Implementation of nursing process in clinical settings: the case of three governmental hospitals in Ethiopia, 2017
Semachew BMC Res Notes
Implementation of nursing process in clinical settings: the case of three governmental hospitals in Ethiopia, 2017
Ayele Semachew 0
0 com Department of Nursing, College of Medicine and Health Sciences, Bahir Dar University , PO Box. 79, Bahir Dar , Ethiopia
Objective: The purpose of this survey was to evaluate the implementation of the nursing process at three randomly selected governmental hospitals found in Amhara Region North West Ethiopia. Result: From the total 338 reviewed documents, 264 (78.1%) have a nursing process format attached with the patient's profile/file, 107 (31.7%) had no nursing diagnosis, 185 (54.7%) of nurses stated their plan of care based on priority, 173 (51.2%) of nurses did not document their interventions based on plan and 179 (53.0%) of nurses did not evaluate their interventions. The overall implementation of nursing process among Felege Hiwot Referal hospital, Debretabor general hospital and Finoteselam general hospitals were 49.12, 68.18, and 69.42% respectively. Nursing professionals shall improve documentation required in implementing the nursing process. Nursing managers (matron, ward heads) shall supervise the overall implementation of nursing process. Hospital nursing services managers (matrons) shall arrange and facilitate case presentations by the nursing staffs which focus on documentation and updates on nursing process. Hospitals need to establish and support nursing process coordinating staff in their institution.
Nursing; Nursing process; Implementation; Survey; North West Ethiopia
Nursing has always been directed to keep people healthy
and provide comfort, care, and assurance to the patients.
The nursing care, therefore, may involve any number of
activities ranging from carrying out complicated
technical procedures to something as simple as holding a hand
of the patient. The central focus of nursing care is the
person receiving care and included the physical,
emotional, social and spiritual dimensions of that person.
Nursing care, therefore, refers to care of others [
Nurses have many demands on their time as they
provide care and document their work in a descriptive
manner. In order to better meet the needs of their patients,
the nurses developed a care plan with special forms [
Nursing process (NP) is a systematic method which
utilizes scientific reasoning, problem-solving and critical
thinking to direct nurses in caring for patients effectively
The 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 steps; Assessment, Diagnosis, planning,
implementation and evaluation [
The nursing process was initially an adapted form of
problem-solving technique based on theory used by
nurses every day to help patients improve their health
and assist doctors in treating patients. Its primary aim
is to know the health status and the problems of
clients which may be actual or potential. It is made up of
a series of stages that are used to achieve the objective—
the health improvement of the patient. The use of
nursing process can stop at any stage as deemed necessary or
can be repeated as needed. This process is inclusive of
physical health as well as the emotional aspects of patient
health. Nursing knowledge is used throughout the
process to formulate changes in approach to the patient’s
changing condition [
Many nurse researchers and theorists are in agreement
that nursing process is a scientific method for delivering
holistic and quality nursing care. Therefore, its effective
implementation is critical for improved quality of nursing
care. When the quality of nursing care is improved,
visibility of nurses’ contribution to patient’s health outcomes
becomes distinct. In this way, nurses can justify the claim
that nursing is a science and an independent profession
Nurses are the largest group of health professionals in
all countries. Nursing care quality is closely related to a
health care system’s effectiveness. In order to achieve
the quality of health care service, quality of nursing care
is the key element and to fill this demand application of
the nursing process has a significant role, but, in practice,
application of the nursing process is not well developed
The gap between research evidence and clinical
practice is one of the most persistent problems in the
provision of quality healthcare. Approximately 30–40% of
patients do not receive health care according to current
scientific evidence and some patients receive
unnecessary or harmful care [
Since nurses are the key caregivers in hospitals, they
can significantly influence the quality of care provided
and, ultimately, treatment and patient outcomes. Despite
their knowledge of the nursing process, certain factors
limited the ability of nurses to implement it in their daily
practice, including lack of time, high patient volume, and
high patient turnover. Despite these hurdles, the daily
application of the nursing process is characterized by
the scientific background of the professionals involved
since it requires Knowledge and provides individualized
human assistance [
Though application of nursing process is running as a
standard of care for many developed countries
practically it faces many challenges. Despite there is no strong
commitment on the implementation of nursing process
in many hospitals in our country the problem is rampant.
As we know many studies has been conducted and they
identified different factors for the implementation of
nursing process. Irrespective of many identified factors
that impend nursing process implementation, the
purpose of the current survey was to evaluate the
implementation of the nursing process at three randomly selected
governmental hospitals found in Amhara Region North
The study was conducted in three randomly selected
governmental hospitals found in Amhara Regional state,
North Western Ethiopia, Namely Felege Hiwote
Comprehensive Referral Hospital, Debre Tabor General Hospital
and Finoteselam General Hospital. The study was
conducted from February 30 to March 30/2017.
Hospital-based descriptive and retrospective study
design was used and the nursing process registration in
inpatient records was also checked to inquire all
pertinent information regarding on the implementation of
All patient documents’ found in the selected hospital’s
record unit and in the nursing station room.
All sampled patient documents’ found in the selected
hospital’s record unit and nursing station room
having Medical Registration Number (MRN) in the last
Inclusion and exclusion criteria
All cases from medical, surgical and orthopedics wards
were included whereas cases from the outpatient
department were not included.
Sample size determination
Sample size (n) is determined using a single proportion
formula using proportion (p) of nursing process
implemented 32.7% from a study conducted in Arbaminch
General Hospital, South Ethiopia [
] level of precision
(d) 0.05 at 95% confidence interval (Zα/2) that gives 338
cases to be included.
In order to select a representative sample from each
hospital, the total number of inpatients in the last 6 months
were obtained and then samples were proportionally
allocated for each hospital. Based on this, 160 patient’s
documents were seen from Felege Hiwote Comprehensive
Referral Hospital, 110 from Debre Tabor General
Hospital and 68 were seen from Finote Selam General Hospital.
Then systematic random sampling using patients MRN
was used to select eligible documents.
Data collection procedures
Instrument for data collection
Socio-demographic information that includes: age, sex,
educational status, marital status, occupation, ethnicity,
previous hospitalization, length of hospitalization were
included. Nursing process implementation checklist was
prepared in English language to assess the
documentation which was done by nurse professionals in the three
Personnel for data collection
A total of 3 personnel were involved for data collection
process and one BSc nurse was assigned to supervise the
overall data collection process. All data collectors were
oriented for a half day about the instrument and the data
Data quality control
Before conducting the actual data collection, pretest was
done on 5% of the total sample size in Debre Markos
Hospital. The collected data were reviewed and checked
for completeness and relevance by the supervisor.
Incomplete questionnaires were returned to the data collectors
on the following day for the correction by revisiting the
Implementation of nursing process.
• Socio-demographic factors
• Nursing care provided.
Operational definition and definition of terms
Nursing process A deliberate problem-solving approach for
meeting people’s health care and nursing needs;
common components are assessment, diagnosis,
planning, implementation, and evaluation
Assessment The systematic collection of data to determine the
patient’s health status and any actual or potential
Nursing diagnoses Actual or potential health problems that can be
managed by independent nursing interventions
Planning Development of goals and outcomes, as well as
a plan of care designed to assist the patient in
resolving the diagnosed problems and achieving
the identified goals and desired outcomes
Implementation Actualization or carrying out of the plan of care
through nursing interventions
Evaluation Determination of the patient’s responses to the
nursing interventions and the extent to which
the outcomes have been achieved.
Nursing process Hospitals that document all the components of
implemented nursing process in the patient file
Data procedures and analysis
The data were edited, coded and entered into Epi-Data
version 3.1 and exported to IBM SPSS Statistics
Version 20 for analysis. Results of the data analysis were
presented in the form of descriptive statistics which
included mean, standard deviation and percentages.
The results were summarized and presented by tables,
charts, and graphs.
Among the reviewed documents 190 (56.2%) were male
and 148 (43.8%) were female. Two hundred twenty-four
(66.3%) were married whereas 9 (2.7%) were widowed.
Three hundred seven (90.8%) were orthodox
Christian while 2 (0.6%) were protestant in their religion.
Regarding educational status 138 (40.8%) were illiterate
were as 45 (13.3%) were completed college and above.
Concerning to occupation 75 (22.2%) were housewife
whereas 2 (0.6%) were Non-governmental
Organizations (NGOs) worker. One hundred eighty-nine (55.9%)
were living in the rural part whereas 149 (44.1%) were
living in urban areas (Table 1). The minimum age of the
study participants was 18 and the maximum age was
88, the average hospital stay was almost 8 days.
Overall implementation of nursing process
From the total 338 reviewed documents, 264 (78.1%)
have a nursing process attached with the patient’s profile/
file, 107 (31.7%) had no nursing diagnosis, 185 (54.7%)
of nurses stated their plan of care based on priority, 173
(51.2%) of nurses did not document their interventions
based on plan and 179 (53.0%) of nurses did not evaluate
From the total 160 reviewed documents at Felege
Hiwote Referral Hospital 100 (62.5%) of patient’s
documents had nursing process attached with their file, from
110 reviewed documents at Debretabor General
Hospital 99 (90%) of patient’s documents had nursing
process attached with their file. Sixty eight documents were
reviewed at Finoteselam General Hospital; 65 (95.6%) of
patient’s documents had nursing process attached with
Regarding documenting the nursing diagnosis; among
the total reviewed 160 documents at Felege Hiwote
Referral Hospital 95 (59.4%) had nursing diagnosis whereas
from the total 68 reviewed documents at Finoteselam
General Hospital 54 (79.4%) had a nursing diagnosis.
Concerning to nursing intervention; 65 (40.6%) of
reviewed documents at Felege Hiwote Referral Hospital
had a written nursing intervention whereas 63 (57.3%)
of reviewed documents at Debretabor General Hospital
had a written nursing intervention. Sixty-one (55.5%)
documents reviewed at Debretabor General Hospital had
evaluated their nursing interventions whereas 66 (41.3%)
of reviewed documents at Felege Hiwote Referral
Hospital had evaluated their nursing interventions. Overall
discrepancies have been found in the implementation of
nursing process among the three hospitals (Table 2).
The overall implementation of nursing process of the
two hospitals namely Debretabor General Hospital and
Finoteselam General Hospital had almost similar
implementation where as Felege Hiwot Referal Hospital’s
performance in implementing the nursing process was low
in comparision with the aformentioned two hospitals
The aim of this survey was to evaluate the
implementation status of nursing process at three
governmental hospitals of Amhara Region, North West Ethiopia.
Ethiopia as one of the developing country faced limited
resource to implement different health and health-related
Is there nursing process attached with the patients’ file?
Is there a clearly stated nursing diagnosis?
Does the plan of care stated based on priority?
Does the nursing intervention well documented based
on their plan?
Do nurses evaluate their intervention?
Many studies on the implementation of Nursing
Process and associated factors among nurses have been done
here in Ethiopia and as well in abroad. But almost all
of the study subjects were nurses themselves and as we
know these will lead a social anticipated bias that may
overestimate the finding. But the current survey may
overcome this drawback since we are collecting the data
after reviewing patient documents (document review).
And the finding of the current survey was low which was
Utilization of the nursing process in many low and
middle-income countries has been a challenge [
of the respondents said that they did not use the
nursing process during provision of care to their patients at
the time of the study. The majority (75%) of the
respondent said that the nurse to patient ratio was not optimal
to apply the nursing process [
]. The main discrepancy
here is that before 2015 the implementation of nursing
process was not a big deal in many hospitals rather there
was a format which was prepared by the federal
ministry of health which was different from nursing process.
A study was done in Nigeria also revealed that although
the trained nurses at the hospital had good theoretical
knowledge of the nursing process, they did not apply it in
the care of their patients [
Hospital nursing services managers (matrons) shall
arrange and facilitate case presentations by the
nursing staffs which focus on documentation and updates on
The current study is a survey of secondary data from a
nursing process implementation and this method does
not provide the cause effect relationship.
NP: Nursing process; MRN: Medical Registration Number; NGOs:
Non-governmental Organizations; RERC: Research Ethical Review Committee.
AS wrote the proposal, participated in the data collection, analyzed the
data, and drafted the paper including the manuscript. The author read and
approved the final manuscript.
For data collectors and respective hospital administrators.
The author declare no competing interests.
Availability of data and materials
Consent for publication
Ethics approval and consent to participate
Ethical clearance was obtained from Research Ethical Review Committee
(RERC) of Bahir Dar University College of Medicine and Health Sciences, and
permission and supporting letter was secured for each respective hospital
administrators before data collection. Written informed consent was also
obtained from each ward heads. No names or identifying information were
indicated on the checklist, and all confidentiality issues were assured.
No fund was obtained.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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