Challenges associated with the implementation of the nursing process: A systematic review.

BACKGROUND: Nursing process is a scientific approach in the provision of qualified nursing cares. However, in practice, the implementation of this process is faced with numerous challenges. With the knowledge of the challenges associated with the implementation of the nursing process, the nursing processes can be developed appropriately. Due to the lack of comprehensive information on this subject, the current study was carried out to assess the key challenges associated with the implementation of the nursing process.
MATERIALS AND METHODS: To achieve and review related studies on this field, databases of Iran medix, SID, Magiran, PUBMED, Google scholar, and Proquest were assessed using the main keywords of nursing process and nursing process systematic review. The articles were retrieved in three steps including searching by keywords, review of the proceedings based on inclusion criteria, and final retrieval and assessment of available full texts.
RESULTS: Systematic assessment of the articles showed different challenges in implementation of the nursing process. Intangible understanding of the concept of nursing process, different views of the process, lack of knowledge and awareness among nurses related to the execution of process, supports of managing systems, and problems related to recording the nursing process were the main challenges that were extracted from review of literature.
CONCLUSIONS: On systematically reviewing the literature, intangible understanding of the concept of nursing process has been identified as the main challenge in nursing process. To achieve the best strategy to minimize the challenge, in addition to preparing facilitators for implementation of nursing process, intangible understanding of the concept of nursing process, different views of the process, and forming teams of experts in nursing education are recommended for internalizing the nursing process among nurses.

INTRODUCTION

Decade of 1950 in Europe coincided with a period during which nursing was gradually modified from hospital-based to university-based profession and became an independent medical field. In this period, experts on nursing science emphasized clinical models instead of models based on the medical profession for the development of nursing, and thus, the use of some theories such as Maslow theory of human motivation and hierarchy of basic human needs, Erickson's theory of psychosocial personality development, and Selye's theory of physiologic stress adaption started to be considered more. Despite the high values of these theories, medical experts found that the use of these models was not sufficient for professional development of nursing and there was a need for a framework dedicated to nursing, which represented the nursing profession as a unique field. In 1955, Hall used the term “nursing process” and argued that by applying the nursing process as a framework for patients’ caring, the nursing care can be fully offered to patients.[1] Following the efforts made in this regard, in 1961, Orlando presented three steps to implement nursing care based on the nursing process, including client's behavior, reaction of the nurse, and nursing actions.[2] Over time, various authors and scholars have proposed different forms of the nursing process, but the latest is the six-step nursing process as a step provided by the American Nurses Association (ANA) that was based on evaluation and recognition, nursing diagnosis, specifying the objectives and expected outcomes, as well as planning, implementation, and evaluation.[3] It should be noted that the different phases of the nursing process are not separated. The relationship between the six steps of nursing process can be compared to a large container with six chambers, in which each chamber is connected with others through a window. Therefore, although the chambers (steps) seem to be independent from each other, they eventually interact with each other and are not separated.[3]

Nursing process is now running as a standard for nursing in healthcare systems in most developed countries. In the United States, all nursing students who are enrolled in the first year of nursing are trained using this model.[3] The use of the nursing process helps in making and planning a good, clear, and effective nursing care that is finally effective for improvement of the quality of patients’ care.[4] But despite the results obtained, some studies have shown that nursing process in practice is faced with numerous challenges.[5] Some experts believe that nursing process in the present framework is not clear, is time-consuming, and is difficult to perform.[67] In order to find the determinants of appropriate implementation of the nursing process, few studies have been conducted.[8] In the lack of knowledge about challenges associated with the implementation of the nursing process, it is not to be develop the nursing process.[9] The main objective of this study was to determine the major challenges associated with the implementation of the nursing process. The results of the present study can be useful to develop nursing process in clinical setting.

MATERIALS AND METHODS

Search strategy and article selection

For this systematic review, we explored 1114 published papers in nursing process that fulfilled the eligibility criteria by searching in some databases such as Iran medix, SID, Magiran, PUBMED, Google scholar, and Proquest. Our research was restricted to English language studies published after 1970 and Persian language studies published after 1990.

The main keywords used for the search included: nurse, nursing process, and systematic review. Review of literature and selection of relevant articles was carried out in three steps. At first, using keywords, 1114 articles were found. During the second step, all articles were screened one by one by surveying the abstract of articles and based on inclusion and exclusion criteria [Table 1]. Then, 125 articles were chosen to be surveyed. Finally, based on the above-mentioned criteria, only the articles that included the desired conditions and whose full text was accessible by Tabriz University of Medical Sciences were chosen.

Table 1

List of considered articles related to challenges in implementation of the nursing process from 1970 to 2013 (from 1370 to 1392 on Hijri Shamsi date) in second retrieval phase

Inclusion criteria

Studies were included and eligible if the papers were associated with problems related to the nursing process, were original or review articles, and access to the full text of the articles was available.

Exclusion criterion

Studies that focused only on a particular part of the nursing process (i.e. the difference between planning and diagnosis).

Analysis of studies

In this step, data collected from the studies included authors’ names, year, purpose, basic concepts, methodology of the studies (study design, data collection, and analysis), the study sample, the response rate, and also validity and reliability of the study. The data were collected regularly in data files and were used as raw data. The validity of analyses was confirmed on agreement of the researchers.

Focus of the studies

The focus of the studies can be classified into six categories. Some studies focused on the challenges related to the effects of impediments or individual or managerial facilities in implementation of the nursing process.[589101112] Another group of studies focused on the challenges associated with the outcome of the implementation of the nursing process in clinical setting,[1314151617] the use of computers in recording and performing the process,[1819202122232425] different attitudes of the teams toward the implementation of the nursing process,[7891011121314151617181920212223242526] different understanding of the nurses and specialists on the concept of nursing process,[627282930] and its effects on implementation phases manner of nursing process and challenges associated with the recording of nursing process[31] [Figure 1].

Figure 1

Frequency and percent of the focus of studies on challenges related to performing the nursing process from 1970 to 2013 (from 1370 to 1392 on Hijri Shamsi date)

Types of studies

Descriptive method was the main methodological method used in the assessment of studies.[571011121618313233] The tool used in this assessment in the majority of studies was a questionnaire.[57101112161831] In a descriptive study, human factors engineering was applied to collect information[32] and in another study, reviewing patients’ recorded files was the basis of data collection.[16] In another descriptive study, the method of designing and implementing software systems installed on mobile was described and interviews and observations of nurses were used to describe and evaluate the performance of the system.[33] In three qualitative articles, the main method for collection of information was interview.[8927] The structure of three other studies in which the questionnaire was used was experimental or quasi-experimental.[131520] The main approach in six papers was review approach,[61725282930] and in four articles was interventional approach with unclear methodology for data collection[19212224] [Figure 2].

Figure 2

Frequency and percent of the types of studies on challenges related to performing the nursing process from 1970 to 2013 (from 1370 to 1392 on Hijri Shamsi date)

Participants in the studies

Some of the studies were performed as reviews,[61725282930] or the main purpose in some other studies was describing the design and development of a new tool (using a computer program) to help facilitate the nursing process.[1522] But most participants in the studies were nurses.[79131520212223242732] In a study, nurses and managers and in another study, nurses[12] and other personnel were the participants.[18] In two studies, faculty members and nursing students[1026] and in another study, faculty members, managers, and nursing students were the main participants[8] [Figure 3].

Figure 3

Frequency and percent of the participants in studies on challenges related to performing the nursing process from 1970 to 2013 (from 1370 to 1392 on Hijri Shamsi date)

Reliability and validity of the studies

Reliability and validity of most studies was clearly described. In the study of Ammenwerth et al., the tool used was a standard questionnaire, but did not have a clear explanation of its details.[21] In Medina et al.'s study, the focus was on describing a new tool (software installed on the phone) to facilitate the implementation of the nursing process with little explanation regarding the validity or accuracy of the tools used to obtain views of nurses who used mobile.[23] In six studies, reliability and validity of the studies were not comprehensive described.[51522242634] Among three qualitative studies, strategies used to increase the validity of the study were not clearly described in one study [Table 2].

Table 2

Reliability and validity of studies on challenges related to performing the nursing process from 1970 to 2013 (from 1370 to 1392 on Hijri Shamsi date)

RESULTS

Results of the studies showed that the differences in understanding the meaning of nursing process by members of the healthcare teams resulted in some challenges in the administrative proceedings of the nursing process.

Challenges about philosophical nature of the nursing process

One of the most significant studies in this field was that of Varceo et al.[6] In this study, criticism of the nursing process was mainly on the philosophical nature of the nursing process. Based on the viewpoints of these critics, the origin of the philosophical nature of nursing was positivism and empiricism. Nursing philosophy emphasizes the science as a source of knowledge and, thus, focus is less on intuition during clinical judgments. In this study, unbalanced distribution of power is introduced as a challenge in the nursing process, as nursing process is nurse-centered in the view of some critics and is patient-centered in the view of other critics. The first group believes that excessive focus on the power of nurses may reduce the coordination between the different members of the healthcare team within patient care. The second group also believes that patient-centered approach may lead to lack of protection of patient privacy and, thus, the patient has to disclose all personal information to participate in the care process. Challenges related to the professional performance formed the third part of criticism. Critics believe that nurses use the nursing process for development of their profession and, thus, the patients’ benefits are less considered. In the opinion of some critics, nursing process has been developed as a deductive process and is not based on nurse's actual performance.

Challenges about the lack of understanding of the true meaning of the nursing process

Another challenge is the lack of understanding of the true meaning of the nursing process. In many cases, the nursing process and nursing is considered to be uniform.[6] Tanner[29] criticizes considering the nursing process and critical thinking as equivalent. Varceo[6] also believes that the cause of criticism of the nursing process is lack of understanding of the meaning of the nursing process. Furthermore, there are numerous definitions of the nursing process. For instance, some researchers define nursing process as dynamic and some others define it as a linear process; the first group emphasizes on the processing nature, while the second group emphasizes on the problem-solving nature of the nursing process.[6] The descriptive or prescriptive nature of the nursing process depends on different philosophical outlooks of people about the nursing process.[628] In response to criticism on the linearity of decision-making process, Atree[30] stresses on lack of sufficient evidence for this claim. Besides, it has been revealed that nurses apply nursing process as a tool for clinical decisions successfully. But people's competence influences non-linear decision-making process. On the other hand, more sophisticated people use the linear process less. In the opinion of Atree, it can also be considered that among physicians, less-experienced physicians use more linear process in clinical observations and evaluations.

Challenges related to management system

Factors relating to the management system and also individual factors as barriers or facilitators of the nursing process can cause challenges in implementing this process.[10111235] Lack of proper knowledge on the concept or on how to implement the process has been found to be the most important factor in preventing a proper implementation of the process.[10111227] Domination of physicians in management systems,[27] lack of adequate support from the management systems,[10111227] and lack of enough time for the process due to large number of patients can cause an impediment to perform the nursing process. Sometimes, there is a difference between what is taught in school and what is actually being done in clinics, creating some challenges.[9]

Challenges about the nurses’ attitudes toward the nursing process

Nurses’ attitudes toward the nursing process can be effective on implementing the process. In this regard, in two studies,[2627] female students had more positive attitudes than male students regarding the ability to use the nursing process in providing high-quality caring. Most nursing students (80%) believed that nursing process was able to uniquely define nursing actions and presented an appropriate image of nursing. However, only 50% of students thought that using the nursing process is only a way for providing nursing cares. In the viewpoints of 14% of students, nursing cares on nursing process can be very difficult.[26]

Challenges related to determination of nursing diagnosis

Assessment of the effects of performing nursing process in clinical setting can be helpful for determination of challenges related to this process. One of the challenges faced in the field is nursing diagnosis by nurses.[1516] The results of the study of De Moraes[15] showed that only 48.5% of the studied reports of nurses were recorded as nursing diagnosis that was associated with the method of patients’ evaluation. In fact, failure to obtain a proper history of the patient[1516] or spending too much time to obtain the earliest history of the patient can be challenging in nursing diagnosis.[1517] Receiving appropriate education in relation to the nursing process can lead to improvement in quality of the provided cares.[36] In ideal conditions, meeting the client needs would be done on an individual basis. But if the nurse has to take care of several patients simultaneously, this concurrent caring can cause some challenges in the nursing process and even impair nursing intellectual integrity in clinical decision-making process.[32]

Challenges related to recording steps of the nursing process

Another challenge associated with the nursing process is related to the process of recording steps of the nursing process. It has been shown that despite awareness of the need for registration of nursing process, interventions, and outcomes, nursing records may not be completely provided.[31] Use of computers and relevant software has been introduced as an approach to reduce the time and simplify the process of recording.[202425] The result of Ammenwerth's study showed that nurses’ tendency to the use of nursing process was linked to the use of nursing care planning system aided by computer. On the other hand, most nurses agree on the use of nursing process; but because it takes a lot of time, they are less willing to use it. However, by using the computer system, nurses are able to quickly plan the nursing cares and, thus, spend less time on the recording process. In some studies, theoretical basis was used to design facilitator software for performing the nursing process. The theoretical basis used was Virginia Henderson theory. The ability of recording vital signs with the date of record and name of controller nurse, having a guide to plan care based on the entered data, and the ability to transform quantitative data into qualitative are the main characteristics of this tool.[33] However, the use of computerized systems may have some potential limitations including lack of access to adequate numbers of computers, lack of appropriate space, and lack of sufficient knowledge of all nurses in the use of computers.[20] During the last decade, using a computer system for nursing records was started in Iran. The results of a descriptive study in 2008 showed that less than half of the nurses had partial satisfaction in the effect of a computerized hospital information system on patient care activities and most personnel did not record the data and entered data on characteristics of the patient in his/her nurs ing reports. The main reasons for this were insufficient time and sense of reworking in the task. Nurses believed that this system did not reduce the use of paper and, thus, led to reworking.[18]

DISCUSSION

Nursing process has been frequently accepted by nursing experts as a scientific method for providing nursing cares with a high quality. According to the standards of nursing actions in the United States and Canada, performing professional nursing cares requires using the nursing process and, thus, participation of nurses in activities that lead to increase in knowledge toward nursing process is strongly recommended.[37] However, evidences have shown that in most cases, nursing process is not systematically performed,[16] and sometimes the nursing process is replaced by a routine caring performance.[19] Number of patients, number of nurses, and having sufficient knowledge toward nursing process are the important factors affecting the nursing process. Lack of nurses’ knowledge plays a key role on lack of adequate enforcement of nursing process. Most of the nurses easily use the nursing process when caring the special patients individually; but with increase in the number of patients, this process may not be used.[14] Lack of knowledge and skills among nurses, doctors’ domination, lack of proper record system, and lack of adequate support institutions have been known as the most significant obstacles in performing this process.[27] In fact, one of the main challenges is the level of nurses’ knowledge.[101112] Results of some studies show that following the training of nurses in relation to the implementation of nursing process, nurses’ ability to its use and recognize nursing diagnosis have been increased.[3638] Thus, it seems that by continuing education programs for nurses and with emphasis on education for nursing students, the problems associated with nursing process are minimized. However, learning process in nursing and nursing process are two different categories. For example, some nurses perform the planning and implementing steps, but are not able to perform the evaluating step. Determination of nursing diagnosis is one of the main challenges faced by nurses in performing the nursing process.[1415] Most of the nurses have appropriate knowledge theoretically, but cannot perform it practically.[15] Varceo believed that criticism of the nursing process was regarding the philosophical nature of the nursing process and the main reason for this criticism is lack of understanding of the meaning of the nursing process.[6] In this regard, the experiences of nurses on understanding the meaning of nursing are contradictory.[15] Thus, it has been argued that increase of knowledge and educating nurses are not enough for implementation of nursing process. Acquiring knowledge means achieving awareness, but understanding needs to develop meaningful relationships between types of knowledge and skills.[39] As long as the knowledge of nursing process is not properly internalized, challenges associated with the implementation of the nursing process will continue. Internalization means entering external subjects and elements in psychological structures that lead to structural changes or integration with existing structures.[40] For recording and implementing a systematic nursing process, using paper-based tools is common, but the use of these tools has met with some criticism. The large volume of notes and the low quality of the provided records have been emphasized as the negative aspects. In recent years, some efforts have been made in order to use computer program to help perform and record the nursing process. The use of ready and designed plans for nursing process results in project planning with greater efficiency and speed, as well as in clearing the steps of nursing process. But it should be noted that the management of the use of computers is dependant to the number of patients and clinical conditions of the wards. If the number of patients is small or the location of computers is considered to be work rooms, a few computers would suffice; but if the computer needs to be kept beside the patient's set, the use of movable computers or using software installed on the mobile seems to be necessary. Also, coordination should be considered in all parts of care systems for using computer. On the other hand, physicians and other healthcare team members will also be able to access the computer, leading to acceleration of the process of patient care.[21]

CONCLUSION

Analysis of the present studies showed different challenges in performing the nursing process. Intangible understanding of the meaning of nursing process, difference in attitudes toward the nursing process, lack of awareness of the nurses, and supportive management of problems related to recording the nursing process are the main challenges in reviewed literatures. The use of software programs is a strategy for time management as well as for facilitating and accelerating the implementation of the nursing process.

The main limitation of the present study was lack of access to full-text articles. It is recommended to perform more studies considering this limitation. Because intangible understanding of the meaning of nursing process has been identified as the most important challenge, it is also recommended to consider education of nursing process besides preparing facilitators for enforcement of nursing process. These strategies result in internalizing and understanding the concept of the nursing process. Forming the team of experts in nursing education is recommended as the best way to minimize the current challenges.