Perceived barriers and facilitators to nursing process usage: a narrative review

BMC Nursing https://doi.org/10.1186/s12912-026-04739-0 Article in Press Perceived barriers and facilitators to nursing process usage: a narrative review Kashif Khan & Fazal Khaliq Received: 10 October 2025 Accepted: 5 May 2026 Cite this article as: Khan K. & Khaliq F. Perceived barriers and facilitators to nursing process usage: a narrative review. BMC Nurs (2026). https://doi. org/10.1186/s12912-026-04739-0 A We are providing an unedited version of this manuscript to give early access to its findings. Before final publication, the manuscript will undergo further editing. Please note there may be errors present which affect the content, and all legal disclaimers apply. S S If this paper is publishing under a Transparent Peer Review model then Peer Review reports will publish with the final article. I T R E L C IN E R P © The Author(s) 2026. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. ACCEPTED ARTICLEMANUSCRIPT IN PRESS Perceived Barriers and Facilitators to Nursing Process Usage: A Narrative Review Kashif Khan1, Fazal Khaliq2 1. PhD Nursing Scholar at Zhengzhou University, Zhengzhou, Henan, China, at School of Nursing and Health. 2. PhD Nursing Scholar at Zhengzhou University, Zhengzhou, Henan, China at School of Nursing and Health. Corresponding Author: Kashif Khan S S E R P PhD Nursing Scholar at Zhengzhou University, School of Nursing and Health. E L C I T R A IN ORCID: https://orcid.org/0009-0006-2333-4507 Email ID: Abstract Background: The nursing process (NP) is a systematic, patient-centred framework fundamental to professional nursing practice, yet its implementation remains suboptimal, particularly in low- and middle-income countries (LMICs). This narrative review examines the global implementation of the NP, with a focused case analysis of evidence from Pakistan (n=2 studies) and other LMICs, and identifies barriers, facilitators, and research gaps. Pakistan was selected for focused analysis due to the ACCEPTED ARTICLEMANUSCRIPT IN PRESS authors' direct knowledge of its healthcare system and the absence of any previous synthesis of NP implementation evidence in this context. Methods: This narrative review employed a literature search across PubMed, CINAHL, and Google Scholar using Boolean operators with keywords including "Nurses' Perceptions," "Nursing Process," "Barriers," and "Facilitators." Inclusion criteria captured original research and reviews published between January 2017 and September 2023, with seminal older studies included for theoretical context. Exclusion criteria: editorials, commentaries, non-English publications, and studies without original data S S E R P on NP barriers or facilitators. The search prioritized evidence from LMICs, with additional Pakistan-specific database searching. Twenty-six studies were included in the final synthesis. E L C I T R A IN Results: The synthesis reveals a stark disparity in NP implementation. While high-income countries report adoption rates exceeding 80%, implementation in LMICs including Ethiopia, Ghana, and Nigeria is inconsistent (approximately 50-60%). Key facilitators identified included supportive supervision (reported in 4 studies), availability of documentation tools (6 studies), and continuing education (5 studies). Thematic analysis identified critical barriers across four domains: (1) systemic and resourcerelated factors, (2) educational and knowledge-based factors, (3) administrative and socio-cultural factors, and (4) nurse-related individual factors. In Pakistan, two studies suggest good theoretical knowledge among ACCEPTED ARTICLEMANUSCRIPT IN PRESS nurses (86.7-89.5%), but practical application is hindered by similar systemic barriers. Conclusion: The nursing process remains a cornerstone of high-quality care, yet its potential is unrealized in many resource-constrained settings. To address the implementation gap, strategic investments in administrative support, continuous professional development, and resource allocation are needed. This review identifies an urgent need for qualitative inquiry in Pakistan to explore nurses’ lived experiences regarding NP implementation in clinical settings—specifically, how contextual factors (workload, S S E R P supervision, resource availability) shape daily practice decisions. Keywords: Nursing Process, Nurse perceptions, Barriers, Facilitators, Patient-centred Care, Pakistan E L C I T R A IN 1. Background The nursing process (NP) is a practical tool that guides nurses' critical thinking for independent decision making, crucial to addressing client needs and facilitating healing [1]. Globally, the NP has been widely recognized as a valuable scientific instrument for guiding nursing practice and maintaining the quality of nursing care [2]. Nurses utilize this process to achieve better patient outcomes, including reductions in length of stay, mortality, and morbidity rates [3]. However, an integrative review by Lotfi et al. [4] revealed that the NP is not applied correctly in lower-income countries due to a lack of human ACCEPTED ARTICLEMANUSCRIPT IN PRESS resources, proper knowledge, and the unavailability of electronic or manual tools. The NP is a core component of nursing curricula [5], yet graduating from nursing schools does not automatically qualify individuals to implement it in their professional settings [4]. Its successful implementation is influenced by various individual and management factors. Substantial perceived barriers hinder NP implementation in clinical settings, such as insufficient human and material resources, lack of supervision, demotivation of hospital management, and stressful working conditions [6]. Exploring nurses' perceptions and identifying the barriers and facilitators to S S E R P NP use is critical for informing policy decisions aimed at advancing the profession and improving quality care. Despite growing attention to NP IN implementation globally, specific knowledge gaps remain: (1) no previous E L C I T R A narrative review has systematically synthesized NP implementation barriers using a structured thematic framework across LMICs, (2) no review has critically examined the Paki (...truncated)