UTILISATION OF THE NURSING PROCESS FOR PATIENT CARE IN GHANA: THE CASE OF NURSES OF TAMALE TEACHING HOSPITAL

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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