Introduction

A nursing care plan provides direction on the type of nursing care the individual family / community may need. It is a systematic method of assessing, diagnosing, planning, delivering and evaluating individualized care for clients in any state of health or illness. It provides an organized framework for the practice of nursing and the knowledge, judgments, and actions that nurses bring to patient care. It is the framework for providing professional, quality nursing care. It directs nursing activities for health promotion, health protection and disease prevention and is used by nurses in every practice setting and specialty. The nursing process provides the basis for critical thinking in nursing (Alfaro-LeFavre, 1998). According to Adeyemo and Olaogun [2], nursing process is described as a modified scientific method of clinical judgment used by nurses in clients’ care. The main focus of a nursing care plan is to facilitate standardised, evidence-based and holistic care.

The survey was done in the trauma department of a resource constraint teaching hospital Ghana. A mini questionnaire was designed to seek the opinion of the nurses and other stakeholders on the challenges of the implementation of the nursing care process. The result was augmented with interview sessions and a focus group discussion.

Statement of the problem associated with the nursing process

Nursing quality is closely related to a healthcare system’s effectiveness. In order to achieve quality of health care service, quality of nursing care is the key element and to fill this demand application, the nursing process has a significant role, but, in practice, application of the nursing process is not well developed (Mason and Attree, 2000). The problem is that it is skill uncertainty how far nurse have gone towards effective utilization and effective implementation of nursing process in nursing practice. The essence of nursing process for client care lies on the great benefit to the client, nurses and nursing profession as a whole. There are many reasons mentioned in several studies as hindrances for the execution of the nursing process, such as infrastructural issues related to: physical plant, insufficient personnel, lack of time, excessive attributions of the nurse, lack of leadership abilities by the supervision when overseeing this activity, lack of administrative support, lack of material resources [1]. The nurses’ lack of knowledge to perform the process is the main reason leading these professionals to avoid executing it in their day-to-day routines. Consequently, they are unaware of the importance of their agreement and involvement with the methodology of care for the systematization of nursing care. This leads them to doubt, and therefore not comply with the nursing process. In turn, they do not get the social recognition of their profession from society, when they do not link their professional activity to the object of their profession: healthcare planning [15].

In Africa, many countries have adopted the nursing process, but problems are found in its implementation in the clinical setting. A study conducted in four African countries found that while nurses generally agree on the benefits of the nursing process, it is not commonly used in practice. These constraints identified by the study included, its time-consuming nature, failure of nurse leaders to motivate others, shortage of staff and negative attitudes (Forsberg, Edlund and Standardvardplaner, 2003). It seems that this innovation in our health institutions often meet with obstructions, and the motivations which might help us to understand and overcome the implementation of the nursing process are lacking. The utilization of nursing process in health institutions in is a big problem. There seem to be factors causing the proper implementation of nursing process, thus preventing quality care despite the fact that many nurses have acquired more knowledge about it. Since the introduction of the nursing process in Ghana in 1970, there has been a decrease in the use of the care plan among professional nurses at the clinical area. Despite the benefits of using the nursing process and a written care plan, there is still a limited use of these tools by nurses in Ghana. Currently, there is no evidence of the use of the nursing process; since the care plan form is not common among the admission documents used at the clinical area in Ghana (Addison & Commey: use of the nursing process among professional nurses, unpublished). There are only limited studies conducted in Ghana and especially in KBTH and only little is known regarding reasons behind the nonimplementation of the nursing process. KBTH, being a teaching hospital should not suffer setbacks in the implementation of nursing process in it clinical setting. Nevertheless, it seems the reverse is the case. Having interviewed a few nurses at the Department of Trauma, it came to light they feel they did not have much time or time wasting, taken into consideration the massive amount of documentation generated by the implementation of the nursing process. Interacting with the nurses came to light that they have either poor knowledge on the nursing process or have forgetting about the process after completing their basic nursing training. Some of them saw the process as more theoretical than practical and that it was a mere record keeping process which seems cumbersome. Others in the department were also of the view that there are not enough logistics and materials as well as enough professional nurses to help in the implementation of the care plan. Therefore, the aim of this survey is to assess the challenges affecting the implementation of the nursing process in caring for patients in the Department of Trauma of the KBTH.

Literature review on the nursing process

The utilization of the nursing process

The utilization of the nursing process and a nursing diagnosis has been identified as critical to nursing practice. CarpenitoMoyet [6]. Some of the factors affecting the use of the nursing process have been studied among nurses working in various health institutions. Several factors were found to interfere with the efficient implementation of the nursing process. Operational difficulties involved in the systematization of nursing care in practice, such as, a lack of knowledge of the steps involved in the process, an excessive number of tasks assigned to the nursing team, the poor quality of professional education, and inadequate reports on the physical examination related to the disease, are among these factors. Today, learning and using the nursing process are two different categories. Besides, most of the nurses learn the nursing process when they have an individual or specific patient but when the number of the patients increases, they may not use this process. According to Akbari and Shamsi [3], nurses are responsible to a reasonable extent for non-implementation of Nursing Process in many ways. In this study, 32 (50.6%) subjects had mentioned that they have done the nursing cares based on the nursing process, while the truth is that most of the nurses had not learned the nursing process in the clinical practice correctly [3]. A study by Pokorski, Morae, Chiarelli, Costanz and Rabelo, [12] reviewed a total of 302 Medical records of adult patients admitted to a surgical, clinical or intensive care unit to identify the nursing process steps accomplished during the first 48 hours after admission. The results revealed that the nursing records and physical examination were included in over 90% of them. Nursing diagnosis was not found in any of the records. Among the steps performed, intervention was the least frequent [12]. A study on evaluation on how the nursing process has been registered at a Brazilian Teaching

Hospital found some failures in the record of some steps of the nursing process. Although all steps had been used, they were not carried out consistently [10]. The result of the study conducted among 137 nurses at rural and university hospitals in the western and southern region of Sweden on factors and conditions influencing the implementation of standardized nursing care plan (nursing process) show that 98% of the respondents used standardized nursing care plan in their everyday work [9].

According to O’Connell in [11], many Africa countries have adopted the nursing process; however, the problem as he stated is its utilization in the clinical setting. In Ethiopia, although the government has been investing on educating student nurses in different educational status at school level based on the nursing curriculum, the implementation of nursing process in practical setup is not well developed [8]. A study conducted in four African countries including Ghana, in 2005, found that nurses generally agree on the benefits of the nursing process but it is not commonly used in practice [13]. Furthermore, the extent of its implementation in the clinical setting has not been extensively studied and documented in many countries in Africa including Ghana.

Nurses knowledge on the nursing process

In clinical settings where nursing process is implemented, inadequate knowledge and incompetence are cited as barriers to its implementation [3]. According to Fissehe, Fessehaye, Fikadu, Semarya and Alemseged [8], poor knowledge on nursing process is a major a gap among nurses which acts as one of the barriers to nursing process implementation. Takahashi et al., [15] also posited that lack of knowledge to perform nursing process is the main reason leading nursing professionals to avoid implementing of nursing process on their day-to-day routines care. A study by Adeyemo and Olaogun [2], in health institutions at Ogbomosho town in Southwest Nigeria concluded that the knowledge factor has the most important influence on the use of nursing process. Again, the result of study by Abebe et al [1] showed that nurses who were knowledgeable were more likely to implement nursing process. On the basis of the fact that knowledge on the nurse has an influence on the implementation of the nursing process, Campbell [5] comments that the success of the nursing process relied on sensible interpretation and much depended upon guidance given by tutors and trained staff as well as previous experience. Whitfield [16] mentions a need for nurses to keep themselves up to date with the nursing process while Bellamy [4] says that in order for the nursing process to develop, more nurses needed to be educated outside ‘the stifling conformity of hospitals’. Smith [14] also views the nursing process as a work method and identified nurse educators did not foster a link between it and a theoretical base. This is an indication that lack of proper knowledge on the concept or on how to implement the process has been found to be one of the most important factors in preventing a proper implementation of the process. It is also a common believed that “most nurses are resistant to change, professional development and advancement. Some nurses tend to hold onto previous knowledge and skills without making efforts to improve and maintain new skills.

Nurses’ attitude towards the nursing process

A study was conducted in United States in 2009, to assess the nurse’s attitudes towards nursing process using Dayton Attitude Scale. The results revealed that participants were knowledgeable of the nursing process and held a relatively positive attitude toward the nursing process and nursing diagnosis. Higher nursing degrees were associated with more positive attitudes. However, Martin, Dugan and Freundl (2009), identified insufficient time as the most common barrier to the use of the nursing process. In a study by Jooste, Van der Vyfer and Van dyk (2010), to assess the implementation of the Nursing Process in Namibia showed that some of the study participants doubted about the usefulness of the nursing process; claiming that they knew what to do concerning nursing care. They found out that apart from the Negative beliefs about the nursing process some participants take the nursing process as being merely record keeping. The major thematic areas identified were: Nurses did not see the need for the nursing process, Negative and positive attitudes and beliefs, the nursing process was time consuming, Staff shortage hampered the utilization of the nursing process and Management did not demonstrate support for the utilization of the nursing. Factors associated with failure to implementation of the nursing process in clinical settings in low and middle-income countries such as Kenya can be categorized into negative attitudes, incompetence and lack of resources (Mahmoud and Bayoumy, 2014). One attitude that has been identified has a barrier towards the implementation of the nursing process is the lack of time (Ashworth, 198O; Wright, 1985). Henderson (1987) also believe that the whole time-consuming nature of the nursing process impose a guilt on nurses when they are not able to give the time that such records demand. Cowper-Smith [14] identifies attitudes such ·as ·adherence to tradition ‘and reluctance to change as hindering the use of the nursing process. Carpenito-Moyet [6] also admitted that many nurses have a negative attitude toward the nursing process.

Organizational related factors toward the utilisation of the nursing process

A number of researches have reported inadequate staffing and excess work load were rated highest by nurses as barriers to implementation of the nursing process followed by insufficient material resources while the least barrier perceived by the nurses were poor incentive and low level of perceived self-efficacy in handling the nursing process (Jooste et al. 2010). In addition, the most important management barriers that emerged from other previous studies were lack of enough time for doing the nursing process due to excessive number of the patients so that nurses do not have enough time to use this systematic method. On the other hand, lack of belief and support of the authorities of the country from application of the nursing process is the other management barrier which can be due to lack of information about the importance and impact of this method on improving health care quality [3,9]. According to a study by Manal & Hala (2014), inadequate staff, lack of specified nursing care document, insufficient equipment and the absence of supplies and materials were some of the factors hindering the implementation of the nursing process. Additionally, Akbari and Shamsi [3], excess number of the patients and shortage of nurses are some of the main reasons in the lack of application of the nursing process. The result of study conducted on the perception of nurses on implementation of Nursing Process in the Brong Ahafo region of Ghana, showed that one of the variables that hinder implementation of the process was poor motivation in form of promotions (Nabaale, 2003). There is a backlog of staff nurses who have served over a decade without any promotion. This affects other categories of nurses as well. Nurses who have served over a decade could also be given certain incentives to make them stay. For lack of these incentives many leave the service for better places abroad, thus reducing their numbers drastically. In one district hospital there were not more than eight senior registered nurses, there. In another one, the senior registered nurses were only four, including the matron (Nabaale, 2003). A study in Ethiopia identified lack of equipment supply in hospitals for giving nursing care as one of the factors 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 (Aseratie, 2011).

Other barrier on the implementation of the nursing process

One of the common negative criticisms of then nursing process is the excess of paperwork. The duplicative nature of documentation is being met with hostility by nurses who view the nursing process as adding to the workload (Melia, 1990). Previous study showed that nurses identified barriers related to work as the most commonly encountered barriers followed by barriers related to nursing process and resources factors when executing the nursing process. Correlation analyses between ages, years in service and nurses reported facilitators for execution of nursing process was carried out and years in service had a significant relation to both using books as reference source (p˂0.05) and has enough time for performing the phase (p˂0.05) (Manal & Hala, 2014). The result by Edet, Mgbekem and Edet (2010) identified type of ward as a factor associated with barrier perception and the finding revealed that nurses on medical wards are 3 times more likely to perceive barriers compared to nurses on the surgical ward. A study conducted in Ethiopia showed that working experience of more than 4 years was double more likely to implement nursing process than working experience of less than or equal to 4 years [1].

Ethical consideration

Bless & Higson-Smith (2000), generally accepts the ethical rights of a participant to be the right to privacy and voluntary participation, anonymity and confidentiality. For this survey:

1. Approvals were sought from the Acting Deputy Director of Nursing of Nursing Services, the Nursing Administration of the Trauma Department, the ward in charges of the five (5) units of the department and the participants and were assured of anonymity and confidentiality.

2. Participants were given codes and their names did not appear on questionnaires.

Causes of challenges related to the implementation of the nursing care plan/process at the trauma department of KBTH

Colleagues and other stakeholders perspective

After interviews, analysis of the mini-questionnaire and focus group discussions with colleagues and other stakeholders the following were identified as causes of the challenges related to the implementation of the nursing care plan / process at the trauma unit in a teaching hospital.

The reasons given for the non-implementation of the nursing care plan included lack of time. They said nurses do not have enough time to implement the care plan because the work load is too much. They also said the shortage of professional nurses will have a toll on documentation. There is also lack of enough equipment and stationaries. For those who have attempted implementing the care plan said patients are normally discharged before completing the plan.

The survey revealed that nurses lack adequate knowledge to utilize nursing process. Some said they never understood the process while in school and have not had the opportunity to have a hand-on practice of the care plan; however they are willing to apply the nursing process in the care of their patients. The survey again indicated that nurses had favourable attitude towards the nursing process. This might be because prior to this study a workshop was conducted to sensitised nurses’ at KBTH on the nursing care plan.

Some members of the focus group said the hospital administration do not fully support the application of the Nursing Process because logistics are not available for the implementation. It’s very difficult to get administration to make the document available.

Researcher’s perspective

Based on the literature reviewed and the opinions of the stakeholders and colleague nurses the following are what I believe are the causes of challenges related to the implementation of the nursing care plan.

1. The shortage of professional nurses to implement the nursing care plan

2. Lack of logistics for the implementation.

3. Nurses lack adequate knowledge to utilize nursing process.

4. Hospital administration do not fully support the application of the Nursing Process

5. The nursing process is time consuming

6. There is no motivation by the hospital the nurse leaders to motivate others s

7. The negative attitudes of the nurses towards the nursing care plan

8. There is lack of information about the importance and impact of the method on improving health care quality

9. Inadequate staff, lack of specified nursing care document, insufficient equipment and the absence of supplies and materials were some of the factors hindering the implementation of the nursing process.

Solutions and recommendation

In-service training, seminars and workshop programmes were suggested to be organised by the training and research unit for nurses on regular basis to educate and update their knowledge theoretically and practically on the use of the NURSMID tool which has the care plan embedded in it and also to show commitment in applying nursing process to improve the quality of nursing. The first workshop for the department on the use of the NURSMID was organised on 11^th April, 2018.

Discussed with the ward in-charges of the various units to organise frequent workshops for all professional nurses on the use of the NUSMID and the care plan, do a practical session and presentation as well as mini ward conferences.

A monitoring tool has been designed with the help of the trauma nursing administration to monitor the use of the care plan weekly with a monthly evaluation to identify and address challenges encountered.

Each ward was encouraged to form a mini monitoring team with a leader to monitor daily on the implementation of the care plan for each shift. A departmental monitoring team has been set up to conduct monthly evaluation to get feedback on care plan use.

Nurse Managers were tasked to provide each patient in their unit with the Nursing Process Protocol. This will serve as a guide in utilizing the Nursing Process in the NURSMID assessment tool.

The department administrator was involved in most of the discussions on the benefits of using the NURSMID on patient care in terms of its outcome. This is to ensure that logistics are readily available for the implementation allowing the nurse managers implement, monitor and evaluate the nursing process documentation in each patient record.

More nurses should be employed to reduce the workload. This will boost the staff strength thus creating effectiveness and efficacy in practice.

With the help of the departmental monitoring team, I have developed a protocol on the common problems identified in the unit and based on this; the nursing diagnosis from NANDA has been made simple. The protocol has been displayed on every ward to make it easier for use.

Declarations

Conflict of interest: Author declares she has no competing/ financial interest.

Funding information: There was no funding for the survey.

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