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 Table of Contents  
Year : 2023  |  Volume : 4  |  Issue : 1  |  Page : 29-33

Knowledge, practices and factors affecting in application of nursing process: A cross-sectional study

1 Medicine Department, Command Hospital Airforce, Bengaluru, Karnataka, India
2 College of Nursing, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission17-Sep-2021
Date of Decision27-Feb-2022
Date of Acceptance17-Nov-2022
Date of Web Publication23-Feb-2023

Correspondence Address:
Dr. Rakesh Sharma
College of Nursing, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JME.JME_87_21

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Background: The nursing process is an important tool that has transformed the standards of nursing practices. Application of the nursing process required proper training, guidelines and resources to be used by the nurses. Aim: The objective of this study was to assess the knowledge and practice of nursing process among nurses and explore factors influencing its applications by nurses. Methods: An exploratory, descriptive study was conducted among 210 nurses using a simple random sampling technique. A pre-designed, self-structured questionnaire on knowledge and practice of nurses regarding nursing process and factors influencing its application were used to collect data. The data were analysed using descriptive and inferential statistics. Results: Most of the nurses were female (60.5%), had General Nursing and Midwifery (76.2%) as professional education, working in general medicine units (52.5%) and had more than 5 years of professional experience. The mean knowledge and practice score regarding nursing process were 13.93 ± 5.204 and 6.51 ± 0.96, respectively. Major hindering factors were the absence of a format for recording nursing process, poor nurse–patient ratio and excessive workload and never attended in-service education on the nursing process. Many nurses reported working in a stressful environment and were dissatisfied due to excessive clerical paperwork. Conclusion: The majority of nurses had average knowledge of nursing process, but they were not practicing. Certain factors such as no format, in-service education and equipment supplies affected the nursing process application in clinical areas. Hence, it is recommended to modify the above factors for proper application of nursing process.

Keywords: Knowledge, nurses, nursing process, nursing process, practices

How to cite this article:
Sharma J, Sharma R, Negi R, Jelly P. Knowledge, practices and factors affecting in application of nursing process: A cross-sectional study. J Med Evid 2023;4:29-33

How to cite this URL:
Sharma J, Sharma R, Negi R, Jelly P. Knowledge, practices and factors affecting in application of nursing process: A cross-sectional study. J Med Evid [serial online] 2023 [cited 2023 Jun 7];4:29-33. Available from: http://www.journaljme.org/text.asp?2023/4/1/29/370397

  Introduction Top

Nursing care is a continuous process that needs to be documented in a structured format. Initially, it was acquired from the general system theory and then incorporated into the nursing curriculum.[1] Nursing process is a scientific tool to identify, plan, implement and reevaluate individualised patient care. It is an evidence-based, problem-solving approach, and it constitutes the foundation for nursing practice. Health-care accrediting agencies and nursing organisations have developed standards of nursing practice that focus on the system of belief of the nursing process, that is, assessing, diagnosing, planning, implementing, evaluating and documentation of ongoing client care.[2]

There is a demand to establish the nursing process in clinical care in each health-care institution, within hospitals and in the community as a whole. However, in practice, all the steps are not systematically implemented and always believed that it is time-consuming and practically impossible. The nursing process helps nurses prioritise individual patients' needs and treat them accordingly not by medical diagnosis.[1]

The World Health Organization (1982) promoted the application of the nursing process as a foundation for nursing documentation.[3] Currently, one of the biggest problems being faced by the nursing profession is that of implementing the nursing process for patient care.[4]

The nursing process is always a patient-centric approach, ensures quality and individualised care and motivates clients to participate in all phases of the process. Similarly, nurses also have benefits, as it increases job satisfaction and heightened professional growth. In the nursing profession, the nursing process defines the scope of nursing practice and contributes to the autonomy of the profession.[1],[5] A study conducted by Moghadas T, Kesbakhi MS. found that the nursing process implementation in many countries has encountered many challenges. Applying nursing process requires understanding the factors affecting its implementation from the perspective of nurses.[6] Although the nursing care process is a global practice, the International Council of Nurses recommends implementing standardised international diagnoses and classifications.[1]

In various literature from developed countries, nurses have reported various hindering factors in the utilisation of nursing process, including organisational, work environment, resources, education and motivational factors in the implementation and use of nursing process.[7],[8]

While working in the hospital, the investigator observed that the student nurses study and practice the nursing process during their clinical learning. But, they do not practice after joining the job while caring for the patients. This clearly shows there is a gap between nursing education and nursing practice. Hence, the investigator got interested in finding out the level of knowledge, practice and factors that influence the application of the nursing process.

  Methods Top

Study settings

The study was conducted in a 710-bedded multispeciality tertiary care hospital from the northern part of India from January to March 2013. A total of approximately 600 nurses were working.

Study design, participants and sampling procedure

A cross-sectional, quantitative study design was employed. The study aimed to assess the knowledge, practice and factors influencing the application of the nursing process among nurses. The researcher sought individuals with certain characteristics specific to the study through a simple random sampling technique. A total of 210 nurses from general medicine, surgery, critical care units (CCUs), paediatric and obstetrics and gynaecology wards were selected.

The sample size for the study was calculated using the formula: N (sample size) = (Z2 × P × [1–P])/d2. Here, Z2 (standard normal score of 95% of confidence interval) =1.96; d (is the degree of accuracy or the margin of error) =0.05; P = was the population = 600. The estimated sample size was 210 nurses.

Reliability and content validity of the tool

Reliability and internal consistency of the tools were assessed using the test–retest method. The test–retest reliability coefficient was found to be 0.9, so the tool was considered to be reliable. The content validity of the tool was established based on suggestions given by seven nursing experts, one physician and one statistician. The tools were prepared using the English language.

Sampling procedure

A list of nurses working in selected wards (general medicine, surgery, CCUs, paediatric and Obstetrics and gynaecology) was collected from the office of the nursing superintendent. A simple random method (lottery) was adopted to select the nurse; if a nurse was denied participation or not eligible as per inclusion criteria, another nurse was chosen from the same ward.

Data collection tools

The tool was prepared after a thorough review of all relevant literature. Electronic databases such as PubMed, Cochrane Library, Google Scholar, CINAHL and Scopus were used in the literature search.

The data collection tool consists of four sections; baseline information and the professional status of study participants were collected in the first section.

Section two consisted of a structured knowledge questionnaire to assess the knowledge regarding nursing process was developed. A blueprint was prepared to assess knowledge domains after reviewing related and relevant literature from various sources. The knowledge questionnaire consisted of 28 multiple-choice questions with four options. The maximum score was 28, and minimum was 0 (zero). The knowledge score was further classified into three categories arbitrary, i.e., Good (70%–100%), Average (35%–64%) and Poor knowledge (0%–34%).

Section three was a structure observational practice checklist to assess the practice of nursing process. Blueprint was prepared to assess the practice domains after reviewing related and relevant literature. The structured observational practice checklist consisted of 23 questions on the steps of nursing process. Each nurse had 2–10 patients in their assignment for complete patient care management for everyday shift duty. From each nurse, one patient's file was selected to assess the practice of nursing process.

The investigator-assessed 210 patients' files in the study with the help of a structured observation checklist for documentation of the nursing process. Patients' files for practice assessment of nurses were randomly selected for each nurse during their duty timings to eliminate the risk of bias. Patients' files were graded and given one mark for complete documents and 0 (zero) for incomplete or missing documentation. The total score ranged from 0 to 23.

Section four was a semi-structured questionnaire to explore the hindering factors influencing the application of nursing process among nurses. It consisted of seven questions influencing the application of nursing process. The validity of the tool was established by getting it validated by five experts in the field of nursing. Furthermore, the reliability of the tool for all structured knowledge questionnaires was found to be acceptable with Cronbach's alpha value of 0.9. The Structured Observational Practice Checklist, reliability was measured by the interrater method, and the percent agreement was 80%.

Data collection procedure

Data were collected by a pre-tested, self-structured questionnaire, structure observational practice checklist and semi-structured questionnaire to explore the factors affecting the application of nursing process. The researcher collected the data from January to March 2013. Each participant was interviewed in their respective wards during break time.

Ethical considerations

Ethical clearance was obtained from the research and ethical review board of the institution (HIHT/HCN/2013/19). Written and verbal consent were obtained from each nurse for participation in the study. Privacy and confidentiality were ensured during the interview. Information was recorded anonymously; beneficence was assured throughout the study period.

  Results Top

Almost 60% of the nurses were female. A majority (75.7%) of the participants were in the age group of 20–30 years. A large proportion (76.2%) of nurses had a general nursing and midwifery diploma as their professional qualification. Nearly half (52.5%) of nurses working in general medicine wards, and approximately one-third (37%) had <2 years of work experience [Table 1]. The mean knowledge and practice scores regarding nursing process were 13.93 ± 5.2 and 6.51 ± 0.96, respectively, among nurses [Table 2].
Table 1: Demographic profile of nurses (n=210)

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Table 2: Knowledge and practice score regarding nursing process (n=210)

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Domain-wise knowledge scores showed that a large number (72%) of nurses had general knowledge about the nursing process, and the least (39%) knowledge was about nursing diagnosis [Figure 1]. Approximately one-third of nurses mentioned assessment and planning domains, whereas none has written nursing diagnosis and evaluation in the nurses' records [Figure 2].
Figure 1: Domain-wise knowledge score of nurses about nursing process

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Figure 2: Domain-wise practice scores of nurses about nursing process

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The most common hindering factors were not maintaining the nurses–patient ratio as per standards (87.1%), absence of nursing process (71.8%) format, no in-service educational activity regarding nursing process application (81%) and excessive clerical and paperwork (66.2%), which indicated nurses involvement in written documentation in regard to different procedures for referral and other patient-related work other than patient care [Table 3].
Table 3: Hindering factors influencing the application of nursing process (n=210)

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  Discussion Top

Student nurses are taught nursing process during training as they care for a limited number (1–3) of the patient, but once they start practicing nursing care as a registered nurses in a clinical setting, nurses are assigned many patients, as the number of patient assignment increases, the practice is compromised.

In this study, the knowledge and practice regarding nursing process were at an average level, which is a very important factor for the use of nursing process. In the three domains of nursing process, nursing diagnosis, planning and implementation had below 50% knowledge scores, which indicate nurses lack knowledge regarding nursing process. Furthermore, the practice scores in each domain were low; nurses recorded even no records related to nursing diagnosis and evaluation. Similar findings were reported in a study conducted in Ethiopia, where nurses had a low level of knowledge due to variations in the training across the country and the application of nursing process in the hospitals.[4],[9] A study from Brazil has indicated that knowledge is one of the essential aspects in the application of nursing process.[10]

Among all the domains, knowledge of assessment had the highest scores (61%), whereas in practice, only 34.4% of nurses recorded assessment part. None has recorded diagnosis and evaluation in the nurses' record. Similarly, a study conducted in Brazil revealed that most nurses recorded the assessment partly on the day of admission. Whereas they did mention intervention without nursing diagnosis. It shows incomplete use of nursing process steps, and there was no consistency.[11] A systematic review and meta-analysis by Shiferaw et al. found that nurses had high knowledge about the nursing process and positively associated with patient care implementation.[12]

In India, the nursing process is taught in the 1st year, and its application on patients in nursing participants such as medical-surgical nursing, child-health nursing, midwifery, mental health nursing and community health nursing are given in subsequent years of diploma and graduation in nursing courses. However, there is heterogenicity in nursing education in India.[13],[14]

Akbari and Shamsi reported in their study that half of the nurses working in CCUs recorded ongoing patient care using nursing processes that they did not learn earlier during clinical posting.[15] In the present study, shortage of staffing was one of the hindering factors to the use of the nursing process, which was in line with another study from Ghana that found that nurses had theoretical knowledge of the nursing process but were unable to use it due to short staffing and excess workload.[7]

As per India Nursing Council, a nurse can take care of four to six patients in the general ward, and in CCUs, one nurse for one patient can be assigned.[16] One hundred and eighty-three (87.1%) nurses said that the distribution of patient assignments to nurses was not as per standards, which affected the use of the nursing process, which was in line with the other study from Iran that reported an imbalance nurse–patient ratio.[15],[17]

A large number (71.9%) of nurses reported that there is no structured format of nursing process available to record nursing care of the assigned patients. This result is supported by a Nigerian study where nurses reported an irregular supply of nursing process material.[2],[9],[18]

The present era is dominated by technology, and if it is used scientifically, it can save lots of resources, and better outcomes can be obtained. In a study, digital nursing process was developed in the mobile and used in the neonate unit. This could help nurses document their nursing care and evaluate it in continued patient care based on patients' needs.[19]

Other hindering factors in the application of the nursing process were lack of in-service educational activities, lack of proper format, excessive clerical paperwork and policies and protocols related to patient care were made without considering nurses and burden to complete assigned work. The above findings are also comparable and supported by various literature with the finding of poor equipment, shortage of nurses, lack of training to nurses, poor knowledge, unrecognised by authority, unattractive service conditions, no enough motivation, lack of cooperation between professionals, engaging in other manual tasks and non-professional tasks, unclear and undefined job descriptions, excess workload and poor payment for the profession.[2],[6],[15],[17],[19],[20] This indicates that the above-mentioned factors must be rectified for the proper application of the nursing process.

  Conclusion Top

The overall findings of the present study indicated that most of the study participants had average knowledge of nursing process. Still, they did not implement it due to innumerable influencing factors, including unavailability of structured format, excessive workload due to imbalance nurse–patient ratio and non-professional work. There is a need to strengthen national policy frameworks and interventions to improve nursing process training and implementation in clinical settings. Hence, this can be concluded that modifying the factors can help the proper application of nursing process.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Adraro Z, Mengistu D. Implementation and factors affecting the nursing process among nurses working in selected government hospitals in Southwest Ethiopia. BMC Nurs 2020;19:1-7. Available from: https://bmcnurs.biomedcentral.com/articles/10.1186/s12912-020-00498-8. [Last accessed on 2021 Sep 09].  Back to cited text no. 1
Baraki Z, Girmay F, Kidanu K, Gerensea H, Gezehgne D, Teklay H. A cross sectional study on nursing process implementation and associated factors among nurses working in selected hospitals of Central and Northwest zones, Tigray Region, Ethiopia. BMC Nurs 2017;16:54.  Back to cited text no. 2
Granero-Molina J, Fernández-Sola C, Peredo de Gonzales MH, Aguilera-Manrique G, Mollinedo-Mallea J, Castro-Sánchez AM. Nursing process: What does it mean to nurses from Santa Cruz (Bolivia)? Rev Esc Enferm USP 2012;46:973-9.  Back to cited text no. 3
Pokorski S, Moraes MA, Chiarelli R, Costanzi AP, Rabelo ER. Nursing process: From literature to practice. What are we actually doing? Rev Lat Am Enfermagem 2009;17:302-7.  Back to cited text no. 4
Sharma R, Goel D, Srivastav M, Dhasmana R. Psycho-Physiological parameters of nurses in critical and non-critical units. Int J Nurs Sci 2017;7:107-10.  Back to cited text no. 5
Moghadas T, Kesbakhi MS. Factors influencing implementation of nursing process by nursing students: A qualitative study. Med Educ 2020;19:e110810. Available from: https://sites.kowsarpub.com/jme/articles/110810.html. [Last accessed on 2021 Sep 09].  Back to cited text no. 6
Agyeman-Yeboah J, Korsah KA, Okrah J. Factors that influence the clinical utilization of the nursing process at a hospital in Accra, Ghana. BMC Nurs 2017;16:30.  Back to cited text no. 7
Milne D. The more things change the more they stay the same': Factors affecting the implementation of the nursing process. Adv Nurs 1985;10:39-45. Available from: https://pubmed.ncbi.nlm.nih.gov/3844413/. [Last accessed on 2021 Sep 09].  Back to cited text no. 8
Hagos F, Alemseged F, Balcha F, Berhe S, Aregay A. Application of nursing process and its affecting factors among nurses working in mekelle zone hospitals, Northern Ethiopia. Nurs Res Pract 2014;2014:675212.  Back to cited text no. 9
Reppetto MA, de Souza MF. Evaluation of nursing care systematization through the phases of nursing process performance and registration in a teaching hospital. Rev Bras Enferm 2005;58:325-9.  Back to cited text no. 10
de Moraes Lopes MH, Higa R, Dos Reis MJ, de Oliveira NR, Christóforo FF. Evaluation of the nursing process used at a Brazilian teaching hospital. Int J Nurs Terminol Classif 2010;21:116-23.  Back to cited text no. 11
Shiferaw WS, Akalu TY, Wubetu AD, Aynalem YA. Implementation of nursing process and its association with working environment and knowledge in Ethiopia: A systematic review and meta-analysis. Nurs Res Pract 2020;2020:6504893.  Back to cited text no. 12
Goswami G, Sharma SK, Sharma R, Rani R. Simulation and skill training facilities in nursing institutes at uttarakhand: A cross-sectional study. Iran J Nurs Midwifery Res 2021;26:449-54.  Back to cited text no. 13
Garadi S, Sharma R, Jelly P, Rani R. Transformation in nursing education in India: Current issues. IP Int J Med Paediatr Oncol 2021;7:115-8. Available from: https://www.ijmpo.com/article-details/14978. [Last accessed on 2022 Feb 27].  Back to cited text no. 14
Akbari M, Shamsi A. survey on nursing process barriers from the nurses' view of intensive care units. Iran J Crit Care Nurs 2011;3:181-6. Available from: https://www.sid.ir/en/journal/ViewPaper.aspx?id=213349. [Last accessed on 2021 Sep 09].  Back to cited text no. 15
India Nursing Council. Recommendations of Nursing Staffing Norms by the Staff Inspection Unit. Available from: https://www.indiannursingcouncil.org/uploads/pdf/16001723668133537865f60b14e8d657.pdf. [Last accessed on 2021 Sep 09].  Back to cited text no. 16
Aseratie M, Murugan R, Molla M. Assessment of factors affecting implementation of nursing process among nurses in selected governmental hospitals, Addis Ababa, Ethiopia; cross sectional study. J Nurs Care 2014;3:1-8.  Back to cited text no. 17
Latimer J. The nursing process re-examined: Enrollment and translation. J Adv Nurs 1995;22:213-20.  Back to cited text no. 18
Zeleke S, Kefale D, Necho W. Barriers to implementation of nursing process in South Gondar Zone Governmental hospitals, Ethiopia. Heliyon 2021;7:e06341.  Back to cited text no. 19
Farahani ZB, Rastian M, Rassouli M, Sarbakhsh P. The impact of training on nursing process implementation skills of surgical'ward nurses. Int J Med Res Heal Sci 2016;5:268-72. Available from: https://www.ijmrhs.com/abstract/the-impact-of-training-on-nursing-process-implementation-skills-of-surgicalward-nurses-4065.html. [Last accessed on 2021 Sep 09].  Back to cited text no. 20


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3]


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