implementation, and evaluation [5]. In fact,
nursing process provides holistic and quality nursing care and effective implementation is critical part for patients. However, it was highly challenges for its fully implementation in most of the hospitals in developing countries [6]. In Sweden, standardized nursing care plans (SNCPs) was successful in 73 %. In spite of their knowledge of the nursing process, certain barriers limited the ability of nurses to implement it in their daily practice; including lack of time, high patient volume, and high patient turnover [7]. Despite of hurdles, the daily application of nursing process is characterized by the scientific background of the professionals involved [8]. The several international health organizations highly recommended for the documentation and promote the use of nursing process in patients care [9]. World Health Organization (WHO) measured shortages with nurse to people rations that can vary from region to region within country, country to country and continent to continent.
In Nepal, the average ratio of nurse is 70 per 100,000 population [10]. The ratio was 21, 847 and 858 in Ethiopia, UK and USA respectively [11]. The previous studies indicate that the average ratio of nurse to population is high developed countries almost 8 times greater than in developing countries. Low availability of nurses in many developing countries is exacerbated by geographical maldistribution [6]. These were the clear indication of shortage of nurses in different parts of the world. The researches highlight that as nurse-to-patient ratios increased from 1:4 to 1:10, the number of post-op surgical patient death also climbed up dramatically [12]. Adverse events occur in an estimated 2.9 to 3.7 percent of acute care hospitalizations in the United States America (U.S.A), and it is estimated that between 44,000 and 98,000 patients die in hospital each year as a result, with nearly half due to errors in delivery
of care [13]. On the other hand, nurse who work in stressful environment were 0.23 time less likely to implement nursing process than working in organized environment. Highly knowledgeable nurses were 8.78 times more likely to implementation of nursing process than nurses who were not knowledgeable [14].
The researchers also highlighted the challenges in the implementation of the nursing process. The main barriers were lack of sufficient enthusiasm in using the nursing process, shortage of nursing staff, lack of standard format for writing, lack of follow up and monitoring, inadequate time for using, lack of attention to its importance, deficient in clear instruction, inadequate education and no believe in applying the patient care according to the nursing process [15]. A study reported that the barriers for the implementation of the nursing process were inadequate nursing staff (75.6 %), inadequate equipment (71.5 %), lack of time (62.6 %), lack of theoretical and practical knowledge (47.2 %), lack of nursing records (26 %) and lack of institution for nursing care with in the hospital (17 %) [16].
In practical aspect all the steps are not implemented systematically. The main difficulties in establishing
and using the nursing process within institutions is the complexity potentially associated study variables. Advancing in knowledge on this process involves the exploration and analysis of variables related not only to the usage characteristics of the NP at institutions, but also to the characteristics of the institutional and nursing professionals' environment [17]. In this context, this study explores the status of application of nursing process among nurses working in teaching hospital in Nepal. The research will also analyze the association between status of application of nursing process for different variables.
Materials and methods
Research variables
In this study, dependent and independent variable were considered for statistical analysis purpose. The application of nursing process was considered as dependent variable whereas independent variables were tabulated in Table 1.
Table 1.
Independent variable
Nurses related factor Institutional factors Profession related variables
• Age • Professional qualification • Professional experiences • Current work experiences • Working unit • Self-awareness • Learning approaches • Level of performances • Professional attitude • Participation in in-services education of nursing process • Learning environment • Adequate resources • Available guidelines/ protocol on nursing process • Nurse patient ratio • Positive reinforcement • Practice to motivation • Evidence based practice • Nursing audit • Working environment • Provision for supervision • Staff turnover • Professional role model • Professional commitment • Lack of time • variation between theory and practice • Structural barriers within the hospital's facility • High patients turn over • Attitude of patients • Lack of process check list in patients' medical records • Lack of positive attitude towards Nursing process • Time consuming • Training for the nursing process • Practical skills • Complex process • Exposure to Nursing process • Nurses autonomy • Nurses co operation • Difficulty with in diagnostic characteristic • Frequent change of working wards • Appropriate format for nursing process • Attention by authority
Theoretical model
In this study, Synergy Model is used in which nurse-patient interaction as reciprocal and constantly evolving. Synergy, or ideal patient outcomes, can be reached by matching patient needs and characteristics with appropriate nurse competencies to work towards common goals in a mutually enhancing manner. It identifies the patient as the central focus, describing the patient's needs and the skills required of the nurse to best meet those needs. It also provides a framework for outcome evaluation for the patient, the nurse, and healthy working environment. The basic premise of the model is that patient needs drive nurse skill sets; when nurse skills are matched to the needs of the patients, synergy occurs and patient's outcomes are optimized (Fig. 1).
Research setting and population
The setting of study was in Chitwan Medical College Teaching Hospital (CMCTH) which has 750 beds. It provided different services like outpatient services, inpatient services and different wards. The institution is one of the referral hospitals in Chitwan, Nepal. The study was conducted among nurses working in all departments, except Operation theatre and Outpatient Department. The study population (N=325) staff nurse working at CMCTH.
• Sample size calculation
Sample size was calculated by using the empirical relationship for finite population on the basis of proportion of application of nursing process. The total of 33.1 % from the study total sample were considered for assessing barriers to implementation of nursing process among nurses [18].
viorkjjig^a^v
QL---/- _■
rOv / «
/ /Vurse competences'
^ / / / /SNP* \ Patient need (
S?/ -W Application of [SYNE Quality nursing ,
! 1 . ' RGY Icare trom nurses , O / ^_[_^ \ Nursing -'
ËL1 '
Fig.1. Theoretical model on application of nursing process among nurses working in teaching hospital
• Inclusion criteria
Nurses who were qualified of PCL/BN/BSC working at CMCTH and giving inform consent to participate and personal data processing were included in the study.
• Exclusion Criteria
The nurses who are working at outpatient department and the Matron of the hospital as well as nurses having educational degree of Master in Nursing was excluded.
• Sampling Technique
Sampling technique with simple random table method was used for selection of nurses by considering CMCTH.
Research instrumentation
A structured questionnaire for application of nursing process and barriers for the application of nursing process was developed by the researcher through extensive literature review. The research instrument consists two parts: a) questions related to barriers for the application of nursing process (nurses related, institution related and profession related) and b) question related to application of nursing process.
Analysis of statistical data
The collected data was checked, edited, coded and entered into epi data then was exported to IBM SPSS program. The results were calculated in terms of descriptive statistics for frequency, percentage and inferential statistic for chi-square test.
Results and discussion
Analysis and interpretation of results
In this section, the analysis and interpretation of the results obtained from the 182 nurses working in different wards of Chitwan Medical College and Teaching Hospital in Nepal was presented and discussed.
Status of the application of nursing process
Age, education, professional experience, self-awareness level and professional attitude are considered as nurse related variables. The data exposes that nurses
age ranged from 19-35 years with the median age of 22. Majority of the nurses (67.6 %) belongs to age group of 20-25 years. Total 78.6 % of nurses have Proficiency Certificate Level Nursing (PCL) degree. In regards professional experience 37.4 % of nurses had more than 1-year work experience. More than half of the nurses (67 %) reported that they were self-awareness by themselves. Regarding level of performance 45.6 % nurses are competent in performance. Majority of nurses 97.3 % reported that they had good professional attitude towards friends. Most of the nurses (95.6 %) did not received the in-service education.
The clinical learning environment, resources for patient care, protocol/ guidelines, nurse patient ratio, awareness aware the application of nursing process, evidence-based care and staff turnover are considered as institutional related variable. The results show that 78 % of nurses reported that there is inadequate clinical learning environment. Majority of nurses 90.1 % reveals that inadequate resources for the patient care in the wards. 90.1 % of nurses reported that there are no any protocol/guidelines for nursing process in their wards. Must of the nurses 89 % reveals that nurse patient ratio is not maintained according to ward. Majority of nurses 80.8 % had positive reinforcement toward nursing process. 84.1 % nurses reveal that they are motivated to apply nursing process by seniors. More than half 51.1 % of nurses are practicing evidence-based care for the patients. Majority of nurses 82.4 % reported that nursing audit had done monthly. More than half 67 % of nurses reveals that they had stressful working environment. Regarding supervision by seniors is adequate, 95.6 % nurses reported. Majority of nurses 98.9 % reported due to high turn-over of staff is the barriers for the application of nursing process.
The participants respond on the barriers for the application of nursing process related to professional reason are: lack of professional role models (80.8 %), lack of commitment with in profession (79.7 %), lack of time (85.2 %), variation between theory and practice (90.7 %), structural barriers within hospital (96.7 %), high patient turn over (94 %), attitude of patient (95.1 %), lack of nursing process check list
in patient medical records (94 %), lack of positive attitude towards nursing process (81.3 %), due to time consuming (76.4 %), lack of training for nursing process (74.2 %), lack of exposure to nursing process (89.6 %), lack of nurses cooperation (63.7 %), difficulty in diagnosis (61.5 %), frequent change of staff in wards (67.6 %), lack of appropriate formats for nursing process (97.8 %), lack of attention of authority for the importance of nursing process (61 %).
The finding of the present study revealed that overall compliance of practice to application of nursing process was 100 % not applicable which is similar to the study [19]. In level of application of nursing process only 23.1 % of nurses had moderate level of practice followed by 76.9 % of nurses had low level of practice regarding application of nursing process which is less than the previous studies [18, 20]. The discrepancy may be because of many barriers within the country which are normally associated with nurse, institution and profession. Overall compliance of practice along with moderate level of practice regarding nursing process among nurses less than 25 % indicate that low level of practice which warrants very immediate action for the improvement. The differences in the overall compliances of practice regarding application of nursing process among nurses in context of Nepal might be due to lack of protocol /guidelines regarding application of nursing process, nurses competency level, shrinking of clinical field, lack of exposure to the care plan, privatization of nursing education with profit motive, limited use of evidence based practice, limited exposure of nurses, brain drain, loop holes during accreditation of nursing college and hospitals, lack of attention by the authority regarding importance of nursing process.
Findings of the study unveiled that practice level of the nurses regarding nursing process was significantly associated with age (p=0.001) younger nurses were more likely to do application of nursing process which is similar to the study [21]. Bachelor nurses were more likely to do application of nursing process, though only 21.4 % nurses acquired bachelor level nursing education which is less than the previous study [22]. Likewise,
level of practice of nurses regarding nursing process was significantly associated with lack of practical skill among nurses (p=<0.001), lack of nurses' cooperation among nurses (p=0.008), difficulty with diagnostic characteristic (p=0.010) which is similar to the study [23].
Association between status of application of nursing process among nurses and selected variables
The analysis indicates that the application of nursing process is 100 % not applicable. The application status has been further divided into three different levels as low, moderate and high. Among 182 nurses 76.9 % had low (< 55 %) application of nursing process, 23.1 % moderate (55-80 %) application of nursing process among nurses.
Barriers encountered for the application of nursing process
Results indicate that there was statistically significant association between the application of nursing process and age of the nurses (p=0.001), professional qualification (0.001), learning approach (0.022). It indicates that application of nursing process is comparatively higher in bachelor level nurses. There was no significant association between application of nursing process and others nurses related variables. There was no significant association between application of nursing process and institution related variables. The results also show that there is significant association between application of nursing process and lack of practical skill among nurses (p=<0.001), lack of cooperation among nurses (p=0.008), difficulty with diagnosis characteristic (p=0.010). There was no significant association between application of nursing process and others profession related variables.
The nurses in this study had positive attitude (80.8 %) towards nursing process but did not practice nursing process. The barriers for the application of nursing process were did not get in-service education (95.6 %), no any protocol/guidelines for nursing process (92.9 %), inappropriate nurse patient ratio (89 %), stressful working environment (67 %), lack of training (85.7 %), lack of time
(85.2 %), inadequate resources for patient care (90.1 %), were not found statistically significant with the level of application of nursing process among nurses.
Bivariate logistic regression for the application of nursing process
In the bivariate analysis of logistic regression, six variables were statistically associated with the level of application of nursing process. Namely age of the more than 25 years was almost double more likely to do the application of nursing process than less than age of 20 years (OR=0.044, 95 % CI= 0.005-0.373) and more than age of 20-25 years (0R=0.411, 95 % CI= 0.175-0.969). Professional qualification of the BN/BSC nurses were more likely to do application of nursing process than PCL nurses (0R=0.274, 95 % CI=0.127-0.590). Learning approaches of deep learner (0R=2.551, 95 % CI= 1.120-5.813) were more than two times likely to use application of nursing process than surface learner (0R=0.891, 95 % CI=0.297-2.676) and strategic learner. Due to lack of practical skill among nurses were four time likely to be the profession related barriers for the application of nursing process were moderately applying the nursing process during care of patient (0R= 3.805, 95 % CI= 1.821-7.949). Due to lack of cooperation among nurses were double likely to be the barriers related to profession where moderately application of the nursing process (0R=0.333, 95 % CI=0.144-0.771). Due to difficulty in diagnostic characteristic were double likely to be the barrier related to the profession where moderately application of the nursing process (0R=0.353, 95 % CI =0.157-0.793).
Conclusion
From the study, it is concluded that more than three 75 % of nurses falls under the low level of application of nursing process and 25 % nurses fall under moderate level of application of nursing process. The study indicates that the level of application of nursing process was low among nurses working at teaching hospital during the study period. The general practice in study hospital is 1:16 which is in the lower range than the standards set by the government. Barriers
associated with application of nursing process among nurses working in hospital were; age of the respondent, professional qualification, learning approaches, practical skills, cooperation among nurses, difficulty in diagnosis characteristic and low level of application for nursing process were identified in this study.
Implications for nursing practice
• The study findings can enable the nurses to focuses on patients' needs and to apply the nursing knowledge in the organization.
• The findings of this study can be helpful to the nursing administrator/ Matron, Nursing Council, Nursing Association for planning and implementation of in-service education program on application of nursing process by nurses.
• It develops and implement guidelines on «application of nursing process».
• The findings of this study can be useful as a source of baseline information for future researcher.
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Применение сестринского процесса в клинической больнице Непала
К. Кател ®
Больница и исследовательский центр медицинского колледжа Гандаки, г. Покхара, Непал
ЕЕЗ katelkalpana@gmail.com
Аннотация. Актуальность. Сестринский процесс—это научный метод организации и оказания сестринской помощи. Из-за дисбаланса соотношения медсестер и пациентов применение сестринского процесса в реальных клинических условиях очень ограничено, что снижает качество сестринского ухода. Несмотря на важность применения сестринского процесса, в больнице, где проводилось исследование, не существует стандартного протокола сестринского процесса. Правительство установило стандартное соотношение медсестер и пациентов в Непале, Великобритании и США: 1:10, 1:8 и 1:5 соответственно. Тем не менее, при исследовании было выявлено неправильное соотношение медсестер и пациентов, которые не могут реализовать сестринский процесс для ухода за пациентами, что является основной причиной смертности пациентов в больницах. Цель исследования. Исследование было проведено для оценки применения сестринского процесса среди медицинских сестер, работающих в поликлинике. Кроме того, в этом исследовании изучается связь между статусом применения сестринского процесса и выбранными переменными. Материалы и методы. Был использован дизайн перекрестного исследования. Для медсестер, работающих в больнице третичного уровня в Читване, Непал, был применен простой метод случайной выборки. Данные были собраны с помощью структурированного вопросника у 182 медсестер. Инструмент статистического анализа хи-квадрат использовался, чтобы выяснить связь переменных, препятствующих, применению сестринского процесса, связанных с медсестрами и профессией; и логистический двумерный метод,—чтобы выяснить отношение шансов. Результаты и обсуждение. Результаты показывают, что только 23,1 %
медицинских сестер имеют средний уровень применения сестринского процесса. Большинство медсестер не следовали стандартам сестринского процесса. В этом исследовании также изучались переменные, препятствующие, применению сестринского процесса, связанные с медсестрами и профессией. Возраст (p = 0,001), профессиональная квалификация (p = 0,001) и подход к обучению (p = 0,022) были значимой переменной, связанной с медсестрами, тогда как практические навыки (p = <0,001), сотрудничество между медсестрами (p = 0,008) и трудность диагностики (p=0,010)—препятствия, связанные с профессией. Выводы. Большинство медсестер, работающих в клинической больнице Непала, не следовали стандартным протоколам сестринского процесса, поэтому были выявлены препятствие для применения сестринского процесса. Общее соотношение медсестер и пациентов в учебной больнице составляет 1:16, что ниже стандартов, установленных правительством. Таким образом, необходимо уделять особое внимание соблюдению стандартизированного протокола сестринского процесса для качественного оказания медицинской помощи.
Ключевые слова: применение, медсестры, препятствие, сестринский процесс
Вклад авторов. Катель К.—концепция, сбор и обработка материала, анализ полученных данных, интерпретация данных и написание рукописи.
Благодарности. Автор благодарит всех участников исследования, которые любезно сотрудничали в предоставлении необходимой информации даже во время пандемии.
Информация о конфликте интересов. Автор декларируют отсутствие конфликта интересов.
Поступила 07.11.2021. Принята 17.01.2022.
Для цитирования: Kaplana K. Nursing process application in Nepal teaching hospital // Вестник Российского университета дружбы народов. Серия: Медицина. 2022. Т. 26. № 1. С. 79-87. doi: 10.22363/2313-0245-2022-26-1-79-87
Corresponding author: Katel Kaplana—Lecturer, College of Nursing, Gandaki Medical College Teaching Hospital and Research Center. 33700, Pokhara-27, Nayabazar Rd, Kaski, Nepal. E-mail: katelkalpana@gmail.com ORCID 0000-0002-1615-4261
Ответственный за переписку: Кател Каплана—доцент Медицинского колледжа, клинического и исследовательского центра Гандаки, Непал, 33700, ул. Найабазар, г. Покхара. E-mail: katelkalpana@gmail.com Каплана К. ORCID 0000-0002-1615-4261
