Mónica Ruth Batista-Sánchez,1 Elsa Alvarado-Gallegos2
1Unidad de Vigilancia Epidemiológica Hospitalaria/Vacunación, Hospital General de Zona 50
2Coordinación de Cursos de Enfermería, Centro de Investigación Educativa y Formación Docente
Instituto Mexicano del Seguro Social, San Luis Potosí, San Luis Potosí, México
Registration number by local research and ethics committee in health research: 2402: R-2012-2402-32
Correspondence: Mónica Ruth Batista-Sánchez
Received: May 5th 2014
Judged: January 19th 2015
Approved: February 26th 2015
Introduction: The nursing care process (NCP) is the method of intervention that distinguishes nursing as discipline; in addition, the current practice demands application according to strategies raised by the IQS; however, the incorporation into clinical practice has been slow and the staff continues referring deficiencies in its understanding and application.
Objective: To analyze the level of application of NCP in hospitalization area nursing staff at the Instituto Mexicano del Seguro Social´s General Hospital No. 50 in San Luis Potosí.
Methods: Observational study, descriptive and transversal, with a sample of 44 nurses of hospitalization areas, 2 instruments were used that analyzed the level of application of NP in nursing records and the factors that influence the application of NP.
Results: 86 % women, aged 31-40 years (54 %), 72 % with a university degree, and 50 % San Luis Potosí University graduated, year of graduation of the 2001-2005 (27 %), seniority of 6-10 years (39 %). The level of general application tied between regular and deficient (43.2 %); by stages: for assessment was 38.6 %, diagnostic 30.6 %, planning 25.7 %, implementation 45.9 % and evaluation 37.5 %. Factors related to the application referred to by the staff were the lack of time (40.9 %), lack of knowledge on NP (25 %) and lack of supervision, feedback and evaluation (15.9 %).
Conclusions: Continuous training could be the first strategy outlined, however, the time, supervision, feedback and evaluation are key elements that require a different plan for their solution.
Keywords: Nursing process; Nursing records; Nursing staff hospital
Nursing care in situations of health are the expression and fulfillment of an essential service in certain circumstances of life; no other group of professionals provides this comprehensive range of services.1 In 1975, the guidelines to be followed and the role of nursing were delineated; and this addressed not only nursing activities derived from the medical regimen, but the activities derived from autonomous function.2 Over the years, the struggle for the professionalization of nursing as a discipline has led to the creation of models, theories, and instruments to systematize, inform, and differentiate daily practice.
The nursing process (NP) is the method of intervention that distinguishes the discipline. At present, its application is becoming more essential today in the fields of teaching and daily practice.1 In 1977 the World Health Organization (WHO) recognized the NP as "a system of interventions within nursing about the health of individuals, families and communities. It involves the use of the scientific method for identifying the health needs of the user; it defines the objectives, sets the priorities, identifies the care to be provided, and the resources they have."
In 2007 some international organizations such as the Pan American Health Organization (PAHO), in a bid to ensure the quality of health care, established in their fifth line of action to develop a regional strategy to strengthen the quality of health care and patient safety. In response, in Mexico, the Programa Nacional de Salud (2007-2012) in their third strategy originated the Integrative Quality System (IQS), which among its many programs started with the implementation of the program of Nursing Care Plans (NCP), to strengthen the implementation of the NP.3
From that time on it would be required for the curricula of schools and nursing schools to include the elementary theoretical bases of the process and use including NANDA, NIC and NOC (NNN) taxonomies, and other educational technologies to standardize care, and their application in practice; for public health institutions (IMSS, ISSSTE, SEDENA, SSA, PEMEX) as well as private, the implementation of training courses or continuous update of theoretical and practical topics in question were also required.4 This was in order to start rigorously using guidelines defining the theory and to avoid discrepancies in implementation between one professional and another, and moreover the standardization of language through the exclusive use of the process.
For its part, the Instituto Mexicano del Seguro Social (IMSS) in the Hospital General de Zona (HGZ) No. 50, in accordance with IQS, has led training and updating courses and workshops concerning NP since 2004, and for the knowledge of NNN taxonomies and the development of NCP by the end of 2010; moreover, nursing records have been updated since 2011 so that the content corresponds to each of the stages, in order to exercise it and apply it every day after caring for each patient. Also, according to the office of nursing, head floor staff is responsible for assessing the log in the nursing charts according to NP.
Despite institutional efforts for the implementation of the NP, its integration into the practical nursing field has been slow and uneven; and nurses of the hospital areas still express shortcomings in their understanding, management and implementation. Its lack of implementation may be due to factors such as the limited knowledge there is on the subject,1,5-7 or resistance by the personnel to applying it.7,8 If the problem in the application of this process were to prevail, the discipline might never reach full professionalization and might never achieve a unified language, since the scientific bases shown in practice to substantiate care provided would be lacking, patient care would not be standardized, and quality would be in question.
With the conviction that NP enables objectivity and analysis of human responses in different aspects, that these situations can clearly be for the benefit of patients, families, and professionals, and that, moreover, it is regarded as the alternative methodology that will distinguish the discipline in the new millennium,5 it was necessary to know the level of implementation of the process and factors reported by staff as influential when they perform it, since from there it can be determined if they are really applied, and how, to define strategies and areas of intervention for the problem. Therefore the present study sought to analyze the level of implementation of NP in the nursing staff of the hospitalization areas of HGZ 50 of IMSS in San Luis Potosi.
The study was observational, descriptive, and simple cross-sectional. The level of implementation of NP was analyzed in nursing staff of IMSS HGZ No. 50 in the morning, evening, and night shifts in areas of hospitalization (Trauma-Orthopedic Services and Hematology, Internal Medicine and Surgery). The information was collected at one time. It was applied to a sample of 44 general nurses (calculated with a confidence level of 95% and maximum error of 5% according to STATS, version 2), the universe was 212 and the population of 49 nurses who work in the hospitalization areas of HGZ 50. The sample was not probabilistic for convenience until the sample was completed, of which 18 belonged to Trauma-Orthopedics and Hematology, 7 to General Surgery and 19 to Internal Medicine.
The variables that were identified in the study were sociodemographic (gender, age) and academic and work data (school of origin, title obtained, year of graduation, time working in the institution), the level of implementation of the NP, and personal opinion data. We included general nurses from all three shifts in Trauma-Orthopedics, Hematology, Surgery and Internal Medicine who were responsible for patients, and who answered over 90 % of the survey. Also according to the Ley General de Salud for research, informed consent was obtained, and they were informed about their ethical rights, anonymity, confidentiality, and the right to leave the study.
Two instruments were used, which had been validated by type of content by a panel of five experts and by implementing a pilot test. The first instrument was based on the nursing sheet used and updated by IMSS starting in 2011, and it assessed the level of implementation of NP in nursing records during the practice of patient care. It consisted of 20 dichotomous questions, each worth one point if it was answered correctly and 0 points if it was incorrect; the total score was 20 points. To obtain the application level, a Likert scale determined it Deficient if the result was 0-6 points, Regular if it was 7-12 points, Good if it was 13-18 points and Excellent if it was from 19-20 points.
The second instrument was a small survey consisting of seven open questions, two dichotomous, and one multiple choice with numbers from 1 to 9, which were determined by the study objectives. The first two open questions were aimed at obtaining demographic data of nurses (age and sex); the following four (school of origin, year of graduation, title obtained, and time working in the institution) related to specifics of their training and employment situation, and the remaining questions were aimed at staff opinion about the existence of factors influencing the application of NP. The survey responses were handled solely with descriptive statistical analysis (without scale).
The study was reported in the Electronic Registration System for Health Research Coordination (ERSHRC), and with that, authorization was gotten through the Local Committee on Health Research (LCHR) at HGZ 1 in San Luis Potosi. With this authorization, coordination was made with teaching and nursing leadership to implement the study. The data are captured in a database in SPSS, version 20. The information was analyzed by descriptive statistics for all variables, by frequency distribution, measures of central tendency, percentages, averages and standard deviation; the Fisher test and Pearson statistic correlation test were also used to obtain relationships between study variables. The results of the analysis were presented in narrative, graphics, and tables.
The study was applied to a sample of 44 nurses, 43.2 % in Internal Medicine, 40.9 % in Trauma / Orthopedics-Hematology and 15.9 % in General Surgery. As shown in Table I the majority were female with 86.4 %, and the most common age range was 31-40 years (54.5 %), with an average age of 34.4, median 35, mode 25, standard deviation (SD) of 5.88. Regarding the school of origin 50 % came from the Universidad Autónoma de San Luis Potosí (UASLP), the highest degree of studies was Bachelor’s level with 72.7 %. The time worked at the institution had an average of 7.15, median of 6, mode of 1, and SD of 5.77; 38.6 % had 6 to 10 years working in the institution. As for year of graduation, with a SD of 6.74, 27.3 % graduated between 2001 and 2005.
|Table I. Academic and work data of HGZ 50 nursing staff|
|Trauma-Orthopedics and Hematology||18||40.9|
|Bachelor's of nursing||32||72.7|
|Years in the institution|
|< 1 year||4||9.1|
|School of origin|
|UASLP (Universidad Autónoma de SLP)||22||50.0|
|UTAN (Universidad Tangamanga)||2||4.5|
|Red Cross (Escuela de Enfermería Cruz Roja-UNAM)||8||18.2|
|CETIS (Centro de Estudios Técnicos Industriales y de Servicios)||6||13.6|
|Year of graduation|
|Source: NP instrument July 2013|
Within the application level, to assess the records by stage of NP in the nursing sheet, it was found that for the evaluation only 34.1 % recorded Gordon functional health patterns and 31.8 % of them agreed with that recorded in the assessment box, 59.1% reported subjective and objective data of the patient, but only 29.5% agreed with registered nursing diagnoses. At the stage of diagnosis, 38.6% reported interdependent problems (IP), but only 20.5 % of those and 25% of potential complications (PC) were correctly made. In turn, 50 % recorded their nursing diagnoses in the correct box, and only 20.5% were formulated correctly, but moreover only 29.5 % were the priority for the patient's condition.
As for the planning and implementation stage, 70.5 % recorded collaborative interventions, although of these only 31.8 % were done correctly, and what’s more only 25 % agreed with the registered IP. 79.5 % recorded nursing interventions in the corresponding site, only 25 % were done correctly and 43.2 % agreed with the registered nursing diagnoses. Regarding the evaluation stage, 52.3 % recorded patient outcome data, only 22.7 % agreed with the assessment, diagnosis and interventions. 20.5 % recorded health education actions (discharge planning) and only 11.4 % agreed with the registered nursing diagnoses.
In turn, Figure 1 shows that when taking an average of NP per stage and overlapping categories, weighting Excellent at 100 %, Good from 80 to 99 %, Regular from 60 to 79 % and Deficient from 0 to 59 %, it was noted that the stage that was applied best was Implementation with 45.9 %, followed by Assessment (38.6 %) and Evaluation (37.5 %); of these, all three fall within the category Deficient. In contrast, for level of application, all stages received a failing grade. Therefore, the total score of the subjects showed an average of 7.23, a median of 7, a mode of 5, and SD of 4.19.
Figure 1. Level of NP implementation by stage by HGZ 50 nursing staff . Source: NP instrument, July 2013.
According to the range of scores obtained, as shown in Figure 2, 43.2 % got 0-6 points, while 43.2 % earned 7-12 points and only 13.6 % achieved 13-18 points. This means that 43.2 % had an NP implementation level of Deficient, 43.2 % Regular, and 13.6 % Good. It is worth emphasizing that 0 % obtained Excellent.
Figure 2. Level of NP implementation by HGZ 50 nursing staff. Source: NP instrument, July 2013
The importance given by the study population to NP application is shown in Table II, in which 97.7 % said they considered it important. Of these, 79.5 % considered it (on a scale of 1 to 10) between 8 and 10, that is, as very important; in turn, 97.7 % said that there are deficiencies in the application.
|Table II. Importance of NP application for HGZ 50 nursing staff|
|Importance of applying NP||Importance of NP from 1 to 10||Total|
|Source: NP instrument July 2013|
Finally, as detailed in Table III, among the factors that study staff revealed as influential in the implementation of NP were: time for implementation (40.9 %), knowledge of NP (25 %) and supervision, feedback and evaluation thereof (15.9 %).
|Table III. Influential factors in NP application for HGZ 50 nursing staff|
|Time for application||18||40.9|
|Knowledge about NP||11||25.0|
|Interest in application||2||4.5|
|Adequate nursing records||2||4.5|
|Personal approval of methodology||2||4.5|
|Motivation for use||2||4.5|
|Supervision, feedback, and evaluation||7||15.9|
|Source: NP instrument July 2013|
The population of this study was similar to studies by Rojas, Orozco, and Morales: 4,10,12 mostly female, average age 34, with 6-10 years working, 72.7 % with Bachelor’s degree, and predominant graduation year between 1996 and 2005. In context, it is a young population, graduated with Bachelor's degree in the last 10 years, already with some work experience, having received the most current knowledge as concerns NP and its application in clinical practice while at school.
However, this study found that in terms of the application of NP in patients, the best-applied stages (Implementation and Assessment) are below 50 %, which contrasts with that reported by Rojas,4 whose application rates are up to twice as high and whose best-applied stages were the same. Of course, there are variations when you take into account that their study analyzed aspects more related to clinical aptitude, while in this study we analyzed what was recorded in the nursing sheet compared with the patient's clinical situation. Here it should be recalled that "what was not recorded, did not happen" and therefore an NP that was not recorded, was not applied.
On obtaining the coefficients of correlation between population age, school of origin, year of graduation, degree obtained, and time working in the institution, and the level of application, no great statistical significance was demonstrated, which would indicate that other factors could have influence. This in contrast to the findings of Rojas,4 linking the ease of application with the level of preparation or academic updating. Differently, Aguilar,1 whose population is mostly technical, demonstrates a relation between low level of knowledge and NP application, but the population of this study consists mainly of nursing graduates, indicating that there are other factors affecting the application.
Most nurses surveyed (98 %) recognized the great professional importance of implementing NP in their daily practice; to be exact, they gave it between 8 and 10 priority, 10 being the highest score. Even more, 98% said there are factors that determine the application, among which they revealed the following: lack of time (41 %), lack of knowledge (25 %) and lack of supervision, feedback and evaluation (16 %) ; in turn, the lack of interest, lack of adequate nursing records, personal approval of the methodology, and lack of motivation to use it tied at 4.5%, all very similar to what reported Diaz and Nieto, Chavez, Pecina, Orozco, Perez, and Morales.7-12
However, it is not enough to say that the results are similar because populations are similar, or because the nursing situation is similar in many of these studies; nor that continuous training is still the favorite strategy for solving the problem; this strategy would address only the second factor mentioned by staff (lack of knowledge: 25 %). Also noteworthy, in the context of this study the institution provides training in NP, so maybe if the information level of staff were examined, it would come out higher than in the application; but then why would it go unimplemented?
The main factor reported is the lack of time, which is also reported in the first place by other studies.7,8,9,10,11,12 What do you do to solve this factor? In most of the studies consulted, training is considered most among their strategies, but they show no clear-cut solutions for the lack of time; probably because the possible solutions are linked to two aspects that are not in the hands only of the Department of Nursing but require interdisciplinary support. The first is the organization (in time) of staff to achieve a proper application of NP, and the second is the definite work overload, which requires the reduction of patients per nurse and therefore, hiring more staff. The management of the latter could improve quality nursing care by a great percentage.
In turn, the nurses in this study reported in third place lack of supervision, feedback and assessment. This issue may be involved with two aspects: head nurses’ level of information on NP, and their scope in terms of functions, i.e., the more functions are allocated to head nurses, the less time they have to assess and provide feedback on records, care, and NP application; therefore, if there is less time to evaluate, there will be even less time to motivate staff to use it, which, even so, can significantly reduce the approval of the methodology by the staff. In this respect, Leon emphasizes the following in his study:
... The main factor that discourages staff for the implementation of NP in their records has been, first, the addition of an indicator that, instead of measuring quality, measured quantity and therefore demands from the professional more work and extra effort, inspiring in them a growing rejection of their own scientific method of performance.13
This leads us to believe that, in addition to several factors mentioned by staff as influential in the application, there is a set of aspects that are impacting them. Quality standards and recent requirements by large organizations on health and quality require the nursing profession to carry out great feats of work, by turns holistic with the patient, intellectual for the implementation of NP (and recently the incorporation of NCP and NNN taxonomies into practice) and administrative, as appropriate; of course, these are the skills and requirements for all nurses, but ... how do you get an answer that is good to excellent with minimal time and human resources?
The results of this study are quite clear: the respondent nursing staff is mostly female, with an average age of 34 years, graduated in general 10 years before, and with 6-10 years working. The level of NP application ranged between regular and deficient (43 %), the most difficult steps for implementation were diagnosis and planning, but all were within the deficient range. It was shown in this study that the factors mentioned as influencing the implementation of NP are lack of time (41 %), lack of knowledge (25 %) and lack of supervision, feedback and evaluation (16 %).
Among the strategies to follow (as claimed by others) are continuous training through other technologies, that are ideally innovative for both operational staff and managers; motivation mainly by managers for use in daily practice; and ongoing management of nursing department human resources for increased staffing of nursing, in order to decrease the rate of patients per nurse and thus contribute to the improvement in quality of care. It is easy to say, but it is a long, ongoing process that involves action in the areas of training, human resources, supervision, and nursing staff.
This study aims not only to report the level of implementation of NP by staff and determining factors that produce the application, but to give staff of the Institute an overview of the vital functions of nursing and the probabilities that yielded these results, without defining or limiting a "responsible party." This study also seeks to define which areas require involvement and cooperation to improve both professional quality and care, which ultimately is a requirement for large organizations and national and global programs.