ADDIS ABABA UNIVERSITY

COLLEGE OF HEALTH SCIENCE

DEPARTMENT OF NURSING AND MIDWIFERY
POSTGRADUATE PROGRAM

ASSESSMENT ON FACTORS AFFECTING IMPLEMENTATION OF

NURSING PROCESS AMONG NURSES IN SELECTED
GOVERNMENTAL HOSPITALS, ADDIS ABABA, ETHIOPIA.

BY: MULUGETA ASERATIE (BScN).

JUNE 2011, ADDIS ABABA, ETHIOPIA.

1
 ADDIS ABABA UNIVERSITY
COLLEGE OF HEALTH SCIENCE
DEPARTMENT OF NURSING AND MIDWIFERY
POSTGRADUATE PROGRAM

ASSESSMENT ON FACTORS AFFECTING IMPLEMENTATION OF

NURSING PROCESS AMONG NURSES IN SELECTED
GOVERNMENTAL HOSPITALS, ADDIS ABABA, ETHIOPIA.

BY: MULUGETA ASERATIE (BScN)

A thesis submitted to the school of graduate studies of Addis

Ababa University in partial fulfillment of the requirements for
the degree of Masters of Science in Adult Health Nursing in
department of nursing.

ADVISOR: RAJALAKSHMI MURUGAN (ASSISTANT PROFESSOR)

JUNE 2011, ADDIS ABABA, ETHIOPIA.

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Acknowledgment

Above all I would like to express my gratitude to my Lord- Jesus Christ and His mother the

Virgin St. Marry who carries all my burdens and shepherded me healthy.

My deepest appreciation is to my advisor Mrs. Rajalakshmi Murugan (Asst. professor) for her

valuable comments and criticism from the beginning of the study to its completion.

I am pleased to thank Ato Fekadu Aga (MSN) and Ato Yoseph Tsgie (MSN), Addis Ababa

University) for their expertise comment on my research questionnaire.

I am grateful to show my appreciation to Abdurahman Mohamed(MPH, lecturer, Debre Birhan

University) for his valuable comment on the final draft of the thesis.

I am thankful to my brother Mulusew A and his wife Etalemahu M. for their moral and material

support. My gratitude also goes to my friends for their direct or indirect contribution to the

development of this study.

The last but not the least I would like to extend my gratitude to data collectors, Addis Ababa

University, , staff of Black Lion, St. Paul, Ras Desta Damitew, and Yekatit12 hospitals for their

cooperation in the realization of the study.

I
Table of Content
Content Page No
Acknowledgment ................................................................................................................................. I
Table of Content .................................................................................................................................. II
List of Tables ..................................................................................................................................... IV
List of Figures ..................................................................................................................................... V
Abbreviations .................................................................................................................................... VI
Summary .......................................................................................................................................... VII
CHAPTER ONE ..................................................................................................................................1
1. INTRODUCTION ............................................................................................................................ 1
1.1. Background ................................................................................................................................ 1
1.2. Statement of the Problem ........................................................................................................... 3
1.3. Significance of the Study ......................................................................................................... 12
CHAPTER TWO................................................................................................................................ 13
2. LITERATURE REVIEW ............................................................................................................... 13
CHAPTER THREE ............................................................................................................................ 22
3. OBJECTIVES ................................................................................................................................ 22
3.1. General Objective ..................................................................................................................... 22
3.2. Specific Objectives ................................................................................................................... 22
CHAPTER FOUR .............................................................................................................................. 23
4. METHOD AND MATERIAL ....................................................................................................... 23
4.1. Study Area ................................................................................................................................ 23
4.2. Study Design ............................................................................................................................ 23
4.3. Source Population .................................................................................................................... 23
4.4. Study Population ...................................................................................................................... 24
4.5. Eligible Criteria ........................................................................................................................ 24
4.5.1. Inclusive ........................................................................................................................... 24
4.5.2. Exclusive Criteria ............................................................................................................. 24
4.6. Sample Size Determination ...................................................................................................... 24
4.7. Sampling Procedure ................................................................................................................. 25
4.9. Method of Data Collection ....................................................................................................... 28
II
 4.10. Variable .................................................................................................................................. 28
4.10.1. Dependent ....................................................................................................................... 28
4.10.2. Independent .................................................................................................................... 28
4.11. Operational Definition............................................................................................................ 28
4.12. Data Quality Assurance .......................................................................................................... 28
4.13. Reliability and Validity of Data Collecting Instruments ........................................................ 29
4.14. Data Analysis ......................................................................................................................... 29
4.14.1. Quantitative .................................................................................................................... 29
4.14.2. Qualitative ...................................................................................................................... 29
4.15. Pretest ..................................................................................................................................... 30
4.16. Ethical Consideration ............................................................................................................. 30
4.17. Dissemination of Result ......................................................................................................... 30
CHAPTER FIVE ................................................................................................................................ 31
5. RESULT ......................................................................................................................................... 31
5.1. Quantitative Study Result ......................................................................................................... 31
5.2. Qualitative Study .................................................................................................................. 49
CHAPTER SIX ..................................................................................................................................56
6. DISCUSSION ............................................................................................................................ 56
CHAPTER SEVEN ............................................................................................................................ 64
7. STRENGTH AND LIMITATION OF THE STUDY ....................................................................64
7.1. Strength of the Study ................................................................................................................ 64
7.2. Limitation of the study ............................................................................................................. 64
CHAPTER EIGHT ............................................................................................................................. 65
8. CONCLUSION .......................................................................................................................... 65
CHAPTER NINE ............................................................................................................................... 67
9. RECOMMENDATION ............................................................................................................. 67
REFRENCES .....................................................................................................................................68
Annex1 ............................................................................................................................................... 73
Annex 2 .............................................................................................................................................. 76

III
List of Tables

Title Page No
Table: 1- Socio demographic characteristics of nurses in selected governmental

hospitals of Addis Ababa, Ethiopia, 1011. --------------------------------------------------32

Table: 2- Professional related characteristics affecting implementation of nursing process

in selected governmental hospitals of Addis Ababa, Ethiopia, 2011. --------------------34

Table: 3- Percentage distributions of organizational factors affecting implementation of

nursing process among nurses in selected governmental hospitals of

Addis Ababa, Ethiopia, 2011. ----------------------------------------------------------------36

Table: 4- Patient related characteristics affecting implementation of nursing process

in selected governmental hospitals of Addis Ababa, Ethiopia, 2011 ------------------- 38

Table: 5- Percentage distribution of nurses‘ knowledge about nursing process among nurses

in selected governmental hospitals of Addis Ababa, Ethiopia, 2011---------------------40

Table: 6- Percentage distribution of nursing skills of nurses while caring their patient

in selected governmental hospitals of Addis Ababa, Ethiopia, 2011---------------------42

Table: 7- Association of implementation of nursing process by selected variables among

nurses working in selected governmental hospitals of

Addis Ababa, Ethiopia, 2011. ----------------------------------------------------------------46

IV
List of Figures

Title Page No

Figure: 1- A conceptual framework showing the factors affecting implementation of

nursing process and its outcome --------------------------------------------------------20

Figure: 2- A schematic diagram showing selection of hospitals and

nurses involved in the study---------------------------------------------------------------26

Figure: 3- Percentage distributions of respondents by selected governmental

hospitals in Addis Ababa, Ethiopia, 2011. ---------------------------------------------------31

Figure: 4- Implementation of nursing process among nurses in

selected governmental hospitals of Addis Ababa, Ethiopia, 2011----------------------------------44

Figure: 5- Percentage distribution of level of knowledge among nurses

working in selected governmental hospitals of Addis Ababa, Ethiopia, 2011------------44

Figure: 6- Percentage distribution on level of skill among nurses

working in selected hospitals of Addis Ababa, Ethiopia, 2011 ---------------------------45

V
Abbreviations

AAU- Addis Ababa University

BLH- Black Lion Hospital

Dx-Diagnosis

ICU- Intensive Care Unit

NANDA- North American Nursing Diagnosis Association

NCP= Nursing Care Plan

NP- Nursing Process

RDDMH- Ras Desta Damitew Memorial Hospital

SPH- St. Paul Hospital

USA- United States of America

VI
Summary

Background: 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.

Objective: To assess factors affecting implementation of nursing process among nurses in

selected governmental hospitals of Addis Ababa.

Method: A cross-sectional study was conducted on selected governmental hospitals in Addis

Ababa from February-April, 2011. Both quantitative and qualitative methods were used.

Purposive sampling was used for selection of hospitals. Black Lion, St. Paul, Ras Desta Damitew

Memorial, and Yekatit 12 hospitals were convenient for the study. The participants were selected

using simple random sampling technique. The minimum sample size was 202. Tools were given

to nurse expatriate to check for its validity and adjustment was made according to the feedback

obtained before pre test. Data was collected using self-administered questionnaire and in-depth

interview. Data was analyzed using SPSS 16th version.

Result: Out of 202 sampled respondents 192 agreed to participate in the study and the response

rate was 95%. One hundred two (53.1%) were females and 90(46.9%) were males. One hundred

forty (72.9%) of the total respondents were working in a stressful working environment where as

31(16.1%) were working in a disorganized working environment, the remaining 21(10.9%)

respondents explained their work place was negligent at a time. Thirty one (16.1%) of

respondents were highly knowledgeable. From the total respondents 89(46.4%) were highly

skillful. One hundred (52.1%) of respondents have implemented nursing process. From binary

logistic regression model analysis those who have implemented nursing process were nurses

working in a stressful working environment were 2.8(adjusted OR: 0.357, 95%CI: (0.157-0.814))

VII
times less likely to implement nursing process than disorganized working environment adjusting

for facility accessibility, knowledge, and sex. Accessibility of facilities needed for nursing care

were 2.248(Adjusted OR: 2.248, 95%CI: (1.079-4.684))times more likely to implement nursing

process than nurses working in an inferior facility controlling for working environment,

knowledge, and sex. Highly knowledgeable respondents were 38.913(Adjusted OR: 38.913,

95%CI: (10.3-147.006))times more likely to implement nursing process than low knowledge

group nurses adjusted for working environment, facility, and sex.

Conclusion: Nursing process implementation is affected by various factors. The study has

identified organizational factors, patient related factors, and level of knowledge and skill were

among those factors highly influenced nursing process implementation. This factors cause poor

quality of nursing care, disorganized caring system, conflicting role, medication error and

readmission with similar problem, dissatisfaction with the care patients have received, and

increased mortality.

VIII
 CHAPTER ONE

1. INTRODUCTION

1.1. Background

The nursing process can be viewed as a problem-solving approach, but we do not know whether

use of the whole process including care plans with interventions based on nursing diagnoses

improves nurses‘ ability to carry out assessments(1).

Based on a nursing theory developed by Ida Jean Orlando in the late 1950′s as she observed nurses

in action, the Nursing Process is an essential part of the nursing care plan (1).

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 (2).

The first step of the Nursing Process is assessment, which includes the collection, organization,

validation, and documentation of the data. It involves taking vital signs, performing a head to toe

assessment, listening to the patient‘s comments and questions about his health status, observing his

reactions and interactions with others (2,3).

The second step of the Nursing Process is diagnosis. Diagnosing includes analyzing the data,

identifying health problems, health risks, and the strengths the patient has, and formulating the

nursing diagnoses. Nursing diagnosis has also been defined by North American Nursing Diagnosis

Association (NANDA) as ―
a clinical judgment about an individual, a family or a community‘s

responses to actual and potential health problems/life processes (2,3). All members of the health

care team should be informed of the patient‘s status, nursing diagnosis, the goals and the plans for

collaborative management of the patient‘s care (1, 2).

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The third step of the Nursing Process is planning. It includes prioritizing the patient‘s problems

and diagnoses, formulating goals and desired outcomes for the patient to meet, selecting nursing

interventions to enable the patient to meet those goals, and writing the nursing orders (2,3).

Setting goals to improve the outcomes for the patient are a primary focus of the nursing process.

Planning also involves making plans to carry out the necessary interventions to achieve those

goals.

The fourth step of the Nursing Process is implementation. It includes reassessing the client,

determining the nurse‘s need for assistance, implementing the nursing orders and documentation of

nursing actions (2,3).

The fifth step of the Nursing Process is evaluation. Evaluation includes collecting data related to

the desired outcomes, comparing the data to see if the patient‘s goals or outcomes desired were

met, relating the nursing actions to the goals and outcomes, evaluating the status of the problem,

and continuing, modifying or terminating the patient care plan (2,3)

Evaluation involves not only analyzing the success of the goals and interventions, but examining

the need for adjustments and changes as well. The evaluation incorporates all input from the entire

health care team, including the patient (4).

2
 1.2. Statement of the Problem

The Nursing Process is a cycle that never ends. As patient needs change, the Nursing Process

allows the nurse to change the patient‘s plan of care to ensure that care is tailored to the patient‘s

present needs. It involves looking at the whole patient at all times and personalizes the patient. It

also forces the health care team to observe and interact with the patient, and not just become the

task they are performing such as a dressing change, or a bed bath. In so doing, the process provides

a roadmap that ensures good nursing care and improves patient outcomes. The nursing process is

one of the most misunderstood nursing theories, and yet one of the most effective as well as

practical. Many students struggle with this theory. It takes time for students and new nurses to get

the hang of this process, and many fight it every step of the way, until one day a light bulb begins

to burn brightly(4, 5).

Nurses are beginning to function as an important part of the multidisciplinary team, speaking to the

physicians and writing progress notes on patient records. However, having this role for the

betterment of the health care of the nation there independent work –nursing process do not get

enough emphasis as it is written in many books (1).

Implementation of the nursing process allows Nurses 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. An oversight or omission

in any of the steps of this process may lead to less than optimal nursing care (6).

The nurse carries personal responsibility and accountability for nursing practice, and for

maintaining competence by continual learning. The nurse maintains a standard of personal health

such that the ability to provide care is not compromised. The nurse uses judgment regarding

individual competence when accepting and delegating responsibility. The nurse at all times

3
maintains standards of personal conduct which reflect well on the profession and enhance public

confidence. The nurse, in providing care, ensures that use of technology and scientific advances

are compatible with the safety, dignity and rights of people (7).

Nurses have many demands on their time as they provide care and document their work in a

descriptive manner. Nurses developed a care plan with special forms for each care unit in order to

meet the needs of their patients (1).

Learning the steps of the process does not necessarily equip a nurse to operationalize the process.

Nursing requires a strong cognitive process as well as developed skills. Most of the time nurses are

not working what they have got from the class (8).

Despite their knowledge of the nursing process, certain factors limit the ability of nurses to

implement it in their daily practice, including lack of time, high patient volume, and high patient

turnover. The daily application of nursing process is characterized by the scientific background of

the professionals involved since it requires knowledge and provides individualized human

assistance. Nursing involves assisting others with basic human needs using a holistic approach, and

the patient is defined as someone who needs care. In theory, the majority of nurses have

knowledge of the nursing process, but they do not apply it in practice. As a result, problems

identified with regard to the nursing practice, including a loss of quality care, disorganization of

the service, and conflicting roles (9).

The formal nursing started in the early 1950s but the prior focus was on the prevention and

curative aspect. In the curative part, nurses have been using the medical approach. This approach is

continued until now especially in rural heath institutions. Nursing education in under graduate

program started to be given in the late 1990s aimed at developing the professional‘s knowledge

4
thereby to improve the nursing care practice. Though the knowledge of students improved the

practice, still do not show a significant change (10).

Nurses comprise the key connective tissue for Ethiopia's health care. They are also the largest

cadre of health-care providers in Ethiopia and function in many different roles, from traditional

bedside nursing to primary health care in regional health centers. It is common to see nurses

working as laboratory personnel, dentists, councilors, and social workers to accommodate the

shortages (8).

Nursing process is a multipurpose approach that enables nurses to perform their activities with

logical justification. It safeguards the right of both the patient and the nurse. Recently in Ethiopia

clients accuse nurses due to their haphazard practice. Clinton foundation is now giving in service

training for nurses working in hospitals. Following this, training nurses are trying to practice

nursing process and it becomes the focus of Ministry of Health throughout the country.

Good nursing care is a critical facet of health care. It has an impact on all aspects of the business of

hospitals and community care. In hospitals, it must be provided over a full 24-hour period, every

day of the year. If it is not present neither patients nor other health professionals will be satisfied

with the service provided (11).

Nurses frequently assert that they know they give good nursing care and that this care makes a

difference to the health outcomes of patients. However, unless it is clear what nursing actions

make a difference to patient care outcomes, and why, the quality of nursing care will continue to

be difficult to assess (11).

The patients' perspective in assessing good nursing care is a neglected area. The patient— or

consumer—is increasingly acknowledged as the focus of all activities in a quality health service. If

nursing quality is to improve, it is important to use both the patients' view and nurses' conceptions

5
of good nursing care to develop frameworks for evaluating care. Such frameworks can also form

the basis for determining that 'good nursing care' makes a difference to patient outcomes.

However, for nurses and nursing it is essential that frameworks established from a definitional

perspective with which other health professionals are not totally familiar do not reach conclusions

that are questioned because others do not understand the basis of the instrument used (11).

Another important factor to be considered in the development of frameworks and instruments to

assess good nursing care is the relationship between the quality of nursing care and the

qualifications of the nursing staff providing care. For many people a nurse is a nurse. However,

some research undertaken in the United States and in the UK suggests that registered nurses

provide a higher quality of nursing care than other categories of nurses and untrained health

workers or assistants. Cutting health care costs by replacing qualified nurses with untrained health

workers is an increasing temptation in many countries with a diminishing health budget. A critical

dimension to quality, therefore, is economic. The International Council of Nurses developed the

theme "Quality, costs and nursing", for International Nurses' Day in 1993 (11).

Registered Nurses represent a patient surveillance system and are essential to the prevention and

early detection of adverse patient events. Adverse events occur in an estimated 2.9 to 3.7 percent

of acute care hospitalizations in the United States of America (U.S.A.), and it is estimated that

between 44,000 and 98,000 patients die in hospitals each year as a result, with nearly half due to

errors in the delivery of care. A recent systematic review of eight studies conducted in the U.S.A.,

Australia, United Kingdom (U.K.), and Canada revealed that the median overall incidence of in-

hospital adverse events was 9.2%. From those 43.5% of the incidents were preventable and 7.2%

leading to death (11).

6
Theoretically, if nurses fail to carry out necessary nursing care, then the effectiveness of patient

surveillance may be compromised and lead to a preventable adverse patient event (13).

WHO measures shortages with nurse-to-people ratios that can vary from region to region within a

country, country to country and continent to continent. In the US, the Health Resources and

Services Administration (HRSA) reports that the average ratio of nurses was 858 per 100 000

people in 2005 (HRSA 2005) as compared with Ethiopia which had 21 nurses per 100 000 people

(WHO 2006). The average ratio in Europe is similar to that in the US, with 847 nurses per 100 000

people in the UK (WHO 2006). The average nurse-to-population ratio in high-income countries is

almost eight times greater than in low-income countries. Low availability of nurses in many

developing countries is exacerbated by geographical maldistribution; there are even fewer nurses

available in rural and remote areas. Factors contributing to the nursing shortage vary in different

parts of the world (14). As registered nurse-to-patient ratios decrease from 1:4 to 1:10, the number

of post-op surgical patient deaths climbs dramatically (15).

Decision-making is based on having the appropriate number of positions and the competencies

required to ensure safe, competent and ethical care. Safety and client outcomes are primary

concerns. While cost efficiency is an essential element, the need to achieve good client outcomes,

through an evidence-based approach, is central in making staffing decisions (16).

The heavy workload of hospital nurses is a major problem for the American health care system.

Nurses are experiencing higher workloads than ever before due to four main reasons: (1) increased

demand for nurses, (2) inadequate supply of nurses, (3) reduced staffing and increased overtime,

and (4) reduction in patient length of stay (17).

Nursing workload measures can be categorized into four levels: (1) unit level, (2) job level, (3)

patient level, and (4) situation level. These measures can be organized into a hierarchy. The

7
situation- and patient-level workloads are embedded in the job-level workload, and the job-level

workload is embedded in the unit-level workload. In a clinical unit, for example, numerous nursing

tasks need to be performed by a group of nurses during a specific shift (unit-level workload). The

type and amount of workload of nurses is partly determined by the type of unit and specialty (e.g.,

intensive care unit [ICU] nurse versus general floor nurse), which is the job-level workload. When

performing their job, nurses encounter various situations and patients, which are determinants of

the situation- and patient-level workloads (17). A heavy nursing workload seems to be related to

suboptimal patient care and may lead to reduced patient satisfaction (18). Much of the research

investigating the impact of nursing workload on patient safety focused on linking nursing staffing

levels with patient outcomes. There is strong evidence in the literature that nurse-staffing levels

significantly affect several nursing-sensitive patient outcomes (19, 20). Several studies found a

significant relation between lower nurse staffing levels and higher rates of pneumonia. For

example, a multisite study in California found that an increase of 1 hour worked by registered

nurses (RNs) per patient day correlated with an 8.9 percent decrease in the odds of pneumonia

among surgical patient (21). Another study found a significant relationship between full-time-

equivalent RNs per adjusted inpatient day and rate of pneumonia: the rate of pneumonia was

higher with fewer nurses (22).

As more than just staffing levels affect workload, a deeper understanding of nursing workload is

required to better assess the impact of workload on patient outcomes. Later, a human factors

engineering approach to nursing workload that can provide this deeper understanding of nursing

workload and its causes will be described, allowing for the development and implementation of

solutions aimed at reducing or dealing with workload (23).

8
Nurses staffing level has been shown to have a significant impact on nosocomial infections. For

example, Needleman and colleagues found that among medical patients, a higher number of hours

of care per day provided by register nurses (RN)s were related to lower urinary tract infection

rates. A retrospective cohort study in a neonatal intensive care unit (ICU) revealed that the

incidence of E cloacae infection in the unit was significantly higher when there was understaffing

of nurses (24). A prospective study in a pediatric cardiac ICU found a significant relation between

the monthly nosocomial infection rate in the unit and the nursing hours per patient ratio. There

were more nosocomial infections when the number of nursing hours per patient day was lower

(25).

Although not as strong, some evidence exists regarding the impact of nurse staffing levels on

failure to rescue (death within 30 days among patients who had complications) and mortality. A

study using administrative data from 799 hospitals in eleven States revealed that a higher number

of hours of RN care per day were associated with lower failure to rescue rates (26). In a study of

168 nonfederal adult general hospitals in Pennsylvania found that each additional patient per nurse

was associated with a 7 percent increase in the likelihood of mortality within 30 days of admission

and in the likelihood of failure to rescue. An earlier study found that hospitals that had more RNs

per admission had lower mortality rates (27).

Four studies found a relationship between nurse staffing and patient outcomes. One study found

that having a nurse-patient ratio of less than 1:2 during evening shifts was associated with a 20

percent increase in length of stay in patients who had abdominal aortic surgery in Maryland

hospitals between 1994 and 1996 (28). Researchers conducted studies in 1992 and 1994 using

hospital cost reports and discharge data in New York and California, finding that more nursing

work hours were associated with reduced length of stay (29). Additionally, a critical incident study

9
of Australian ICUs revealed that insufficient nursing staff was linked to drug administration or

documentation problems, inadequate patient supervision, incorrect ventilator or equipment setup,

and self-extubation (30).

Nursing workload definitely affects the time that a nurse can allot to various tasks. Under a heavy

workload, nurses may not have sufficient time to perform tasks that can have a direct effect on

patient safety. A heavy nursing workload can influence the care provider‘s decision to perform

various procedures (31). A heavy workload may also reduce the time spent by nurses collaborating

and communicating with physicians, therefore affecting the quality of nurse-physician

collaboration (32). A heavy workload can lead to poor nurse-patient communication (33).

Several studies have shown the relationship between nurses‘ working conditions, such as high

workload, and job dissatisfaction (34). Job dissatisfaction of nurses can lead to low morale,

absenteeism, turnover, and poor job performance, and potentially threaten patient care quality and

organizational effectiveness (35).

High workload is a key job stressor of nurses in a variety of care settings, such as ICUs. A heavy

nursing workload can lead to distress (e.g., cynicism, anger, and emotional exhaustion) and

burnout. Nurses experiencing stress and burnout may not be able to perform efficiently and

effectively because their physical and cognitive resources may be reduced; this suboptimal

performance may affect patient care and its safety (36).

Workload can be a factor contributing to errors. Errors have been classified as (1) slips and lapses

or execution errors, and (2) mistakes or knowledge errors. High workload in the form of time

pressure may reduce the attention devoted by a nurse to safety-critical tasks, thus creating

conditions for errors and unsafe patient care (37).

10
Workload also exposes nurses to violations (deliberate deviations from those practices (i.e., written

rules, policies, instructions, or procedures) believed necessary to maintain safe or secure

operations). The literature on violations emphasizes the role of the social and organizational

context, where behavior is governed by operating procedures, codes of practice, rules, and

regulations (38).

A survey describing medical practice was administered to 315 nurses, doctors, and midwives and

350 members of the general public in the United Kingdom. The study examined two factors

manipulated within nine scenarios of surgery, anesthetics, and obstetrics. The first factor, behavior,

was described as an improvisation (no rule available), a violation of clinical protocol, or

compliance with a clinical protocol. The second factor, patient outcome, was described as good,

bad, or poor. Samples of health care providers and the general public were asked to evaluate the

nine scenarios with regard to the inappropriateness of the behavior, the likelihood that they would

take further action (i.e., reporting by health care provider and complaining by the public), and

responsibility for the outcome (e.g., the health care professional, the patient, the protocol itself, the

hospital). Results showed that violations of protocols and bad outcomes were judged most harshly.

Whether outcomes were good or bad, violations were evaluated more negatively. The authors of

the study warned against overreliance on procedures (or protocols) as a form of organizational

defense against accidents or claims. Procedures may stifle innovation and make people less able to

function in novel situations (39).

A survey of 120 nurses (59 percent response rate) in three units of pediatric hospitals to assess self-

reports of violations in the medication administration process. Between 8 percent and 30 percent of

the nurses reported violations in routine situations, and between 32 percent and 53 percent of the

nurses reported violations in emergencies. The most frequent violations or work-around occurred

11
in matching the medication to the medication administration record and checking the patient‘s

identification.

1.3. Significance of the Study

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.

This study identified how the factors affecting implementation of nursing process performed by

nurses apply its influence on the nursing practice in Black Lion Hospital (BLH), St. Paul

Hospital (SPH), Ras Desta Damitew Memorial Hospital (RDDMH), and Yekatit 12 Hospital.

The results of the study will be used as base line information to design appropriate intervention

strategies for the factors that can influence nurses‘ capacity to conduct nursing process for their

patients (40).

12
 CHAPTER TWO

2. LITERATURE REVIEW

The nursing process has been traditionally used in the patient–nurse relationship. However, other

applications of the process are documented. Qualey (1997) applies the nursing process to the

patient and the family caregiver of the patient. Adams and Gilman (2002) use the nursing process

in implementing a new teaching strategy with nursing students. Wingard (2005) applies the

nursing process of assessment, planning, implementation, and evaluation to patient education.

Although not previously documented in the literature, the nursing process was applied to a cross-

cultural clinical mentoring situation (5).

The experience acquired as nurse teacher on the nursing process has generated frequent relations

with care practice in the hospital context. Thus, it could be verified that the nursing activities

performed in patients were focused on already established procedures and routines, with no

reference to theoretical principles and how to put the nursing process into practice (40, 41).

Some scholars have recently shown the investments made to use the nursing process in care

practice, providing information on what nurses know, believe and adopt in various situations and

difficulties encountered in hospitals. These studies indicate the potential of investments in its

practice, by approaching nursing practice and health care, education and research (5).

Based on the above, we reaffirm the researchers‘ view that the nursing process is an action full of

meaning that can be used by nurses in practice, as a method for care delivery, which represents

challenges in education and in practice. The nursing process needs to be depended in the hospital

context, based on the perception of nurses working there, highlighting their doubts, uncertainties

and questions about how to put it into operation (3)

13
Yet hospitals confront challenges with regard to nursing involvement, including: scarcity of

nursing resources; difficulty engaging nurses at all levels—from bedside to management; growing

demands to participate in more, often duplicative, and quality improvement activities. The

burdensome nature of data collection and reporting; and shortcomings of traditional nursing

education in preparing nurses for their evolving role in today‘s contemporary hospital setting(44).

Because nurses are the key caregivers in hospitals, they can significantly influence the quality of

care provided and, ultimately, treatment and patient outcomes. Consequently, hospitals‘ pursuit of

high-quality patient care is dependent, at least in part, on their ability to engage and use nursing

resources effectively, which will likely become more challenging as these resources become

increasingly limited (43).

In recent years, emphasis on improving the quality of care provided by Brazilian national hospitals

has increased significantly and continues to gain momentum. Because nurses are integral to

hospitalized patients‘ care, nurses also are pivotal in hospital efforts to improve quality. As

hospitals face increasing demands to participate in a wide range of quality improvement activities,

they are reliant on nurses to help address these demands (5).

Gaining a more in-depth understanding of the role that nurses play in quality improvement and the

challenges nurses face can provide important insights about how hospitals can optimize resources

to improve patient care quality (44).

Quality improvement is not a new concept for hospitals. Hospitals have had quality improvement

departments and employed related staff for many years. What is new, however, is the proliferation

of these activities and the escalating pressure on hospitals to participate (44).

Nurses are ―
the largest deliverer of health care in the U.S.,‖ according to a representative of an

accrediting organization, and as hospital participation in quality improvement activities increases,

14
so does the role of nursing. Universally, respondents described how vital nurses are to hospitals;

that nursing care is a major reason why people need to come to a hospital. As one hospital, CEO

said of nurses, they are the ―

heart and soul of the hospital‖ (45).

Respondents reported that nurses are well positioned to serve on the front lines of quality

improvement since they spend the most time at the patient‘s bedside and are in the best position to

affect the care patients receive during a hospital stay. As one hospital CNO noted, ―
Nurses are the

safety net. They are the folks that are right there, real time, catching medication errors, catching

patient falls, recognizing when a patient needs something, avoiding failure to rescue.‖ Other

respondents described nurses in similar veins as the ―

eyes and ears‖ of the hospital and being in a

particularly good position to positively influence a patient‘s experience and outcomes. The scarcity

of nurses is a major challenge for hospitals because it impacts not only their ability to provide

nursing coverage for patient care, but also to provide adequate nursing resources for other key

activities, such as quality improvement. Nurses usually have multiple patients and meeting all of

their physical and emotional needs is challenging, if not impossible. Consequently, nurses

continually evaluate what needs to be done, reprioritizing their tasks to meet patients‘ changing

needs (46).

The model steps of the nursing process proposed include assessment, diagnosis, planning,

implementation, and evaluation of nursing activities. The nursing history is a systematic guide

for data assessment that permits the identification of nursing problems. The nursing diagnosis

identifies the needs that require care and determines the degree of dependence on nursing care.

The nursing intervention involves determining the overall nursing care that should be established

based on the diagnosis. The nursing implementation includes the beginning and completion of

actions required to achieve results, which involves the implementation and recordation of the

15
interventions performed. Finally, the nursing evaluation is a daily report of the successive

changes that occur while under professional assistance. At this stage, it is possible to assess the

human response to the nursing care provided (5)

However, a study that investigated the meaning of nursing process among nurses in an

intensive care unit showed that their experiences were contradictory: although the nursing

process was seen as a form of professional recognition with regard to its role in society.

Something that allows nurses to have authenticity and freedom of action in their practice, it

was also viewed with feelings of anger, dissatisfaction, and frustration (45).

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 (9).

The activities of nurses are technical and administrative in nature. Nursing involves assisting

others with basic human needs using a holistic approach, and the patient is defined as someone

who needs care. In theory, the majority of nurses have knowledge of the nursing process, but

they do not apply it in practice. As a result, problems identified with regard to the nursing

practice, including a loss of quality care, disorganization of the service, and conflicting roles

(44).

Furthermore, a study developed in a Brazilian private hospital showed that the phases of the

nursing process were not integrated and that there was a lack of coherence in the prescribed

16
actions related to patient health conditions. They additionally asserted that a lack of preparedness

and a lack of a holistic view has hindered the perception and record of the essential care provided

(44).

One of the barriers to the development of the nursing process is the implementation of the

nursing diagnosis. However, studies have shown that the implementation of the nursing

diagnosis is a challenge for nurses (46). An evaluation of the implementation of the nursing

diagnosis highlighted the importance of the survey of needs, and of the mobilization of resources

to meet those needs. This included the technical resources required to provide structural

resources and the time required to participate in ethics and policy training, which promote

enhanced knowledge and creative potential. Taken together, these factors support positive

assessment and allow its continuity (6).

After a gradual increase in their theoretical–practical training during the implementation of the

nursing diagnosis, nurses reported a positive change in their feelings after their initial discomfort

and unfavorable perception of the nursing diagnosis. Besides allowing the nurses to share their

feelings, decisions, and responsibility for the outcomes, this stepwise approach to the nursing

process allowed them to believe that they would be able to overcome difficulties (7).

It is reasonable to conclude that the nursing process is important for the practice of nursing;

however, its use is not an easy task. Therefore, a continuous evaluation of how the nursing

process is executed within the health services is required (41).

A majority of the studies on nursing workload and patient safety used nurse-patient ratio as the

measure of nursing workload. According to research on workload in human factors engineering

17
it is well known that workload is a complex construct, more complex than the measure of nurse-

patient ratio (17). It is unlikely that the multidimensional, multifaceted structure of workload can

be captured by one unique, representative measure. Therefore, the belief is that researchers who

use the nurse-patient ratio as a measure of workload offer a limited contribution to understanding

the impact of nursing workload and designing solutions for reducing or mitigating nursing

workload. One reason for the extensive use of the nurse-patient ratio may be that this measure is

easy to use and is readily available in existing databases. However, tools used by human factors

researchers can comprehensively assess workload, facilitate the identification of the sources of

excessive workload, and provide direction for corrective interventions (17).

A study conducted in Europe to test the establishment of a validated model of nursing records

aimed to promote individual care. The results showed limitations of the nursing process

conducted according to the model, particularly in the identification of problems presented by the

patients and, consequently, diagnosis and the possible intervention procedures. A study

conducted in the United Kingdom to assess whether data obtained from nursing records could be

reliably used to identify interventions for patients who had suffered acute myocardial infarction

or a fracture of the head of the femur, showed that the analyzed nursing records did not provide

an adequate picture of patients' needs for nursing interventions (47).

An investigation of the steps of the nursing process actually implemented in the routine of a

university hospital showed that all phases were performed however, problems were identified in

the nursing process, involving recording the history and implementing nursing prescription. The

evolution of expected results, in particular, was not adequately recorded (48).

18
Specifically seeking to investigate the phases of the nursing process performed in the care

practice of a university hospital in Brazil, the authors identified the implementation of all stages.

However, the existence of failures was shown among the nursing diagnoses in the patients'

history, as well as the implementation of nursing prescriptions without recording the evalution of

the expected results (6). Similar results were also shown in a study published in 2006 during the

implementation of the nursing diagnosis, in which the research subjects indicated difficulties in

developing the nursing process at all stages, and the need for changes to speed up the work

process and optimize the quality of actions in care and education (7). This research was done in

University hospital where students are doing clinical practice. Students who attached in those

hospitals learn from patient records but if there is no full implementation of nursing process, they

cannot obtain what they should get from patient record. Furthermore, the patient care outcome

might be poor which results into poor quality of life. Poor quality of life of an individual is one

determinant factor for family disturbance. Family health will be impaired and societal problem

become complicated.

19
 Conceptual Frame Work

FACTORS

Knowledge of
nursing process

Work load (Nurse to

patient ratio) OUTCOME

Unmet nursing care (poor

implementation of
Nurse’s demographics Implementation of
nursing process)
nursing process

Organizational
structure and facilities

Poor quality of nursing care,

Disorganization of the service,
Patient’s income Conflicting roles,
Medication error,
Poor diseases prognosis,
Patient turnover Readmission,
Dissatisfaction with the care provided, and
Increased mortality
Skill

Figure: 1 A conceptual framework showing the factors affecting implementation of

nursing process and its outcome

20
Nursing process implementation is affected by different factors. Among those knowledge of

nursing process, work load (nurse to patient ratio), nurse‘s demographics, organizational

structure and facilities, patient‘s income, patient turnover, and skill were identified using the

literature review used in this study. When these factors negatively affect implementation of

nursing process there will be unmet nursing care (poor implementation of nursing process). As

a result of this 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 will be resulted.

21
 CHAPTER THREE

3. OBJECTIVES

3.1. General Objective

To assess factors affecting implementation of nursing process among nurse in selected

governmental hospitals of Addis Ababa.

3.2. Specific Objectives

1. To assess factors associated with knowledge and practice of nurses on implementation of

nursing process in selected governmental hospitals.

2. To identify organizational factors affecting implementation of nursing process in selected

governmental hospitals.

3. To assess the impact of poor implementation of nursing process on patients outcome in

selected governmental hospitals.

22
 CHAPTER FOUR

4. METHOD AND MATERIAL

4.1. Study Area

The study was conducted in four selected governmental hospitals in Addis Ababa - the capital

city of Ethiopia. It is the largest city in Ethiopia, with a population of 3,384,569 according to the

2007 population census in an estimated area of 530.14 square kilometer. People from different

regions of Ethiopia populate the city. There are 12 governmental hospitals among them BLH,

SPH, Yekatit 12, RDDMH provides multi-dimensional aspects of care to clients who need health

care service. The study was conducted from February-April, 2011

4.2. Study Design

A cross-sectional study was conducted using quantitative and qualitative methods from

February-April 2011.

4.3. Source Population

All nurses who have been working in Addis Ababa hospitals.

23
 4.4. Study Population

BSc nurses those who were working in selected hospitals of Addis Ababa during the study

period.

4.5. Eligible Criteria

4.5.1. Inclusive

a. All BSc nurses with more than 6 months of working experience.

b. Nurses who were willing to participate in the study.

4.5.2. Exclusive Criteria

a. Diploma clinical nurse

b. BSc nurses served less than six months

4.6. Sample Size Determination

Qualitative: Point of information redundancy or saturation was the sample size.

Quantitative: The overall minimum sample size was determined using single population

proportion calculation formula:

2
z ( p(1  p))
ni = 2
2
d

Where n= minimum sample size required for the study

24
 Z= standard normal distribution (Z=1.96) with confidence interval of 95% and ⍺=0.05

P=prevalence/ population proportion (p=0.5)

d=is a tolerable margin of error (d=0.05)

= 1.96(1.96) (0.5(1-0.5))/0.05(0.05) = 384.16 => n i =384

This calculated result was more than the total population we had in the study area. To get sample

from the total population we used correction formula. The exact sample size therefore was

calculated as follows.

nf= n xN i
Where n i = calculated sample size
n N
i

n f = exact sample size

N= sample population

= (384x354)/ (384+354) =135,936/738=184.19=184

= 184+10% none response rate = 184+18.4 =202.4

=202

4.7. Sampling Procedure

Selection of hospitals for the study was carried out using purposive sampling. After all hospitals

in the city were identified, governmental hospitals were purposely selected.

From the total 30 hospitals in the city 12 found to be governmental (four owned by Federal

Ministry of Health, five owned by Addis Ababa regional health bureau and one owned by Addis

25
Ababa University(Ministry of Education), one owned by federal police and one by ministry of

defense) two owned by NGO‘s and the rest 16 were privately owned.

From the 12 governmental hospitals in the city BLH, SPH, RDDMH, and Yekatit 12 were

selected for the study based on the general service they have been provided. Alert, St. Peter,

Amanuel, and Gandhi hospitals were excluded since they provided special service. This might

influence the result to lay into segments of information that could be difficult to manage. Police

and Bella hospital also excluded by their service they provide to a specific population. From the

remaining hospitals BLH, SPH, RDDMH, and Yekatit 12 hospitals were selected by their high

number of nurses and their appropriate location.

Simple random sampling method has been used to select the participants. According to the data

obtained from the selected hospitals there were 126, 100, 59, and 69 BScN nurses in BLH, SPH,

RDDMH, and Yekatit 12 hospital respectively. There were a total of 354 BScN nurses.

For the hospitals to proportionate the number of study subject using nf/N x n

BLH = (202x126)/354=71.89=72

SPH = (202x100)/354=57.06=57

RDDMH = (202x59)/354= 33.66=34

Yekatit 12 = (202x69)/354=39.3=39

26
 Twelve government
hospitals in Addis Ababa

Alert St. Peter Amanuel Gandhi Zewditu Police Bella

Minilik II

BLH SPH Yekatit 12 RDDMH

BLH (126) SPH (100) YEKATIT 12(69) RDDMH (59)

Purposive sampling

Simple random sampling 72 57 34 39

Figure: 2- A schematic representation of sampling method

4.8. Data Collection Tools

There were two types of questionnaire for quantitative and qualitative

For quantitative method of data collection structured questionnaire was used. Structured English

version questionnaire was prepared by using literature review used in this study and related

studies done in other countries. It includes five main parts about nurses‘ socio demographics,

knowledge of nursing process, work load (nurse to patient ratio), organizational structure and

facilities, patient turnover and patient‘s income

For qualitative aspect of the study, open-ended questions were prepared to guide an in-depth

interview.

27
4.9. Method of Data Collection

The quantitative data was collected by self administered questionnaire. The data collection

process was supervised by the principal investigator from February-April/2011. Before the actual

data collection, data collectors have obtained half day training about the aim of the study and the

content of the instrument. Therefore, the data collectors became familiar about each question. It

was also a mechanism of minimizing bias during the process of data collection. Questionnaires

were filled by nurses in their work place.

Qualitative questionnaire includes five questions about factors affecting implementation of

nursing process which was not investigated with the quantitative method.

4.10. Variable

4.10.1. Dependent

Implementation of nursing process

4.10.2. Independent

 Hospital organizational stucture

 Year of experience
 Patient turn over
 Knowledge of nurses
 Skill
 Nurse to patient ratio

 Nurse demographics

28
 4.11. Operational Definition

Nursing process: A systematic way of problem solving including (assessment, diagnosis, planning,

implementation and evaluation) practiced by licensed nurses.

Year of experience: Number of year nurses have worked in nursing.

Nurse to patient ratio: The proportion of nurses to the patients.

Knowledgeable nurse: Nurses‘ awareness about nursing process. Highly knowledgeable nurses were

those answered more than 80% of the questions, moderately knowledgeable nurses were those answered

in between 55-79.9%, and low knowledgeable group were those scored <55%.

Patient turnover: A patient visiting hospitals for getting health care and leave before full provision of

care

Workload: Increased working activity of nurses over their capacity.

Organizational structure: The hierarchical level of a hospital in health care delivery.

Skill: Daily nurses practice performed for a patient. Those respondents who have scored >26 were highly

skillful, 18-25 were moderately skillful, and < 17 were low skillful group out of 30.

4.12. Data Quality Assurance

During data collection, both principal investigator and data collectors themselves were checked

data for its completeness and missing information at each point. Further more data was checked

during entry into the computer before analysis.

28
 4.13. Reliability and Validity of Data Collecting Instruments

There were two nursing expatriates checked the instrument for the content validity. According

to their advice, the comments were accommodated before data collection.

4.14. Data Analysis

4.14.1. Quantitative

Data first was cleared, coded and entered into computer using epinfo and exported into SPSS16th

version for analysis. The univariate analysis such as percentage and frequency distribution of

different characteristics of the questionnaire were analyzed. Bivariate analysis was used to see

the association of independent with the dependent variable. Logestic regression model was

employed to control confounding variables, variables included in the model were restricted to

those significantly related to implementation of nursing process at the bivariate level and some of

the statistical test like, odds‘ ratio(crude & adjusted) was used to measure their association and

some of the results were compared with results of other studies available.

4.14.2. Qualitative

Data from an in-depth interview was transcribed by arranging the record according to forwarded

questions. Then comparison was done on the responses of different nurses to identify similarities

and differences and the reasons behind the gap. At last, information was linked and analyzed to

its congruence with data obtained through an interview.

29
 4.15. Pretest

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 11(5%) nurses response one week prior to the actual data collection period in Mahtem

Ghandi Memorial Hospital, Addis Ababa. This was helpful for the investigator to screen out

vague questions and modify some of the question item as soon as possible.

4.16. Ethical Consideration

Paper of approval and letter of permission was obtained before the beginning of data collection

from departmental review board of Nursing and Midwifery, College of Health Science, Addis

Ababa University. Permission letter was provided to selected hospitals for proceeding data

collection. After that participants were oriented about the purpose and procedure of data

collection, and that confidentiality and privacy was ensured. It was also cleared that participation

was fully based on the willingness of participants using written consent.

4.17. Dissemination of Result

The study result will be disseminated through AAU website, AAU nursing library, each hospitals

included in the study, international journals, Ethiopian Nursing Association, and Ministry of

Health.

30
CHAPTER FIVE

5. RESULT

5.1. Quantitative Study Result

Out of 202 sampled respondents in the selected hospitals during the study period 192 agreed to

participate and the response rate was 95%. The majorities of respondents were from BLH

72(37.5%) followed by SPH 58(30.2%), RDDMH 32(16.7%), and Yekatit 12 hospital

30(15.6%). The response coverage of participants by hospital is shown in the figure below.

YEKATIT 12
30(15.6)% BLH
72(37.5%)
RDDMH
32(16.7%)

SPH
58(30.2%)

Figure: 3 Percentage distributions of respondents by selected hospitals in Addis Ababa, Ethiopia,

2011.

31
5.1.1. Socio Demographic Characteristics of the Study Subjects

Table 1: Socio demographic characteristics of BSc nurses in selected governmental

hospitals of Addis Ababa, Ethiopia, 2011.

Characteristics Frequency Percentage

Sex Female 102 53.1
Male 90 46.9
Total 192 100
Age below24 92 47.9
25-44 81 42.2
45-54 17 8.9
55-64 2 1.0
Total 192 100
Marital status Single 135 70.3
Married 52 27.1
Widowed 3 1.6
Divorced 2 1.0
Total 192 100
Year of graduation <2yrs 130 67.7
2-5yrs 57 29.7
5-10yrs 3 1.6
>10yrs 2 1.0
Total 192 100
Work experience < 5 years 144 75
5-10years 23 12
10-15 years 7 3.65
15-20 years 9 4.69
20-25 years 5 2.60
>25 years 4 2.1
Total 192 100
Regarding the sex distribution (Table 1) 102(53.1%) were females and 90(46.9%) were males.

Ninety two (47.9%) of the respondents were in the age range of below 24 years, 81(42.2%) were

in 25-44 years, 17(8.9%) were in 45-54 years, and 2(1%) were 55-64 years. Related to marital

status one hundred thirty five (70.3%) of the respondents were single, 52(27.1%) were married,

the remaining 3(1.6%) were widowed and 2(1%) were divorced. One hundred thirty (67.7%) of

participants were graduated in the last two years. One hundred forty four (75%) of respondents

had less than five years of experience.

32
5.1.2. Professionals Related Factors Affecting Implementation of Nursing
Process

Regarding overt-time work one hundred fifty seven (81.8%) of the respondents were worked

overtime. One hundred thirty four (69.8%) of those who were worked overtime have worked

with payment, while 23(12%) of nurses worked without payment. 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.

One hundred seventy one (89.1%) of the respondents had no misbehavior record on their

personal file while 21(10.9%) had misbehavior record.

Regarding orientation seventy seven (40.1%) of the total respondents have got satisfying

orientation while they join their organization where as 115 (59.9%) of respondents did not get

satisfying orientation.

Regarding on method of making work of nurses visible one hundred sixteen (60.4%),

100(52.1%), 33(17.2%), and 68(35.4%) of the respondents have used recording, nursing process,

reporting to higher officials, and only working on the patient‘s problem to make their work

visible respectively. Nine (4.7%) of the respondents have used nothing to make their work

visible. From the total respondents 116(60.4%) of them were always record their activities while

4(2.1%) never recorded their activities.

In this study forty eight (25%) of respondents were anxious from high patient flow. Among those

15(31.3%), 22(45.8%), and 11(22.9%) have committed knowledge, executive, and slip/slap error

respectively.

33
Table: 2- Professional related characteristics affecting implementation of nursing process
in selected governmental hospitals of Addis Ababa, Ethiopia, 2011.

Characteristics No %
Have physical disability 14 7.3
Have no physical disability 178 92.7
Total 192 100
Have misbehavior record 21 10.9
Have no misbehavior record 171 89.1
Total 192 100
Methods used to Recording every activity Yes 116 60.4
make work visible No 76 39.6
Total 192 100
Nursing process Yes 100 52.1
No 92 47.9
Total 192 100
Reporting to supervisor Yes 33 17.2
No 159 82.8
Total 192 100
Working on patient‘s problem Yes 68 35.4
No 124 64.6
Total 192 100
Nothing used Yes 9 4.7
No 183 95.3
Total 192 100
Frequency of Almost always 116 60.4
documenting Sometimes 47 24.5
Every once in a while 16 8.3
Rarely 9 4.7
Never 4 2.1
Total 192 100
Committed error Slip/lapses 19 9.9
Executive 41 21.4
Knowledge 24 12.5
Not committed error 108 56.25
Total 192 100

34
5.1.3. Organizational Factors Affecting Implementation of Nursing Process

Regarding the great anxieties of nurses (Table 3) one hundred five (54.7%) of the respondents

have had anxiety from nurse to patient ratio followed by rude physician challenges and

unsympathetic manager with equal burden 54(28.1%) and dealing with abusive family member

and everyone who did not do their job 49(25.5%). Thirty six (18.8%) and 26 (13.5%) were get

strain or anxiety from harassing coworker and demanding patients respectively.

From the total respondents 104 (54.2%) of them said the dissatisfying aspect of their job was

caring for so many patients followed by rules being made up without staff or residents in

mind79(41.1%) and useless paper work 40 (20.8%) and new reporting system 31(16.1%). From

those dissatisfied with any reason stated above 95 (49.5%) of the total respondents were

dissatisfied due to their profession (Table 3).

One hundred forty (72.9%) of the total respondents were working in a stressful working

environment where as 31(16.1%) were working in a disorganized working environment the

remaining 21(10.9%) respondents explained their work place as it is negligent at a time.

Regarding working hour distribution (Table 3) seventy eight (40.6%) of nurses have cared for

more than 15 patients per day and 49(22.5%) were cared for 10-15 patients per day while

51(26.6%) have cared for 5-10 patients per day and only 11(5.7%) were cared for less than 8

patients per day. One forty eight (77.1%) of respondents have worked eight hours per day where

as 14(7.3%) have worked more than 12 hours per day.

Eighty eight (45.8%) of the respondents have had belief of job and employee skill mismatch as

the cause for employee turnover while 68(35.4%) of respondents believed that less recognition

and growth opportunity were the other causes for employee turnover (Table 3).

35
Table: 3-Percentage distribution of organizational factors affecting implementation of nursing
process among nurses in selected governmental of Addis Ababa, Ethiopia, 2011

Character Frequency Percentage

Working hours/day <8hrs 11 5.7
8hrs 148 77.1
12hrs 19 9.9
>12hrs 14 7.3
Total 192 100
Distribution of patient flow <8pts 14 7.3
5-10pts 51 26.6
10-15pts 49 25.5
>15pts 78 40.6
Total 192 100
Availability of equipment Available 43 22.4
Not available 149 77.6
Total 192 100
Overtime work Yes With payment 134 69.8
Without payment 23 12
No 35 18.2
Total 192 100
Satisfied with payment Yes 9 5.7
No 125 94.3
Total 134 100
Dissatisfying Caring for so many Yes 104 54.2
aspect of patients No 88 45.8
nursing Total 192 100
New reporting system Yes 31 16.1
No 161 83.9
Total 192 100
Rules made without Yes 79 41.1
considering staff No 113 59.9
Total 192 100
Useless paper work Yes 40 20.8
No 152 79.2
Total 192 100
Dissatisfied due to nursing Yes 95 49.5
No 97 50.5
Total 192 100
The greatest Nurse : patient Yes 105 54.7
anxiety/ strain on No 87 45.3
nurses work place Total 192 100
Everyone one Yes 49 25.5
doesn‘t do their No 143 74.5
job Total 192 100

Dealing with Yes 49 25.5

abusive family No 143 74.5
Total 192 100
Rude physicians Yes 54 28.1
36
No 138 71.9
 Total 192 100
Yes 36 18.8
No 156 81.2
Harassing coworkers Total 192 100
Demanding patients Yes 26 13.5
No 166 86.5
Total 192 100
Unsympathetic managers Yes 54 28.1
No 138 71.9
Total 192 100
Work place Stressful 140 72.9
Negligent at a time 21 10.9
Disorganized 31 16.2
Total 192 100
Oriented while joining the current organization Yes 77 40.1
No 115 59.9
Total 192 100
Effect of staff Decreasing productivity Yes 68 35.4
turnover No 124 64.6
Total 192 100
Disorganized service Yes 134 69.8
delivery No 58 30.2
Total 192 100
Decrease spread of Yes 46 24.0
organizational knowledge No 146 76
Total 192 100
Cause of employee Job and employee skill Yes 88 45.8
turnover mismatch No 104 54.2
Total 192 100
Inferior facility Yes 40 20.8
No 152 79.2
Total 192 100
Less recognition Yes 68 35.4
No 124 64.6
Total 192 100
Less/ no appreciation Yes 55 28.6
No 137 71.4
Total 192 100
Less growth opportunity Yes 68 35.4
No 124 64.6
Total 192 100
Poor training Yes 41 21.4
No 151 78.6
Total 192 100
Poor supervision Yes 28 14.6
No 164 85.4
Total 192 100

37
Regarding the cause of staff turnover (Table 3) one hundred thirty four (69.8%) of respondents

have believed that staff turn over from a specific public health institution can obligate the

organization to provide a disorganized service. Sixty eight (35.4%) of respondents had believed

that staff turnover can cause decrease in productivity where as 46(24%) had believed that staff

turnover can cause decreased spread of organizational knowledge.

5.1.4. Patient Related Factors Affecting Implementation of Nursing Process

Table: 4 Patient related characteristics affecting implementation of nursing process in

selected governmental hospitals of Addis Ababa, Ethiopia, 2011

Characteristics No %
Reason of patient Poor understanding of modern medicine Yes 67 34.9
turnover No 125 65.1
Total 192 100
Poor economic status Yes 92 47.9
No 100 52.1
Total 192 100
Long time required to get service Yes 94 49
No 98 51
Total 192 100
Incurable diseases Yes 37 19.3
No 155 79.7
Total 192 100
Influence of patient Discharge before completing planned Yes 78 40.6
turnover on nursing care intervention No 114 59.4
Total 192 100
Not cooperative for their care Yes 63 32.8
No 129 67.2
Total 192 100
Lack of equipment Yes 63 32.8
No 129 67.2
Total 192 100
Present with complicated problems Yes 75 39.1
No 117 60.9
Total 192 100

Regarding on patient related characteristics (Table 4) ninety four (49%) of the respondents

informed that patients were discharged before they receive full care due to long time required to

get the service. Ninety two (47.9%) of the respondents informed that patients were discharged

38
early before they get relief from their problem due to poor economical income. Sixty seven

(34.9%) of respondents‘ patients were discharged before they receive the appropriate

management for their illness due to poor understanding of the modern medicine while 37

(19.3%) have informed that patients were discharged early before they were treated due to their

incurable illness.

Seventy eight (40.6%) of respondents were challenged to provide their nursing care due to early

discharge of patients before completing the planned intervention. Seventy five (39.1%) of

respondents believed that patients discharged before completing their treatment and came back to

their institution with a complicated problem which was difficult to manage. Sixty three (32.8%)

of respondents got challenge from patients who were discharged before finishing their treatment

due to patient‘s inability to collect the required material for care provision. The remaining

63(32.8%) were challenged due to poor participation of patients for the improvement of their

illness.

39
5.1.5. Knowledge Assessment

Table: 5 Percentage distribution of nurses’ knowledge about nursing process among nurses
in selected governmental hospitals of Addis Ababa, Ethiopia, 2011.

Characteristics Correct Answer Incorrect Total

No (%) Answer No (%) No (%)
1. One is not among the component of nursing 175(91.1%) 17(8.9%) 192(100%)
process
2. A nurse should do one at the first step of nursing 156(81.2%) 36(19.8%) 192(100%)
process
3. The Gordon approach is directly targeted at----- 102(53.1%) 90(46.9%) 192(100%)
4. Which nursing diagnosis is better to solve a 136(70.8%) 56(29.2%) 192(100%)
patient‘s problem with diabetes mellitus chronic
complication in the future?
5. What makes nursing process different from 137(71.4%) 55(28.6%) 192(100%)
medical approach?
6. Among the individuals in a hospital one is not 101(52.6%) 91(47.4%) 192(100%)
mandatory for the better accomplishment of
nursing process.
7. One is not included under the activities to be 64(33.3%) 128(66.7%) 192(100%)
performed in the planning phase of nursing
process.
8. In implementation step of nursing process a nurse 108(56.2%) 84(43.8%) 192(100%)
is expected to perform------
9. One could not be a guide for evaluation of nurses 112(58.3%) 80(41.7%) 192(100%)
performance in nursing process
10. Disturbed sleeping pattern related to unresolved 92(47.9%) 100(52.1%) 192(100%)
fears and anxieties as evidenced by difficulty in
falling /remain asleep. Identify the problem,
etiology and sign/symptom of the above nursing
diagnosis
11. Write one full actual nursing diagnosis 39(20.3%) 153(79.7%) 192(100%)

40
Regarding the knowledge assessment of nurses (Table 5) majority of respondents 175 (91.1%)

have answered the correct answer, which is evidence based practice is not among the five

components of nursing process while the remaining 16(8.9%) have chosen the incorrect answer

one among the components of nursing process.

One hundred fifty six (81.2%) of respondents have answered correctly- collecting baseline

information is the principal activity to be performed in the first phase of nursing process while

the remaining 36(19.8%) have wrongly answered.

More than half of respondents 102 (53.1%) answered human response towards physiological

disturbance is the focus of Gordon approach which is the correct answer whereas the remaining

90(46.9%) have wrongly answered.

One hundred thirty six (70.8%) of respondents have correctly answered as nursing diagnosis for

a problem to be manifested in the future is potential nursing diagnosis while the remaining

56(29.2%) have wrongly answered.

One hundred thirty seven (71.4%) 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 55(28.6%) of them answered wrongly.

One hundred one (52.6%) of respondents have believed that nurse, patient, family of the patient,

and physician are mandatory for the better accomplishment of nursing process. The remaining

91(47.4%) respondents have wrongly answered that the nurse, patient, family, and physician are

not mandatory for the better accomplishment of nursing process.

Sixty four (33.3%) 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

128(66.7%) of respondents have wrongly answered.

41
One hundred eight (56.2%) 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 84(43.8%) have wrongly answered.

One hundred twelve (58.3%) of the respondents knew that nursing diagnosis, collaborative

problems, priorities and nursing interventions, and expected outcomes could be guidelines for

evaluation of nurses performance in nursing process. The remaining 80(41.7%) respondents have

wrongly answered.

Ninety two (47.9%) of respondents were able to identify the problem, etiology and sign and

symptoms of a given actual nursing diagnosis. Only 39(20.3%) of respondents were able to write

a full actual nursing diagnosis that have consisted of problem, etiology, and manifestations of the

problem.

5.1.6. Skill Assessment

Table: 6-Percentage distribution of application of skills among nurses on caring patients in

selected governmental hospitals of Addis Ababa, Ethiopia, 2011
Character Not at Rarely Undecided Some Very
all No (%) No (%) times much
No (%) No (%) No (%)
Application of nursing theories on nursing practice 8(4.2) 11(5.7) 33(17.2) 87(45.3) 53(27.6)
Maintenance of patient dignity, privacy and 3(1.6) 7(3.6) 21(10.9) 59(30.7) 102(53.1)
confidentiality
Application of principles of health and safety 5(2.6) 9(4.7) 20(10.4) 73(38) 85(44.3)
Safe administration of medicine and other therapies 3(1.6) 12(6.2) 21(10.9) 45(23.4) 111(57.8)
Consideration of emotional, physical, and personal 11(5.7) 7(3.6) 31(16.1) 79(41.1) 64(33.3)
care of the patient
Respond to patient needs 8(4.2) 7(3.6) 26(13.5) 70(36.5) 81(42.2)

Regarding the application of nursing skills (shown on table 6) eighty seven (45.3%) of the

respondents were sometimes apply theories of nursing practice while 8(4.2%) were not at all
42
practiced it. One hundred two (53.1%) have had very much ability to maintain patient‘s dignity,

privacy and confidentiality (using nursing skills) where as only 3(1.6%) were not at all maintain

it. Eighty five (44.3%) respondents have practiced 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 5(2.6%) were not at all practiced it. One hundred eleven (57.8%)

respondents were safely administer medicine and other therapies very much but 3(1.6%) were

not at all administered. Seventy nine (41.1%) respondents have had the ability to consider

emotional, physical, and personal care, including meeting the need for comfort, nutrition,

personal hygiene and enabling the person to maintain the activities necessary for daily life;

(using nursing skills, intervention/activities to provide optimum care). Eighty one (42.2%)

respondents were able to respond to patient needs by planning, delivering and evaluating

appropriate and individualized programs of care working in partnership with the patient, their

care givers, family and other health workers.

One hundred (52.1%) respondents were implemented nursing process while 92(47.9%) did not

implemented nursing process as shown in figure 3.

Forty three (22.4%) of the total respondents had enough equipment while they were providing

care for their patient. From those 24(55.8%) and 19(44.2%) had moderately and highly skillful

respectively but no one had low skill.

One hundred forty nine (77.6%) of the total respondents had no enough equipment to provide

care. Of those who had no enough equipment 70(47%), 74(49.7%), and 5(3.3%) had high,

moderate and low skill respectively.

43
 102
100(52.1%)
100

98
Frequency

96
Implemented
94
Not impemented
92(47.9%)
92

90

88
Nursing process implementation

Figure: 4- Implementation of nursing process among nurses in selected governmental hospitals of

Addis Ababa, Ethiopia, 2011.

One hundred (52.1%) of respondents have implemented nursing process while 92(47.9%) were
not implemented nursing process.
60
101(52.6%)
50

40
60(31.2%)
percent

30

20 31(16.1%)

10

0
HIGH MODERATE LOW
level of knowledge

Figure: 5- Percentage distribution on level of knowledge among nurses working in selected

governmental hospitals of Addis Ababa, Ethiopia, 2011.

As it is shown in the figure above 31(16.1%) of respondents were highly knowledgeable and
101(52.6%) were moderately knowledgeable while 60(31.2%) had poor knowledge.

44
 60.00%

50.00%

40.00%
Percent

high
30.00%
moderat
98(51%)
89(46.40%)
20.00% low

10.00%

0.00% 5(2.60%)
Nursing Level of Skilll

Figure: 6-Percentage distribution on level of skill among nurses working in selected

hospitals of Addis Ababa, Ethiopia, 2011.

The above figure shows that 89(46.4%) of respondents were highly skillful and 98(51%) were

moderately skillful while only 5(2.6%) had poor skill

45
5.1.7. Implementation of Nursing Process

Table: 7 Association of implementation of nursing process by selected variables among

nurses working in selected governmental hospitals of Addis Ababa, Ethiopia, 2011.

Characteristics Implementation of Crude COR AOR(95%CI)

nursing process P- (95%CI)

Yes No value

No (%) No (%)

Sex Female 61(32.8%) 41(21.4%) 0.023 0.514(0.289-0.913) 0.712(0.361-1.407)*

Male 39(20.3%) 51(26.6%)

Stress full 80(41.6%) 60(31.3%) 0.014 0.357(0.157-0.814) 0.180(0.065-0.501)

Work place Negligent 10(5.2%) 11(5.7%) 0.266 ---------------------- -------------------------

Disorganized 10(5.2%) 21(10.9%)

Facility Accessible 73(38%) 79(41.1%) 0.031 2.248(1.079-4.684) 3.109(1.277-7.570)

Inferior 27(14%) 13(6.8%)

Knowledge Highly 27(7.924-91.994) 38.913(10.3-147.006)

4(2.1%) 27(6.8%) 0.000
knowledgeable

Moderately 4.417(2.1-9.289) 4.913(2.178-11.084)

48(25%) 53(27.6%) 0.000
knowledgeable

Low
48(25%) 12(41.1%)
knowledgeable

*sex significant variables in the crude were omitted from multivariate analysis

Regarding association of implementation of nursing process with selected variables (Table 7)

sixty one (32.8%) of female and 39(20.3%) of male respondents were implemented nursing

process giving a total of 100 (52.1%) respondents. Out of one hundred respondents who were

implemented nursing process 80(41.6%) were working in a stressful working environment,

46
10(5.2%) were worked in a neglecting environment, and 10(5.2%) were worked in a

disorganized environment. Seventy three (38%) were implemented nursing process without

facility shortage while 27(14%) were implemented with an inferior facility. Among those

implemented nursing process only four nurses were highly knowledgeable and equal number of

respondents 48(25%) were moderately and poorly knowledgeable.

From binary logistic regression analysis shown in table 7 being a female were negatively and

significantly associated with implementation of nursing process than male (COR: 0.514, 95%CI

:( 0.284-0.913), p: 0.023).

From the characteristics work place, nurses who were working in a stressful environment were

0.357 times significantly and less likely to implement nursing process than those worked in a

disorganized environment (COR: 0357, 95%CI (0.157-0.814), P: 0.014). Neglecting working

environment had no significant association with implementation of nursing process.

Working in a hospital with high facility were 2.248 times significantly and more likely to

implement nursing process than those working in an inferior facility (COR: 2.248, 95%CI:

(1.079-4.684), P: 0.030).

Highly knowledgeable nurses were 27 times more likely and significantly associated with

implementation of nursing process than low knowledge group nurses (COR: 27, 95%CI: (7.924-

91.994), P: <0.001). Moderately knowledgeable nurses were positively and significantly

associated with implementation of nursing process (COR: 4.417, 95%CI: (2.1-9.289), P:

<0.001).

In a multivariate analysis (multivariate logistic regression) shown in table 7 nurses working in a

stressful working environment were 0.357(adjusted OR: 0.357, 95%CI: (0.157-0.814)) times less

likely to implement nursing process than disorganized working environment adjusting for facility

47
accessibility, knowledge, and sex. Accessibility of facilities needed for nursing care were

2.248(Adjusted OR: 2.248, 95%CI: (1.079-4.684))times more likely to implement nursing

process than nurses working in an inferior facility controlling for working environment,

knowledge, and sex. Highly knowledgeable and highly skillful, moderately skillful, and poorly

skilful accounting 19,11, and 1respectively were 38.913(Adjusted OR: 38.913, 95%CI: (10.3-

147.006))times more likely to implement nursing process than low knowledge group nurses

adjusted for working environment, facility, and sex. Moderately knowledgeable were

4.913(Adjusted OR: 4.913, 95%CI: (2.178-11.407)) times more likely to implement nursing

process than low knowledge group nurses adjusted for work place, facility, and sex. The

characteristics sex was significantly associated with implementation of nursing process but it is

not significantly associated when it is adjusted with knowledge, facility, and work place.

48
5.2. Qualitative Study

5.2.1. Qualitative Study Result

A total of seven respondents were participated in the interview. The respondents‘ age rage was in

between 22-42 years and most of the respondents were staff nurses in responsibility. The

respondent opinion and experience was written as follows:

Nursing process in our hospital is not well known and nurses do not want to implement it due to
―

high patient flow and lack of adequate knowledge about the concept. Negligence of higher

officials in hospitals makes nursing process a useless principle. Professionals themselves are not

conscious to implement nursing process because of knowledge and practice mismatch. The

knowledge nurses obtained from school is not tailored to the actual practice. For example, the

knowledge I obtained within three months practice in work place is better than three years

university training for my current nursing practice. Sometimes it is not the perception of the

community that limits nursing only to the art but nurses themselves are not sensitive to maintain

professional value and they also keep idle to update themselves specially nurses worked for

many years. They are fatigued to implement nursing process rather they are complaining on the

current practice by recalling the past which had better payment. The cause for this could be

absence of in service training, poor sense of professionalism, attitude of the community and

professionals, and absence of appropriate curriculum to the country‘s health problem. Due to all

the above reasons nursing become a neglected profession in Ethiopia.‖

A 22 years old male staff nurse wit1h 8 months experience

―
Nursing is my identity. So if any one tries to undermine nursing I will scarify even my life

because nursing is everything of my life. It is the reason for my husband, my children, and my

house at all. Nursing was a highly recognized profession previously but later on it becomes

49
neglected. The reasons I suspect are: (1) lack of commitment of professionals (2) training system

(3) poor payment which is not enough for the service. The training system is pivotal for a

profession for example the requirements to be a candidate nurse student have no any hurdle. So

that recently everyone is joining nursing and it become dispensable like commodity. I agree that

nursing process can return the good time of nursing by equipping us with our own care delivery

system. The reason for poor implementation of nursing process in hospitals is not work load but

it is lack of knowledge and commitment. Nurses do not believe that nursing process could bring

any observable change. The absence of good foundation of nursing makes nurses to shift their

profession in to other fields. Previously there was no nursing process implementation so nothing

is obtained from old nurses.‖

A 42 years old female head nurse with 18 years experience

―
Upgrade nurses are resistant to change. They only want the previous system to be continued.

This problem may be emanated from poor training while they upgrade themselves into their

current position. Increased workload obligates nurses in our hospital to focus on implementation

part of nursing process without documenting the preceding steps. When we retrospectively

observe the history of nursing process in Ethiopia it has not been implemented starting from the

initial. The other factor that hinders implementation of nursing process in our unit is poor

supervision. Supervisors are from one unit controlling the whole units of the hospital. They are

not oriented about the nature of each unit. Most of the time supervisors come to our unit to

supervise and check what we have documented but they only observe whether there is written

information on the prepared sheet regardless of the content documented. Documenting habit of

nurses is highly significant factor which can affect implementation of nursing process. Some of

my colleagues said we have documented throughout our career of nursing but we cannot bring

any change on the health status of the society as well our life. There is no lack of knowledge to

50
implement nursing process rather professionals commitment limits them to implement it. Aging

of nurses couldn‘t be a factor which can limit implementation of nursing process. In the contrary

nurses will develop experience and make caring system easy.‖

A 26 years old male staff nurse with 2 years experience

―
There could be many factors affecting implementation of nursing process. In our hospital

particularly in my unit the most challenging factors are :( 1) decreased nurse to patient ratio for

example there are 10 nurses for 40 patients in our wing which means one nurse for eight patients.

(2) The format we used now focuses on public problems than the focus of nursing in hospitalized

patients. (3) Knowledge deficit. Most of the time nurses who have served for many years have

poor information updating habit. (4) Long time occupancy. This is because patients‘ inability to

pay for medical services timely. (5) Poor recording habits. It is common among nurses who have

been working for many years due to adaptation with the hospital environment. (6) Job and skill

mismatch. Therefore nurses are exhausted from daily routine activities which need immediate

and long term intervention.‖

A 23 years old male staff nurse with 9 months experience

―
I have implemented nursing process only while I was in university. After I join this hospital

there is nothing that initiates me to implement it. Higher officials are not aware of the importance

of nursing process. Furthermore, nurses themselves cannot show the importance for the

improvement of patients‘ problem. Professionals are highly exhausted from high patient flow.

High patient flow causes time shortage to care the patient. Due to this nurses are obligated only

to perform following the instruction of physicians. Nurses have forgotten knowledge of nursing

process due to long time working experience without implementing it. Additionally, nurses are

not committed to perform nursing process. This is due to the culture developed in hospitals, lack

of facilities, structure of hospitals, and payment we get.‖

51
 A 27 years old female staff nurse with 4 years experience

―
In our hospital it seems as if nurses have no knowhow about nursing process. I said it because

of the habit of nurses‘ inspiration to deal about nursing process. This leads to poor/ absence of

implementation of nursing process. This is due to absence of encouraging working environment

that can initiate nurses to implement nursing process. It is obvious that nurse‘s independent role

is not separately known. So that nurses follow physician‘s decision. If nurses‘ independent role

were distinctly known, nurses would have take their responsibility and become accountable for

their actions. For example, a patient ready for surgery will enter to Operation Theater if he/she

can tolerate anesthesia prescribed by the anesthesiologist and administered by anesthetist without

considering the role of nurses. Additionally, Lack of knowledge took its own part for poor

implementation of nursing process. Nurses have no enough knowledge to assess & identify

patients‘ problem and plan & implement the appropriate management. Sometimes there is

unfamiliarity with instruments. This unfamiliarity might be lack/ inappropriate training. For

example, I have attended different trainings focused on how to assist physicians than the way to

perform independent role. Additionally, nurses training system is general but it needs

specialization. It makes nurses to have superficial knowledge.‖

A 24 years old male staff nurse with 1 year experience

―
The life of nursing is build upon caring. So to maintain the professions value we shall to

implement nursing process. Only the name of nursing process is known in our hospital but no

one tries to implement it. Poor implementation of nursing process is a historical practice we have

inherited from our seniors. They were not implementing it rather serving the physician by

leaving their independent role apart. We are also practicing the habit that come down to this

generation.

52
Knowledge management is the other factor influencing implementation of nursing process. A

BSc and diploma holder nurses are practicing on similar set up. There is no a known demarcation

between the role of different academic levels of nursing career. We are abused by patient

relatives and physicians. Due to this we are obligated to work following the instruction from

physicians.‖

A 32 years old male staff nurse with 7 years experience

5.2.2. Summary of Qualitative Study Result

The data collected from interviewees was summarized thematically by identifying the core ideas

they have responded. The whole information is summarized into three themes.

A. 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.

53
 B. Commitment of Nurses

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. Most of highly experienced nurses were complaining about

the payment they have obtained by comparing the payment they were paid previously.

The fourth reason was age difference. Some have believed that aged nurses could not effectively

implement nursing process. In contrast some others believed that aged nurses are highly

experienced and effective in implementation of nursing process using their skill developed

throughout their nursing career.

Generally, inspiration of nurses was low due to the above reasons and they were just working for

food not for their profession.

C. 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. Some others

believed that nurses had adequate knowledge but due to absence of suitable caring environment

54
nurses could not implement nursing process. Some others believed that the knowledge nurses

have obtained from school varies from school to school. They have described that nurses from

private schools are poorly knowledgeable with high grade. Some of interviewees have got

difference between the training system of universities and the actual nursing practice.

Generally, all of respondents have agreed that nurses could improve their knowledge of nursing

process if they can implement it and got in-service education targeted at nursing process.

55
CHAPTER SIX

6. DISCUSSION

The study tried to assess factors affecting implementation of nursing process among nurses

working in selected government hospitals of Addis Ababa. One hundred (52.1%) nurses were

implemented nursing process while 92(47.9%) of them were not implemented nursing process.

From those implemented nursing process 61(61%) were female and 39(39%) were male. Forty

one (44.6%) and 51(55.4%) female and male respectively were not implemented nursing

process.

From the total respondents 104 (54.2%) of them said the dissatisfying aspect of their job was

caring for so many patients. In a research conducted about nurse to physician communication,

nursing workload definitely affects the time that a nurse can allot to various tasks. Under a heavy

workload, nurses may not have sufficient time to perform tasks that can have a direct effect on

patient safety. A heavy nursing workload can influence the care provider‘s decision to perform

various procedures (31). It shows that when nurses become dissatisfied about their job the

nursing care to be provided will not have systematic approach. In other words nursing process

may not be implemented in a hospital with high patient flow beyond the capacity of nurses.

The average nurse-to-population ratio in high-income countries is almost eight times greater than

in low-income countries. Low availability of nurses in many developing countries is exacerbated

by geographical misdistribution; there are even fewer nurses available in rural and remote areas.

Factors contributing to the nursing shortage vary in different parts of the world (14). As

registered nurse-to-patient ratios decrease from 1:4 to 1:10, the number of post-op surgical

patient deaths climbs dramatically (15). In this study seventy eight (40.6%) of nurses have cared

56
for more than 15 patients per day and 49(22.5%) were cared for 10-15 patients per day while

51(26.6%) have cared for 5-10 patients per day and only 11(5.7%) were cared for less than 8

patients per day. This shows that there is a significant difference between a research conducted in

USA and this study due to the average nurse-to-population ratio in high-income countries is

almost eight times greater than in low-income countries.

One hundred thirty four (69.8%) of respondents in this study have believed that staff turn over

from a specific public health institution obligates the organization to provide a disorganized

service. Sixty eight (35.4%) of respondents had believed that staff turnover can cause decrease in

productivity where as 46(24%) had believed that staff turnover can cause decreased spread of

organizational knowledge. Several studies have shown the relationship between nurses‘ working

conditions, such as high workload, and job dissatisfaction (34). Job dissatisfaction of nurses can

lead to low morale, absenteeism, turnover, and poor job performance, and potentially threaten

patient care quality and organizational effectiveness (35). Thus, workload leads to staff turnover

that could be a burdensome for implementation of nursing process.

In this study rude physician challenges and unsympathetic manager were causes of violence on

nurses with equal number of respondents 54(28.1%) and dealing with abusive family member

and everyone who did not do their job with equal number of respondents 49(25.5%). Thirty six

(18.8%) and 26 (13.5%) were get strain or anxiety from harassing coworker and demanding

patients respectively. A survey of 120 nurses in Brazil (59 percent response rate) in three units of

pediatric hospitals to assess self-reports of violations in the medication administration process.

Between 8 percent and 30 percent of the nurses reported violations in routine situations, and

between 32 percent and 53 percent of the nurses reported violations in emergencies. The most

frequent violations or work-around occurred in matching the medication to the medication

57
administration record and checking the patient‘s identification. The cause of nurses‘ abuse is

different in this study the reason may be due to the set up of the research site.

Another important factor to be considered in the development of frameworks and instruments to

assess good nursing care is the relationship between the quality of nursing care and the

qualifications of the nursing staff providing care. However, some research undertaken in the

United States and in the UK suggests that registered nurses provide a higher quality of nursing

care than other categories of nurses and untrained health workers or assistants. Cutting health

care costs by replacing qualified nurses with untrained health workers is an increasing temptation

in many countries with a diminishing health budget. A critical dimension to quality, therefore, is

economic (11). The qualitative part of this study tells us the caring capacity of nurses is affected

by their experience and school. Nurses from private college and those worked for long time have

lesser capacity to give care in a well organized manner.

According to the report released from Cambridge UK workload can be a factor contributing to

errors. Errors have been classified as (1) slips and lapses or execution errors, and (2) mistakes or

knowledge errors. High workload in the form of time pressure may reduce the attention devoted

by a nurse to safety-critical tasks, thus creating conditions for errors and unsafe patient care (37).

In this study forty eight (25%) of respondents were anxious from high patient flow. Among those

15(31.3%), 22(45.8%), and 11(22.9%) have committed knowledge, executive, and slip/slap error

respectively. In turn high patient flow made nurses anxious and causes knowledge, executive,

and slip/slap error while they are caring patients.

A retrospective cohort study in a neonatal intensive care unit revealed that the incidence of E

cloacae infection in the unit was significantly higher when there was understaffing of nurses

(24). A prospective study in a pediatric cardiac ICU found a significant relation between the

58
monthly nosocomial infection rate in the unit and the nursing hours per patient ratio. There were

more nosocomial infections when the number of nursing hours per patient day was lower (25).

Seventy eight (40.6%) of respondents were challenged to provide their nursing care due to early

discharge before completing the planned intervention. Seventy five (39.1%) of respondents

believed that patients discharged before completing their treatment and came back to their

institution with a complicated problem which was difficult to manage. Sixty three (32.8%) of

respondents got challenge from patients who were discharged before finishing their treatment

due to patient‘s inability to collect the required material for care provision. The remaining

63(32.8%) were challenged due to poor participation of patients for the improvement of their

illness. The result in other studies was somewhat different from the result of this study

respondents because the cause of outcome was workload where as in this study was problems

related to patients.

A study conducted in Europe to test the establishment of a validated model of nursing records

aimed to promote individual care. The results showed limitations of the nursing process

conducted according to the model, particularly in the identification of problems presented by the

patients and, consequently, diagnosis and the possible intervention procedures. A study

conducted in the United Kingdom to assess whether data obtained from nursing records could be

reliably used to identify interventions for patients who had suffered acute myocardial infarction

or a fracture of the head of the femur, showed that the analyzed nursing records did not provide

an adequate picture of patients' needs for nursing interventions (47). Similarly in this study

ninety two (47.9%) of respondents were able to identify the problem, etiology and sign and

symptoms of a given actual nursing diagnosis. Only 39(20.3%) of respondents were able to write

a full actual nursing diagnosis that have consisted of problem, etiology, and manifestations of the

59
problem. This tells us the inability of nurses to identify the components of nursing diagnoses and

recording it in a well-organized manner that could be understandable by other staff members.

An investigation conducted in Brazil on the steps of nursing process actually implemented in the

routine of a university hospital showed that all phases were performed. However, problems were

identified in the nursing diagnosis process, involving recording the history and implementing

nursing prescriptions. The evolution of expected results, in particular, was not adequately

recorded (48). From 100(52.1%) respondents who have implemented nursing process 61, 22, 8,

7, and 2 were recorded their activities always, sometimes, every once in a while, rarely and never

respectively. The part of nursing process which was not written is not separately identified in

this study. But we can conclude that nurses could not fully document what they have performed

cognizant of the fact that they have implemented nursing process.

One hundred forty (72.9%) of the total respondents were working in a stressful working

environment where as 31(16.1%) were working in a disorganized working environment the

remaining 21(10.9%) respondents explained their work place as it is negligent at a time.

Stressful working environment make nurses activity full of error. Those worked in a

disorganized working environment will have poor patient outcome, which can affect the socio

economic status of the patient, and later on family and the society. As the in-depth interview

respondents explained it, neglecting working environment was the principal factor that can

influence implementation of nursing process among nurses who had worked for long period.

Eighty seven (45.3%) of the respondents were sometimes apply theories of nursing practice

while 8(4.2%) were not at all practiced it. One hundred two (53.1%) have had very much ability

to maintain patient‘s dignity, privacy and confidentiality (using nursing skills) where as only

3(1.6%) were not at all maintain it. Eighty five (44.3%) respondents have practiced the principles

60
of health and safety, including moving and handling, infection control; essential first and

emergency first aid and emergency procedures very much where as 5(2.6%) not at all practiced

it. One hundred eleven (57.8%) respondents were safely administer medicine and other therapies

very much but 3(1.6%) were not at all administered. Seventy nine (41.1%) respondents have had

the ability to consider emotional, physical, and personal care, including meeting the need for

comfort, nutrition, personal hygiene and enabling the person to maintain the activities necessary

for daily life; (using nursing skills, intervention/activities to provide optimum care). Eighty one

(42.2%) respondents were able to respond to patient needs by planning, delivering and

evaluating appropriate and individualized programs of care working in partnership with the

patient, their care givers, family and other health workers.

As it is shown above most of the nurses were highly skillful related to the practice of nursing

skills yet those of skills were not applicable on implementation nursing process.

This study shows us thirty one (16.1%) of respondents were highly skillful and 101(52.6%)

were moderately knowledgeable while 60(31.2%) had poor knowledge. Eighty nine (46.4%) of

respondents were highly skillful and 98(51%) were moderately skillful while 5(2.6%) had poor

skill. The number of highly skillful nurses is twice of highly knowledgeable nurse and nearly

equal number of nurses was moderately knowledgeable and skillful where as poorly skillful

nurses were one fifth of poorly knowledgeable. Highly knowledgeable nurses were 27 times

more likely and significantly associated with implementation of nursing process than low

knowledge group nurses (COR: 27, 95%CI: (7.924-91.994), P: <0.001). Moderately

knowledgeable nurses were positively and significantly associated with implementation of

nursing process (COR: 4.417, 95%CI: (2.1-9.289), P: <0.001). Thus the numerical discrepancy

61
between level of knowledge and skill could be due to the nature of data collection tool. The

tool used for knowledge assessment was structured questionnaire which could no be biased by

respondents internal interest where as the skill assessment tool was likhert scaled questionnaire

that could be biased by the interest of respondents to keep their dignity.

One hundred forty eight (77.1%) of participants were working for 8 hours per day. From those

55(37.2%), 38(25.7%), 43(29%), 12(8.1%) had provided care for more than 15, 10-15, 5-10,

less than 8 patients per day respectively. It shows us the disproportional nurse to patient ratio.

When there is lesser nurse to patient ratio nurses will be loaded with many disorganized and

unstructured work. This could be a cause for stress and expose nurses to perform clinical error.

In this study forty eight (25%) of respondents were anxious from high patient flow. Among those

15(31.3%), 22(45.8%), and 11(22.9%) have committed knowledge, executive, and slip/slap error

respectively.

Despite their knowledge of the nursing process, certain factors limit the ability of nurses to

implement it in their daily practice, including lack of time, high patient volume, and high patient

turnover. The daily application of nursing process is characterized by the scientific background

of the professionals involved since it requires knowledge and provides individualized human

assistance. In this study also highly knowledgeable nurses were 27 times more likely and

significantly associated with implementation of nursing process than low knowledge group

nurses (COR: 27, 95%CI: (7.924-91.994), P: <0.001). Moderately knowledgeable nurses were

positively and significantly associated with implementation of nursing process (COR: 4.417,

95%CI: (2.1-9.289), P: <0.001). It shows us knowledge is mandatory to implement nursing

process.

62
High workload is a key job stressor of nurses in a variety of care settings, such as ICUs. A heavy

nursing workload can lead to distress (e.g., cynicism, anger, and emotional exhaustion) and

burnout. Nurses experiencing stress and burnout may not be able to perform efficiently and

effectively because their physical and cognitive resources may be reduced; this suboptimal

performance may affect patient care and its safety (36). In this study from the characteristics

work place, nurses who were working in a stressful environment were 0.357 times significantly

and less likely to implement nursing process than those worked in a disorganized environment

(COR: 0357, 95%CI (0.157-0.814), P: 0.014). Neglecting working environment had no

significant association with implementation of nursing process. Hence nursing process

implementation needs a safe and encouraging working environment.

63
CHAPTER SEVEN

7. STRENGTH AND LIMITATION OF THE STUDY

7.1. Strength of the Study

This study used qualitative method to supplement the quantitative result and also to explore

factors that are not addressed by quantitative method.

This study is probably the first/ among the pioneers research related to nursing process in

Ethiopia. It will be helpful as baseline information for other researchers.

7.2. Limitation of the study

The study design was cross sectional which is used to investigate findings on a single point of

time. So that the factors affecting implementation of nursing process out of the study period

could not be investigated. It is also limited to be compared with other studies due to absence of

similar studies.

Sample Bias: because the study subjects were recruited from selected governmental hospitals of

Addis Ababa. The study didn‘t included nurses working in other hospitals. Thus the study may

not be generalized to all nurses in Addis Ababa because nurses out of selected hospitals may

have different experience and opinion.

The quantitative questionnaire was prone to social desirability bias; because of every one do not

want to expose once inability. The mismatch in the result of nurses‘ knowledge and skill was an

evidence for this bias.

64
CHAPTER EIGHT

8. CONCLUSION

Different studies showed that nursing process is indispensable in the health care delivery system.

Nurses should use nursing process to make their work visible and valuable to improve the quality

of care for patients‘ prognosis. Nursing process implementation is affected by various factors,

which causes poor quality of nursing care, disorganized caring system, conflicting role,

medication error and readmission with similar problem, dissatisfaction with the care patients

have received, and increased mortality.

High nurse to patient ratio is one factor that hinders implementation of nursing process; later

causes increase workload. Increased workload again is a stressor for nurses.

Organizational factors took the greatest part for poor implementation of nursing process.

Lack of equipment supply in hospitals for giving nursing care was highly affecting

implementation of nursing process.

Nurses were highly dissatisfied from organizational or patient factors.

Higher officials have no full awareness about nursing process that makes them not to facilitate

the requirements for care plan implementation.

Patients were discharged early from hospitals due to poor understanding of modern medicine,

poor economical status, long time required to get services, and incurable diseases. Early

discharge of patients causes discharge before completing their treatment, decreased cooperation

for their care, inability to afford the materials needed for care, and present with complicated

problems.

65
Knowledge of nurses was one of the factors affected implementation of nursing process. Study

participants have suggested the reason for poor implementation of nursing process might be

curricular problem that do not consider the actual problem of the society.

As per the result of this study, most of the nurses were skillful but their skill is not applicable in

practice for implementation of nursing process.

66
CHAPTER NINE

9. RECOMMENDATION

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. The principal investigator would like to give the

following recommendations

A. Nurses Scholars

1. Nurse researchers should focus to the challenges of the contemporary nursing in Ethiopia

in comparison to the status of the international nursing.

2. Produce a standardized Ethiopian nursing practice.

B. Health Facilities

3. Health facilities must provide in-service education or periodical training to update the

knowledge of nursing process.

4. Hospital officials should get the right information about nursing.

5. Hospitals should provide the appropriate supply of instruments for nursing care.

C. Ministry of Health

Ministry of health and its stakeholders are recommended to:

6. Change the training system to make nursing a well recognized profession by the society

and professionals themselves.

7. Launch standardized qualification and accrediting method controlled by nurse scholars.

8. Check the status of nurses after they are graduated from training centers and take the

right measure for the findings.

67
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72
Annex 1

Information and Consent Sheet

Information sheet and consent form prepared for BSc nurses who were participated in research

project, a cross-sectional study assessment on implementation of nursing process among nurses

for their inpatient in selected government hospitals of Addis Ababa

Name of Principal investigator: Mulugeta Aseratie

Name of the organization: Addis Ababa University, College of Health Sciences, Department of

Nursing and Midwifery

Name of the Sponsor: Addis Ababa University

This information sheet and consent form is prepared to explain the study you are being asked to

join. Please listen carefully and ask any questions about the study before you agree to join. You

may ask questions at any time after joining the study. The investigator is final year MSN

graduate student from the department of nursing, college of health science, Addis Ababa

University, and one advisor from Addis Ababa University.

Purpose of Research Project

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.

This study will identify how the factors affecting implementation of nursing process performed

by nurses apply its influence on the nursing practice in Black Lion Hospital (BLH), St. Paul

Hospital (SPH), Ras Desta Damitew Memorial Hospital (RDDMH), and Yekatit 12 Hospital.

The results of the study will be used as base line information to design appropriate intervention

73
strategies for the factors that can influence nurses‘ capacity to conduct nursing process for their

patients.

Procedure

To assess the factors affecting implementation of nursing process among nurses for their patient

in Selected Government Hospitals of Addis Ababa you are invited to take part in this project. If

you are willing to participate in this project, you need to understand and tick ―
yes‖ the agreement

form. Then after, you will receive the questionnaire by the data collector to give your response.

You do not need to write your name on the questionnaire and all your responses and the results

obtained will be kept confidentially by using coding system whereby no one will have access to

your response.

Risk/ Discomfort

By participating in this research project, you may feel that it has some discomfort especially on

wasting time about 30 minutes. We hope you will participate in the study for the sake of the

benefit of the research result. There is no risk in participating in this research project.

Benefits

If you participate in this research project, there may not be direct benefit to you but your

participation is likely to help us in assessing implementation of nursing process among nurses for

their inpatient. Ultimately, this will help us to identify the gap and take the appropriate

intervention by the authorized stakeholder.

Incentives

You will not be provided any incentives or payment to take part in this project.

74
Confidentiality:

The information collected from this research project will be kept confidential and information

about you that will be collected by this study will be stored in a file, without your name, but a

code number assigned to it. In addition, it will not be revealed to anyone except the principal

investigator and will be kept locked with key.

Right to refuse or withdraw:

You have full right to refuse from participating in this research. You can choose not to respond

to some or all questions if you do not want to give your response. You have also the full right to

withdraw from this study at any time you wish, without losing any of your right.

Persons to contact:

If you have any question to ask, please contact

 Mulugeta Aseratie

Tel: +251-910-03-3462

Email = [email protected]

75
 Annex 2
Questionnaire
Addis Ababa University
College of Health Science
Department of Nursing and Midwifery
Consent Form

This questionnaire is prepared to assess the factors affecting implementation of nursing process

in Addis Ababa selected government hospitals.

The assessment is made for the partial fulfillment of Masters Degree in Nursing. The results of

the study will be used as base line information to design appropriate intervention strategies to

increase nurses‘ capacity to conduct nursing process for their patients.

The questionnaire contains both closed and open ended questions and will be provided in self

administered form. You are therefore kindly requested to provide genuine answers to the

questions.

The information you provide is confidential and is used only for the purpose of this study. If you

have any question, don‘t hesitate to ask the data collector.

Your cooperation and participation until the completion of the questionnaire is very necessary

for the successful completion of the assessment. We therefore ask your genuine willingness.

However, you have the right to turn down if you are not voluntary to participate fill ‗No‘ in the

box below.

If you are voluntary Yes No

Thank you in advance for your cooperation

Data collectors sign: _____________

76
 Quantitative questions

I. Socio-demographic data

1. Sex: A. female B. male

2. Age;

A. Below 24 C. 45-54 E. Above 65

B. 25-44 D. 55-64

3. Marital status;

A. Single B. Married C. Widowed D. Divorced

II. Organizational and nurses related questions

4. When do you graduated for BScN?_______________E.C.

5. How many years you did work in clinical area ___________which unit ______

6. How many hours do you work per day?

A. <8 hrs B. 8 hrs C. 12 hrs D. >12 hrs

7. For how many patients do you care per day?

A. Less than 5 B. 5-10 C. 10-15 D. Greater than 16

8. Do you have all equipments to do your nursing care?

A. Yes B. No

9. Have you worked over time?

A. Yes B. No

10. If yes, is that with payment?

A. Yes B. No

11. Is the payment enough?

77
 A. Yes B. No

12. Have you ever had misbehavior record in your personal file?

A. yes B. no

13. What are the greatest strains or anxieties you have in your working time?

A. The nurse to patient ratio. D. Rude physicians

B. Everyone doesn't do their job E. harassing coworkers

C. Dealing with abusive family F. Demanding patients

members, G. Unsympathetic managers

14. What are the dissatisfying aspects of your job?

A. Having the care for so many C. Rules being made up without staff

patients or residents in mind

B. The new report system D. Useless paperwork

15. If you are dissatisfied with the above any reason from question number 15, Is it due to your

profession?

A. Yes B. No

16. How would you describe the atmosphere/culture of the workplace?

A. Stressful at times

B. Negligent at times C. Disorganized

17. Did you get satisfying orientation while you joined this organization?

A. Yes B. No

18. Do you have any physical or mental problem?

A. Yes B. No

78
19. What do you use to make your work visible?

A. Recording every activities perform D. Working on the patient problem and

B. Using nursing process seeing the outcome

C. Reporting to supervisors E. Nothing used

20. How often you document your work?

A. Almost always C. Every once in a D. Rarely

B. Sometimes while E. Never

21. Have you committed clinical error?

A. Yes B. No

22. If you do, what kind of error you perform?

A. Slip or slap B.Excusive error C. Knowledge error

23. How high rate of staff nurse turnover affect once society health _______________

A. Decreasing productivity C. Lessoning spread of organizational

B. Disorganized service delivery knowledge

24. What do you think the causes of employee turnover?

A. Job and employee skill mismatch E. Less growth opportunities

B. Inferior facilities, tools, etc F. Poor training

C. Less recognition G. Poor supervision

D. Less or no appreciation for work

done

25. What do you think the major reason of patient turnover?

A. Poor understanding of the modern B. Poor economical status

medicine C. Long time required to get the service

82
 D. If they have incurable diseases

26. From the above question, how it influence your nursing care delivery?

A. Discharge before completing C. Inability to collect the required

planed interventions material for care

B. Not cooperative for the care you D. Present with complicated

provide problem which is difficult to

manage

III. Knowledge Assessment

27. One is not among the component of nursing process

A. Assessment D. Evidenced based practice

B. Diagnosis E. Implementation

C. Planning F. Evaluation

28. A nurse should do one at the first step of nursing process

A. Collecting subjective and objective data

B. Directly intervening the problems of the patient

C. Evaluating what has be done for the patient

D. Indicating the activities to be done

29. The Gordon approach is directly targeted at

A. The main physiological disturbance C. Abram Maslow‘s hierarchy of need

B. Human responses towards D. Ethical principles

physiological disturbances

30. Which nursing diagnosis is better to solve a patient‘s problem with diabetes mellitus chronic

complication in the future

83
 A. Actual nursing diagnosis D. Laboratory investigation of sugar

B. Potential nursing diagnosis level

C. Medical diagnosis

31. What makes nursing process different from medical approach?

A. Nursing diagnosis always focuses on the diseases than other human responses

B. Nursing diagnosis always focuses on human responses than diseases process

C. Both focuses on human responses but nursing process is limited to pathological problems

D. Both have similar procedure to resolve a patients problem

32. Among the individuals in a hospital one is not mandatory for the better accomplishment of

nursing process

A. Nurses B. Patient C. Family D. Physician F. No one should be excluded

33. One is not included under the activities to be performed in the planning phase of nursing

process

A. Assigning priorities to the nursing diagnoses and collaborative problems

B. Specifying expected outcomes

C. Recording the data base of the patient

D. Specifying the immediate, intermediate, and long-term goals of nursing action

E. Identifying specific nursing interventions appropriate for attaining the outcomes

F. Identifying interdependent interventions

34. In implementation step of nursing process a nurse is expected to perform

A. Proposing the interventions for the patient‘s problem

B. Implementing the proposed interventions in the planning phase.

C. Performing the planned interventions excluding activity of daily living

84
 D. Finishing the phase if the initial implementation could not bring any observable change on

the patient‘s problem.

35. One could not be a guide for evaluation of nurses performance in nursing process

A. The nursing diagnoses D. expected outcomes

B. collaborative problems E. All could be guidelines

C. Priorities and nursing interventions

36. Disturbed sleeping pattern related to unresolved fears and anxieties as evidenced by difficulty

in falling /remain asleep. Identify the problem, etiology and sign/symptom of the above

nursing

diagnosis.__________________________________________________________________

___________________________________________________________________________

____________________________________________________________________

37. Write one full nursing diagnosis

__________________________________________________________________________

__________________________________________________________________________

85
IV. Skill assessment

Score the following activities according to the frequency you perform

1/ Not at all 2/ Not really 3/ Undecided 4/ somewhat 5/ Very much

Practices 1 2 3 4 5

Ability to apply theories of nursing practice

Ability to maintain patient dignity, privacy and confidentiality(using

nursing skills)

Ability to practice principles of health and safety, including moving and

handling, infection control; essential first aid and emergency first aid and

emergency procedures

Ability to safely administer medicine and other therapies;(using nursing

skills, interventions/activities to provide optimum care)

Ability to consider emotional, physical, and personal care, including

meeting the need for comfort, nutrition, personal hygiene and enabling the

person to maintain the activities necessary for daily life; (using nursing

skills, intervention/activities to provide optimum care)

Respond to patient needs by planning, delivering and evaluating

appropriate and individualized programs of care working in partnership

with the patient, their care givers, family and other health workers.

86
Qualitative Questions

In-depth interview

1. Mention the organizational factors affecting implementation of nursing process in your

institution

2. How patients income affect implementation of nursing process in your institution

3. Which age group of nurses provides much care than others? Why?

4. Explain the impact of patient turn over and nurse turn over on implementation of nursing

process? Which one highly affects it? Explain

5. What is the most challenging factor that can affect implantation of nursing process?

explain

87