EXPLORING FACTORS INFLUENCING IMPLEMENTATION OF NURSING PROCESS

EXPLORING FACTORS INFLUENCING IMPLEMENTATION OF

NURSING PROCESS IN MATHARI NATIONAL TEACHING AND

REFERRAL HOSPITAL.

OPERATIONAL DEFINITIONS

Assessment: This is systematic and continuous data collection process which includes

history taking through interview, physical and mental status examination and

diagnostic tests eg x-rays and laboratory investigations. Assessment aims at getting

information about the patients’ state of health.

Barriers: These refer to something or a situations that makes it difficult or impossible

to achieve a certain level of functioning. Barriers entail the various factors hindering

implementation of nursing process.

Explore: To inquire into or discuss in details a certain phenomenon under study.

Exploring entail discussing factors which influence implementation of nursing

process in management of patient with mental disorders.

Factors: These entail activities, functions or process which actively contributes

towards the accomplishment, result, or a particular process. These factors either

enhance or hinder the implementation of the nursing process and are categorized into

structural and process factors.

Implementation: This is the actualization of the formulated strategies or practices

through allocation of the necessary resources, time, attention and skills. This entail the

extent to which the nursing process is put into practice by the nurses in patient

management through proper interventions and nursing diagnosis.

Influence: To have an effect upon so as to result in a certain desired outcome. It

involves the effect of structural or process factors on implementation of nursing

process.

Management of patients: It includes communication, empathy, examination,

evaluation, diagnosis, prognosis, and intervention. It is the provision of patient care

guided by the nursing process at Mathari National Teaching and Referral Hospital.

Mental disorders: These are syndromes characterized by clinically significant

disturbance in an individual's cognition, emotion regulation, or behavior that reflects a

dysfunction in the psychological, biological, or developmental processes underlying

mental functioning

Nursing process: A systematic rational method of planning and providing

individualized nursing care to individual, family and the community. It’s a problem-

solving approach used to identify, prevent and treat actual or potential health problem

and promote wellness. This process is composed of six steps namely; Assessment,

Diagnosis, Planning, Interventions/Implementation, Evaluation and Documentation.

Practice: The use of one's knowledge in a particular profession. In this study it’s the

utilization of nursing process in management of patient at Mathari National Teaching

and Referral Hospital.

iii

ABSTRACT

Background: Nursing Process is a decision-making approach that promotes critical

thinking towards enhanced patient management and better health outcomes. Its

implementation in most Kenyan hospitals still remain low especially in the mental

health units. Inadequate knowledge, incompetence, high patient turnover, lack of

resources, inadequate administrative support and negative attitude are some of the

factors which undermine the NP implementation.

Objective: To explore factors that influence the implementation of nursing process in

Mathari National Teaching and Referral Hospital.

Material and Methods: MNTRH was purposely selected for the study and mixed

method research design was used. The sample size was 151 nurses selected by simple

random sampling technique while purposive sampling was used to select respondents

for the interviews. Data was collected using questionnaires, interview guides and an

observation checklist and presented in tables, graphs, charts and narrations. The data

was analyzed using thematic analysis and descriptive statistics. Chi-square test of

significance was used to determine the relationships between factors which influence

NP implementation (Level of significance was set at p<0.05). The data was collected

for a period of 4 weeks and study conducted at an estimated cost of Ksh 85,112.50.

Findings: The findings of the study revealed that majority of the respondents

104(93%) were affirmative on their awareness of NP. It was established that

utilization of NP at MNTRH was yet to be successful with the respondents indicating

25-40% success levels. The main utilized phases of NP at MNTRH were; assessment,

diagnosis, implementation/interventions, and documentation but significant gaps

existed in all the phases. Both structural and process factors have positive and

significant influence on NP implementation at MNTRH. The interviewees further

indicated that major barriers affecting NP implementation to be poor nurse-patient

ratio, lack of managerial support and lack of monitoring and follow ups on the NP

implementations.

Conclusion and Recommendations: NP has not yet been fully utilized in patient

care at MNTRH. Structural and process factors significantly influenced the level and

extent of implementation of NP at MNTRH. The management of MNTRH should

highly prioritize implementation of NP in patient care, offer regular in-service training

on NP and monitor its practice. The Ministry of Health, regional health bureau, and

other Non-Governmental partners to ensure that the institution is empowered on

importance of NP and equipped with adequate nursing staffs.

CHAPTER ONE: INTRODUCTION

1.1. Background of the study

Nursing Process (NP) is defined as an organized framework of care that provides

guidelines to sequence of reasoning in clinical settings (Stonehouse, 2017; Sendín &

Ceña, 2018). NP is used by professional nurses to ensure provision of high quality

standards of patient care (American Nurses Association, 2017). The Nursing Council of

Kenya recommends that nursing practice in the country should be based on the scientific

approach of this NP. The main aim of the NP is to ensure delivery of holistic and quality

nursing care in an organized manner (Mahmoud & Bayoumy, 2014; Varcarolis, 2016).

Effective implementation of nurse process is critical in the achievement of high quality

health care which translates to better patients’ health outcomes (Ngao, 2015; Wagoro &

Rakuom, 2015). However, despite this perceived importance in patient management,

reports at the Ministry of Health indicate that in most hospitals, the NP framework is not

completely utilized in nursing care provision (MoH, 2010).

Failure to use the NP leads to low Quality Health Care, disorganization of nursing care

and conflicting roles (Mangare, Omondi, Ayieko, Wakasiaka, & Wagoro, 2016). Factors

such as lack of resources, incompetence’s, negative attitudes among nursing staffs and

inadequate staffing have been associated in failure of full implementation of the NP

(Manal, & Hala, 2014).

The implementation of NP thus tend to be more challenging in mental health units where

most nurses are faced with difficulties in identifying psychological problems and stating

diagnostic labels. Sendín & Ceña, (2018) further argue that implementation of NP in the

mental health facilities are lacking in some instances. The barriers mainly originate

internally from the nurses themselves, the health care facilities and even the patients

(Herr, Marie, Gordon, & Young, 2015; Sendín & Ceña, 2018). These factors not only

hinder the proper identification of the patient problems but also result in delayed

diagnosis.

Given the benefits of the nursing process to both the nursing care and patient outcomes, it

is important that the underlying factors to its implementation be fully understood

(Wagoro & Rakuom, 2015). Measures to ensure proper implementation of KNP will act

to ensure improvements in the quality of mental health care which will go a long way in

achievement of vision 2030 that aims to promote provision of better health care to all

Kenyan citizens. This is through the promotion of optimal health, the prevention of

illness, and the care and treatment of persons with mental disorders through efficient

nursing diagnosis (Prince, et al 2016).

1.2 Statement of the Problem

Nursing Process acts as a decision-making approach that promotes critical thinking

geared towards enhanced patient management and better health outcomes (Melin-

Johansson et al, 2017). However, most nurses have not been able to fully implement it in

their daily practices (Blais, Hayes, Kozier, & Erb, 2015; Zamanzadeh, et al, 2015). The

use of nursing process in most hospitals is still lagging despite all the efforts that have

been made by the nursing professionals to implement its use (Mwenda, Kangethe, &

Maranga, 2016). In this regard, factors such as inadequate knowledge, incompetence,

high patient turnover, and lack of time undermine the NP implementation process

(Sendín & Ceña, 2018; Herr, et al, 2015).

Mahmoud and Bayoumy (2014) observed that most nurses complained of lack of time

and high patient volume as significant barriers to NP implementation. Mangare, et al,

(2016) further found out that though nurses may have a positive attitude towards the NP,

they experience difficulties performing most of the phases of the NP. Ngao, (2015) noted

that the application of the nursing process in patient care was minimal in most healthcare

facilities in Kenya including Machakos Level 5 Hospital. Agyeman-Yeboah, et al, (2017)

found out that clinical utilization of the Nursing Process at clinical settings was

influenced by lack of clear understanding on the Nursing Process and Care Plans.

Ota, (2014) found out that the nurses in Level Five mental health units in Kenya faced

many challenges related to work environment and patient-related factors. Similarly,

Zamanzadeh, et al, (2015) established that most of the mental health institution lacked

well-structured Nursing Processes implementation strategies. Patients with mental health

disorders require individualized and more sensitive care due to their emotional and

mental health concerns which further makes the nursing process implementation more

challenging (Moetsana-Poka, Lehana, Lebaka & McCarthy, 2014; Varcarolis 2016).

Mental Health Disorders account for approximately 16 percent of the burden of disease in

Kenya (MoH, 2010). Therefore understanding the factors influencing implementation of

the nursing process in the care of patients with mental disorders will go a long way in

improving patient outcomes in the mental health sector. Effective implementation of the

NP is essential so as to ensure that all the patient’s needs are met and improving the

quality of patient care.

1.3 Purpose of the Study

The purpose of the study was to explore factors that influence implementation of the

nursing process in the care of patients with mental disorders in Mathari National

Teaching and Referral Hospital.

1.4 Research Questions

The study aimed to address the following research questions;

i. How has nursing process been adopted in management of patients with mental

disorders in Mathari National Teaching and Referral Hospital?

ii. What structural factors influence the implementation of nursing process in

management of patients with mental disorders in Mathari National Teaching and

Referral Hospital?

iii. What process factors influence the implementation of nursing process in

management of patients with mental disorders in Mathari National Teaching and

Referral Hospital?

1.5 Specific Objectives

The specific objectives of the study were to;

i. To establish the extent of nursing process utilization in management of patients

with mental disorders in Mathari National Teaching and Referral Hospital.

ii. To determine the structural factors that influence the implementation of nursing

process in management of patients with mental disorders in Mathari National

Teaching and Referral Hospital.

iii. To establish process factors that influence the implementation of nursing process

in management of patients with mental disorders in Mathari National Teaching

and Referral Hospital.

1.6 Justification

Nursing Process provides a framework for facilitating well-coordinated nursing care and

has proved helpful in accessing quality nursing care. It allows the nurse to apply their

knowledge and interventions in an organized manner as well as ensuring high standards

are maintained. However, despite this perceived importance, the implementation of NP

and its practice is not easily achieved (Mahmoud, 2014). Reports from the Ministry of

Health indicated that in Kenya, the NP is either under-utilized or not systematically

followed (MoH, 2010). Barriers relating to the nurses, patients and hospital facilities have

been established by the studies conducted which tend to limit the effectiveness of the

NPs. The barriers tend to be more pronounced in the mental health institution where the

patients require specialized and individualized care. Herr, et al, (2015) established that

inadequate knowledge of the nursing process is thus a key barrier to the implementation

of the NP especially in the management of patient with mental disorders.

Keating, Thompson and Lee (2010) found out that most hospital facilities do not provide

the needed support. Proper application of nursing process requires a clear understanding

of the factors which undermine the implementation process. This therefore necessitated

this study which was conducted at Mathari National Teaching and Referral Hospital. The

study was able to establish the current situation of NP implementation in the facility and

underlying factors.

1.7 Significance of the Study

The study will benefit mental health nurses in Kenya, particularly Mathari National

Teaching and Referral Hospital on the national and global standards set for the

implementation of the nursing process in the care of patients. The recommendations

made by the researcher aim at improving utilization of NP which will make the task of

assessing and managing the mental disorders of patients to be systematic and organized.

The management will also therefore be in a better position to formulate better policies

and frameworks which will ensure that the barriers to the NP practice are minimized.

This will act to greatly boost the overall effectiveness of the NP in the institution thus

promoting better patient care. In addition, the research will encourage nurse educators to

reexamine the psychiatric nursing syllabus and course of content. That will give them the

opportunity to identify areas that need assessment to be at par with the current psychiatric

nursing practice trends. The study will also form a basis on which further studies in the

area will be conducted.

CHAPTER TWO: LITERATURE REVIEW

2.1 Concept of Nursing Process

Historically, nursing was mainly concentrated on the underlying medical conditions

rather than the person(s) receiving the medical care. The nursing care was therefore

undertaken based on mere intuitions or following the physicians’ instructors. But with the

introduction of the nursing process in the early 60s, in the developed countries, this has

changed drastically (Pokorski, Morae, Chiarelli, Costanzi and Rabelo, 2009). The nursing

process was introduced by North American Nurses Diagnosis Association (NANDA) and

provides a means of not only standardizing nursing care but also the maintenance of the

autonomy of the profession (Ngao, 2015). Nursing Process is a well-structured method

for facilitating rational planning and individualized Quality Nursing Care (QNC)

(Ngao,2015; Magare, et al, 2016; Rakuom & Wagoro, 2016). Similarly, Yildirim and

Ozkahraman, (2013) state that NP is a tool used in planning and offering patient care

which is well organized and tailored to meeting individualized healthcare requirements.

Efficiency in the entire NP practice is evaluated by the nature of approach to patients by

nurses, specific interventions made, documentation quality, increased reflective thinking

and better patient outcomes. Abdelkader and Othman, (2017) further add that the NP may

be assessed by the level of participation in care planning of patients and ensuring that the

provided nursing care is specific to requirements of a patient within the entire group

context. This will ensure patients’ satisfaction, reduced workload as well as improved

communication amongst the nurses.

2.1.1 Global Nursing Process

Nursing process in currently a globally accepted process which represents the

experiences in nurses’ patient care aimed at evaluation of the patient needs, proper

planning, careful interventions and proper documentations (Ledesma-Delgado & Mendes,

2009). NP constitutes a series of steps which assist the nurse to use their theoretical

knowledge in diagnosis and implementing therapeutic actions for attaining, maintaining

and promoting optimal bio psychosocial functioning (Lindberg, 1998). Currently, the

nursing process utilizes the ADPIE acronym which stands for assessment, diagnosis,

planning, implementation, and evaluation. The relevance of the ADPIE is to enhance the

mental, emotional and physical health of patients through analysis, diagnosis, and

treatment (Mamseri, 2012). Specifically, Afolayan, Donald, Baldwin, Onasoga, and

Babafemi (2013) argued that international nursing process is made up of seven phases;

assessment, diagnosis, identification of outcome, planning, intervention, implementation,

and evaluation. Regionally, South Africa mental health hospitals use the 2007

international classification of nursing practice to determine the stages of the nursing

process which include, assessment, diagnosis, planning implementation and evaluation

(World Health Organization, 2013). Most hospitals dealing with patients with mental

disorders in South Africa does not focus on problem-solving as a stage of the nursing

process.

2.1.2 Kenya Nursing Process

The Kenya Nursing Process revised is revised to six steps and included documentation as

the last phase due to the observation by nurse administrators that there was a problem

with documentation in Kenya (Ngao, 2015, Rakuom & Wagoro, 2016; Magare et al,

2016). Kenyan nurses realized it’s structural and processes challenges in nursing

practice necessitated the documentation phase of nursing processes therefore it had to be

treated separately. The structural obstacles were limited number of nurses, task shifting,

and changing policies on care delivery system in nursing and inadequate finance.

Conversely, process factors were the development of an interpersonal relationship with

patients and methods of procedure performance to ensure trust and disclosure at the

assessment time. The Kenya-NP is therefore unique due to; outcome identification is

included as an activity within the planning phase, risk nursing diagnosis is revised into

three parts instead of two parts as in the global concept, documentation is adopted as a

last step instead of evaluation as in the global concept and implementation is within the

context of categorisation of patients and team nursing (Wagoro & Rakuom, 2015).

The Nursing Council in Kenya recommends that the practice of nursing should be based

entirely on the systematic application of the nursing process (Mangare, et al, 2016). KNP

has been further emphasized in the current nursing procedure manual which holds that

nursing process procedures should be able to ensure that the nurses deliver patient-

focused care in an organized manner. Training curricula for both midwives and nurses

have also incorporanted the NP as a framework in enhancing the nursing care. However,

reports at the Ministry of Health still indicate that in most hospitals this framework is not

used in the provision of nursing care and if used, the phases are not systematically

followed (MoH, 2010). Wagoro and Rakuom (2015) stated that nurse educators should

collaborate with the office of CNO to create a software that has a classification of nursing

process terminologies to aid documentation. The Government’s e-health program will be

fundamental in the documentation process.

2.2 Theoretical Framework

This study was guided by the Nursing Process Theory and the Donabedian’s theory. The

Nursing Process Theory was formulated by Ida Jean Orlando’s (Pelletier). The theory

holds that effective interactions between patients and nurses will lead to effective

interventions which will translate to better health outcomes (Parker & Smith, 2010). The

theory focuses on improving the behavior of the patient based on their needs which are

established through effective interactions with the nurse. Based on this theory, the need

for nursing care is heightened more when one is not able to meet the needs that they have.

Orlando’s theory has been tested in various health care settings and the results support

its’ implementation to practice in various nursing fields (Schmieding, 2006).

Zamanzadeh, et al, (2015) found out that Orlando’s theory promoted stress reduction

during admission to surgery. Peterson & Bredow (2009) argue that there is no simplicity

in undertaking and adhering to the nursing guidelines but following this theory acts as a

guideline. The importance of the theory is that it makes it easier for nurses to see a patient

from a nursing perspective. This helps nurses function in a professional manner by using

an established method and body of knowledge through provision of structured care to

patients.

Donabedian’s Theory on the other hand was introduced by Avedis Donabedian (1966)

who proposed a structure-process-outcome framework used in determining the quality of

health care. Incorporation of all these three components provides the necessary

information for the exploration of quality care. This three-part approach of quality

assessment is possible because proper structure increases the probability of good

processes and good processes in turn translate to good outcomes.

2.3 Conceptual Framework

The conceptual framework of the study is adopted from the theoretical framework as

shown by Figure 2.1.The independent variables of the study are the factors influencing

the implementation of the nursing process while the dependent variable is the nursing

process practice and outcomes in Mathari National Teaching and Referral Hospital. The

moderating variables the factors hindering the implementation of NP. The independent

variables are depicted to have a direct influence on the dependent variable.

Independent variables Dependent variables

Figure 2.1 Conceptual Framework

Source; Researcher 2018

Structural factors

Organization structure

Support

Policies

Organization culture

Availability of resources

Patient-Nurse Ratio

Intervening/Moder ating

Variables

NP Policy Frameworks

Usability of the NP

Adaptability of the NP

Quality assurance (audit

practice).

Process Factors

Nursing processes

Professional conduct of the nurses

Nurse – patient interaction

Diagnosis

Treatment

Assessment

Specific interventions

Attitude of the nurse

Nursing Process Practice indicators

Documented assessment data

Documentation quality

Increased reflective thinking with

specific interventions

Application of nursing care plans in

patient care

ProperNursingDiagnosis with three

parts

Outcomes

Better Patient Care

Patient Satisfaction

Nurse Satisfaction

Patient participation

Hospital Performance

Increased NP use

Medico-legal issues

reduced

CHAPTER THREE: METHODOLOGY

3.1 Research Design

This study adopted the mixed method research design. As explained by Setia, (2016) this

research design incorporates both the qualitative and quantitative approaches. The

qualitative approach was undertaken using the phenomenological research approach. This

aided in the determination of the experiences with NP from the nurses’ perspective. This

research design therefore enabled in depth understanding of the study topic and was

achieved using key informant interviews. Descriptive cross-sectional research design on

the other hand was used in the quantitative approach. The cross-sectional research design

enabled the researcher to measure the outcome of NP implementation and the exposures

in the study participants at the same time. The relationship between the factors that

influence the implementation of nursing process in management of patients with mental

disorders was established.

3.2 Study Setting

The study was conducted at Mathari National Teaching and Referral Hospital which its

primary function is to offer services to individuals with mental disorders. The hospital is

situated on Thika super highway opposite Muthaiga police station, about six Kilometers

north of Nairobi City Centre as per appendix I. The hospital was established in 1910 by

the colonial government. The hospital has several wards which include six male wards,

four female wards, an amenity ward, infirmary ward and a drug rehabilitation center. Its

core services include giving pharmacological, psychological and electroconvulsive

treatment. The services are either on outpatient or inpatient basis. The outpatient services

cater for the patients with mental disorders requiring review and/or have a mild illness.

The inpatient service caters for the seriously sick patients, patients dangerous to self or to

others or patients who lack insight and hence require hospital supervision in taking of

medications. The facility has a bed capacity of seven hundred (700) yet the inpatient

population is at nine hundred and ninety seven (997), indicating some patients shared a

single bed. Due to the high population of patient, one nurse takes care of approximately

90 patients at night a ratio way above global standards of one nurse to six patients which

necessitated the study

3.3 Study Population

The study population comprised of nurses involved in the management of in-patients with

mental disorders. All the nurses who are in direct care of patients with mental disorders

were legible for the study. The key informants for the interview were nurse managers and

departmental heads at the facility.

3.3.1 Inclusion Criteria

All nurses working as clinical nurse practitioners, managers or nurse educators in the

mental health units/institutions, or nursing services unit/ward managers at the time of

study who consented to participate in the study.

3.3.2 Exclusion Criteria

Nurses working in the outpatient clinics were excluded from the study as they do not

spend adequate time with the patients to completely undertake the nursing process

implementation. The nurses on study or annual leave and those who did not consent were

excluded from the study as well. Also, the post basic students of RN/MH were excluded

in the study.

3.4 Sample Size Determination

The sample size for the study was determined using the Fisher et al (1999) formula. This

Sample Size Determination technique is termed to be the most appropriate for the study

as it yields a representative sample for proportions (Chow, et al, 2017).

Whereby n is the sample size desired, z entails the normal standard deviation based at the

95% confidence interval (1.6), whereas p entails the prevalence of those with knowledge

of NP who have the desired characters in the study and d is the standard error at 95%

confidence interval while p was assumed to be 50% since the prevalence is not known.

q is (1-p) which is 1-0.5=0.5

Therefore n= {(3.24) ² 0.05 0.5}/ 0.05²

n= 384

Due to the population being not more than 10,000 the alternative formula was employed;

Whereby nf is the sample size being desired (population not more than10, 000); n is

sample size desired (population exceeding 10,000) and N is the population estimate

which is 250 nurses

Hence;

This translates to 151 respondents who were selected using stratified random sampling as

shown below;

Table 3.1 Sampled Nurses according to Wards

Ward Proportion of

Respondents

Total

Female wards 90 x 151

250

Male wards 108 x 151

250

Infirmary Ward 22 x 151

250

Drug Rehabilitation Center 30 x 151

250

TOTAL 151

For the qualitative study, the sample size for the key informants was defined using data

saturation where by approximately 12 to 30 respondents are involved (Polit and Beck,

2012). This involved concurrent sampling, data collection and data analysis until no new

themes on Nursing Process emerged. The saturation thus is used as a criterion through

which data collection/analysis is discontinued whereby failure to attain saturation impacts

on the research conducted. Use of the concept of data saturation is supported by

proponents of qualitative research such as Merriam, (2015) and Cope, (2014).

3.5 Sampling Technique

For the quantitative study, simple random sampling technique was used. The random

sampling technique ensured every subject meeting the inclusion criteria is randomly

selected until the desired sample of 151 respondents achieved (Mathieson, 2014).

Random sampling is preferred as it minimizes biasness in the responses as it ensures

equal representation of the entire study population. Simple random technique was

undertaken without replacement as each nurse who met the inclusion criteria had the

same probability of being selected.

The researcher wrote Yes and No on small pieces of paper which were then folded,

placed in a basket, shaken and each nurse allowed to pick one. All the nurses on each

working shift were requested to pick a paper randomly from the basket. Those nurses

who picked Yes were then included as the sample size while those who picked No were

excluded from the study. For qualitative study, purposively sampling was used whereby

the nursing service unit managers were selected. The main goal of purposive sampling

was to focus on particular characteristics of a population of interest, which was best

enabled to answer the research questions. As such, total of 12 respondents were

purposively selected to participate in qualitative study.

3.6 Data Collection Instruments

3.6.1 Questionnaires

The questionnaire was structured into sections; each section addressing a specific

research objective as per appendix IV. The questionnaire contained both open ended and

close ended questions to ensure comprehensive data collection. The questionnaire was

preferred as it is the most widely used data collection method and was the most efficient

way of collecting responses from a large sample prior to analysis. The questionnaire was

developed after the researcher reviewed the relevant literature pertaining to the study.

3.6.2 Interview Guide

The interviews aided in the collection of qualitative data. The interview was structured

using leading questions directed towards each of the specific objectives of the study as

per appendix V. The use of interview was preferred as it enabled the respondents to

express in detail the study phenomena. The key informants for the interview were nurse

managers and departmental heads at the facility. This enabled the study to be subjective

to obtain institution’s perspective concerning the study topic. Interview responses were

audio recorded.

3.6.3 Checklist

The researcher used a checklist with indicators of nursing process to extract data from the

patient’s files. The checklist had items on work environment, comprehensive assessment,

completion of patient charts and utilization of the nursing care plan as per appendix VI.

The information was extracted from patient’s files and only for the files of patients who

have been in the hospital for a period of not less than 48 hours. This was enough time to

have allowed interaction of the nurse and patient thus enabling utilization of nursing

process in patient care. The Importance of the observation checklist was to enable capture

information on the phenomenon understudy from the researcher’s point of view as well

as complementing the interviews and questionnaires. This is essential in any particular

research as the respondents may not be able to fully indicate all aspects of the study. The

files were protected from unauthorized personnel and locked up in a cabinet for security

purpose.

3.7 Data Collection Procedure

The questionnaires were administered directly to the respondents with the aid of two

research assistants. The research assistants underwent training to be well equipped with

adequate knowledge on how to approach and handle the respondents and to ensure

comprehensive data collection. The researcher and research assistants distributed the

copies of questionnaire for nurses. The respondents were asked to complete and return

the questionnaire to the researcher or the research assistants. The questionnaire copies

were serialized to ensure respondent anonymity.

Qualitative data on the other hand was collected using interviews which enabled the

researcher to acquire information on perspectives of the nurses. The interviews on the

other hand were conducted by the researcher and took approximately 20-30 minutes per

interviewee. This enables the researcher to acquire in depth information which would not

be possible if a questionnaire alone was used (Polit and Beck, 2012). The data collected

was audio recorded using tape recorders which was then transcribed. Privacy was ensured

by conducting the interview in an enclosed place or in any other place the respondent felt

comfortable with. Once this process was complete, the original tape-recording and the

transcribed interview were stored in a secure place and only accessible to the researcher.

3.8 Data Quality Management

Quality research refers to the scientific process encompassing all aspects of study design

and protection against systematic bias, non-systematic bias, and inferential error (Patten

& Mildred, 2016). To assure data quality, training and orientation were given to the

research assistants by the principal researcher. The data collection instruments were

pretested on 5% of the participants one week prior to the actual data collection in

MNTRH. These respondents selected for the study however were not part of the actual

study. The importance of the pre-test is to enable the researcher to familiarise themselves

with the study and access the efficiency of the data collection instruments (Mugenda &

Mugenda, 2012). The outcomes of the pre-test were used in assessing the reliability and

validity of the data collection instruments. Necessary corrections and adjustments were

then considered. During data collection, the data was checked for completeness and

missing information at each point. Data was also checked during entry and compilation

before commencement of analysis. The results of the reliability test obtained as shown by

Table 3.2 implies that all the variables had Cronbach Alpha of greater than 0.7 hence

implying that the research instruments were reliable in carrying out the study.

Table 3.2 Reliability Analysis

Variable

Cronbach's

Alpha

Items

Decision

Nurse-Related Factors Cronbach Alpha>0.7,

0.754 8 acceptable

Cronbach Alpha>0.7,

Patient-Related Factors 0.776 7 acceptable

Cronbach Alpha>0.7,

Hospital-Related Factors 0.702 4 acceptable

Nursing Process Cronbach Alpha>0.7,

Implementation 0.706 4 acceptable

3.9 Data management and analysis

3.9.1 Data Management

Data sources for the study included questionnaires, interview transcripts and checklist

notes. All the collected data were stored in a research file in the computer for data storage

purposes and access only restricted to the principal researcher. To protect the

respondents' confidentiality, all the identifying information were removed and replaced

with a text identification label which was used to represent individual participant. The

collected data will be securely stored for a period of 5 years before being permanently

destroyed.

3.9.2 Data Analysis

The data collection instruments yielded both quantitative and qualitative data.

Quantitative data were analysed using descriptive statistics which included measures of

central tendency such as frequencies, percentages, means and standard deviations. After

the completion of the data collection process, the collected questionnaires were first

examined for completeness. The questionnaires were then coded. Categorical data were

then subject to inferential statistics using Pearson’s’ Chi Square test to determine possible

relationships between the factors influencing NP implementation and the predicted

estimates and P values of 0.05 or less were considered significant.

The data were then presented in tables, graphs, and charts. Quantitative data from the

observation checklist on the other hand were analysed through noting of similar trends

and presented in summary form. Qualitative data were from the recorded information

from interview sessions. The recorded audio tapes were listened to several times,

transcribed and then interpreted independently. This was followed by thematic analysis.

The qualitative data were presented in narrations. Discussion were then done which

integrated both the qualitative and quantitative data which enabled valid conclusions to

be made thereafter.

3.10 Operationalization of Variables

Operationalization involves finding measurable, quantifiable, and valid indent for the

entire research variable and the independent and dependent variables that will aid in the

analysis of study findings. The operationalization of the study variables is shown by

Table 3.3

Table 3.3: Operationalization of Variables

Variable Indicator Measuring of

Indicators

Tools of

analysis

Type of

analysis

Independent Structural •Organization Percentages Descriptive

Factors structure

• Support

Frequencies statistics

• Policies

• Resources

Independent Process Factors •Nurses’ Percentages Descriptive

Competencies

• Nurses’ Experience

Mean score statistics

•Attitude

• Perceptions

• Nursing processes

Independent Factors •Policy Frameworks Percentages Descriptive

hindering

Dependent Nursing

Process

Practice

• Usability of

the NPs

• Adaptability of NPs

• Acceptability of NP

•Patient Compliance

•Approach to patients

including assessment

data(history taking.

p/e, and

investigations done)

•Documentation

quality

• Increased reflective

thinking with

appropriate specific

interventions

• Formulation of

care plans with

seven components

•Proper Nursing

Diagnosis with

minimum of three

cues and three parts

Mean score

Percentages

Mean score

statistics

Descriptive

statistics

3.11 Ethical Considerations

The researcher ensured that participant's autonomy was maintained. To protect the

rights and welfare of participants and minimize risk of discomfort, harm or dangers

from research procedures, ethical clearance was sought from KNH and UoN Research

Ethics Committee. The researcher also obtained permission from the management of

the MNTRH. Consent form was explained and signed prior to the collection of data.

Subjects were allowed to leave the study at any point or not to participate at all if they

so wish. Absolute confidentiality and anonymity of the participants was maintained

throughout the study. Participants did not require to indicate their names or any other

identifying details.

The researcher ensured that participant’s autonomy was maintained. Information was

not obtained through coercion, deception or use of incentives. The study sought

consent for voice recording and make the respondents fully aware of its relevance.

Since the study was aimed at getting insight about a given phenomenon, there was

neither anticipated nor actual risks of harm to the study participants. The rights and

concerns of the subjects were given priority and confidentiality was maintained

during the research. Neither incentives nor compensation were given the nurses

participating in the study as it was conducted based on their normal routines. All

information obtained during the study was treated with outmost confidentiality.

3.12 Study Limitations

The major limitation in the study was the sample size as the entire population was not

used for the study. The responses obtained were limited to only the opinion of a

proportion of the participants. The study was only able to describe the selected factors

influencing NP implementation which may not be an exhaustive list of the available

factors. The researcher however ensured that the data collection instruments were

reliable and valid in collecting all the required information. Additionally, the study

was only conducted at Mathari Teaching and Referral Hospital thus giving a picture

of only one Hospital. Despite this limitations, the researcher ensured comprehensive

data collection through ensuring that the data collection instruments were both valid

and accurate which enabled generalizability of the findings of the study.

3.13 Dissemination Plan

The result will be disseminated to the University of Nairobi, mental health unit of

MTRH and the Ministry of health. Further dissemination shall be through publications

and report prints.

CHAPTER FOUR: RESULTS

4.1 Introduction

This chapter presents the results of the data collected, analysed and interpreted by the

researcher organized by specific research objectives. The aim of the research was to

establish the factors that influence implementation of the nursing process in the

management of patients with mental disorders in Mathari National Teaching and

Referral Hospital. It comprises of the socio-demographic characteristics of the

respondents, utilization of NP at MNTRH and finalizes with the structural and process

factors influencing the implementation of NP at MNTRH. Out of the 151

questionnaires that were issued out, 112 questionnaires were duly filled and returned

translating to a response rate of 74%.

4.2 Socio-Demographic Characteristics

4.2.1 Gender of Respondents

As shown by Figure 4.1, 81% (n=91) were female while 19% (n=21) were male. This

implies that there was a higher female dominance among the nurse’s respondents that

took part in the study. However, there were responses from both genders hence no

biasness in the findings obtained.

Figure 4.1 Gender of Respondent

Gender of Respondents

19%

Male Female

81%

4.2.2 Age of Respondents

Most the respondents 31% (n=34) were between the ages of 51-60 and only 11%

(n=12) were less than 30 years as shown in Figure 4.2. This implies that majority of

the respondents 58% (n=65) were above 40 years indicating that they were mature

hence provided reliable information.

Figure 4.2 Respondents Age

4.2.3 Marital status of Respondents

As shown by Figure 4.3 indicated that majority of the respondents 66% (n=74) were

married with only 5% (n=6) either widowed or divorced.

Figure 4. 3 Marital Status of Respondents

35%

Respondents Age

31%31%

30%

25% 22%

20%

15% 11%

10%

21-30 31-40 41-50 51-60 more than 60

Percentage

4.2.4 Academic qualification(s) of Respondents

The academic qualification of the respondents was measured by the highest education

levels attained. As shown by Table 4.1, most of the respondents 50% (n=56) had

Bachelor degree in Nursing and only 10% (n=11) had Diploma in Community Health

nursing. This implies that majority of the respondents 78% (n=87) had either bachelor

degree or higher diplomas in mental health and psychiatric Nursing hence well

qualified for their respective positions at MNTRH.

Table 4. 1 Education Level of Respondents

Highest Education Level Frequency Percentage

Bsc Nursing 56 50%

Diploma in Community Health Nursing 11 10%

Diploma in Mental Health /Psychiatric Nursing

Higher Diploma in Mental health/Psychiatric

Nursing

13%

28%

Total 112 100%

4.2.5 Work experience of Respondents

As shown by Table 4.2, majority of the respondents 55% (n=61) had work experience

of over 15 years while only 27% (n=30) had under 10 years’ experience as per Table

4.2. This implies that the respondents had worked for a considerable length of time

hence well conversant with the study topic on Nursing Process implementation.

Table 4.2 Work experience of Respondents

Years Worked Frequency Percentage

Below 5 years 22 20%

5-10 years 8 7%

11-15 years 21 19%

16-20 years 29 26%

21-25 years 10 9%

26-30 years 13 12%

Above 30 years 9 8%

Total 112 100%

4.2.6 Designation(s) of Respondents

As shown by Table 4.3, most of the respondent 49% (n=55) were registered nurses

while 13% (n=14) were principal nursing officers. This implies that there majority of

the respondents were registered nurses and senior registered nurses 61% (n=69) hence

affirming the respondents’ appropriateness for taking part in the study.

Table 4. 3 Designation(s) of Respondents

Designation Frequency Percentage

Registered Nurse 55 49%

KRCHN 24 21%

Senior Registered Nurse 19 17%

Principal Nursing Officer 14 13%

Total 112 100%

4.2.7 Respondents Duties

This section aimed at determining the respective duties in which the respondents were

involved in. As shown by Figure 4.4, majority of the 55% (n=62) took part in patient

care and only 13% (n=14) took part in administration activities. This indicates that

there was representation of respondents involved in patient care, care planning and

also administration hence facilitating comprehensive data collection on the nursing

process implementation phenomenon at MNTRH.

Figure 4.4 Respondents Duties

4.3 Utilization of nursing process in management of patients

The study sought to determine the level of utilization of nursing process in

management of patients with mental disorders in Mathari National Teaching and

Referral Hospital. This was undertaken by observing the patient files on whether NP

had been utilized in delivery of patient care. From the interview responses, the NP

stages followed at MNTRH were indicated to be assessment, formulation of nursing

diagnosis, planning, implementation, evaluation and documentation. However, other

respondents argued that they can’t remember the exact systematic sequence of NP

which indicated low knowledge levels of NP stages. While others argued that not all

the stages of NP were fully completed with stages such as interventions,

documentation and evaluation not being comprehensively done

The observation checklist was further utilized in determining utilization of NP in

management of patients having mental disorders at MNTRH. Specifically, three

aspects were used in determination of NP utilization namely; patient assessment,

availability of a nursing care plan and proper documentation. Presence of 50% and

above of the items in the checklist was indicative of NP utilization. The main

Respondent Duties

13%

32% 55%

Patient care

Care planning

Administration

indicators of assessment investigated by the study included identification and

demographic data, history taking, presenting complaints and duration, history of

present illness, past psychiatric history, family history, personal history and premorbid

personality. Out of the 30 patient files examined, only 18 had at least 50% of the

assessment measures investigated. This translate to a 60% assessment level which

implies an above average extent of utilization as shown by Table 4.4.

Availability of a nurse care plan (NCP) was used in assessing the utilization of the

other phases of NP. A nurse care plan describes the nursing diagnoses listed in order

of priority, goals and outcome criteria, plan of action /intervention, implemented

action and evaluation. Out of the 30 patient files examined only 12 of them had

complete nursing care plans translating to 40% which is a very low extent of

utilization of nurse care plans as shown by Table 4.4. The interviewees further pointed

out NP implementation at MNTRH was not fully successful with the only

approximately 25-40% success levels.

Documentation on the other hand was measured using appropriate completion of

patient charts, fluid flow sheets, nurse’s cardex and NCP for inclusion of all relevant

information stated as implemented in the NCP. Out of the 30 patient files investigated

only 16 of them were found out to have proper and complete documentation. This

translates to a frequency percentage of 53% implying a moderate extent of

documentation of the NP as shown by Table 4.4. Most the constructs were observed

to be missing and only present in few files showing that completion of NP

documentation by the nurses at MNTRH was still relatively low.

Table 4. 4 Utilization of nursing process in management of patients

Nursing Process Phase Utilization Number of files

Examined

Frequency Percentage

Availability of Patient Assessment 30 18 60%

Availability of a nurse care plan 30 12 40%

(NCP)

Proper Documentation 30 16 53%

4.4 Structural factors influencing the implementation of nursing process in

management of patients with mental disorders in Mathari National Teaching

and Referral Hospital

The study aimed in establishing the structural factors influencing the implementation

of nursing process in management of patients with mental disorders in Mathari

National Teaching and Referral Hospital. The study found two main structural factors

influencing nursing process implementation namely patient-related factors and

hospital-related factors.

4.4.1 Hospital-related determinants to NP implementation

Four measures of hospital related factors were investigated by the study this included;

recognition of the NP framework by the hospitals, support of NP implementation,

monitoring of the NP process and monitoring of the NP process. On recognition of

nursing process as a framework of nursing care delivery by the hospital, majority of

the respondents 91% (n=102) agreed while only 9% (n=10) disagreed as shown by

Figure 4.5. This is an indication that the hospital was aware of the need and

importance of nursing process in delivery of good patient care.

Figure 4. 5 Recognition of NP by Hospital Management

On the Hospital administration support towards the implementation of NP, 57%

(n=64) of the respondents disagreed while 43% (n=48) agreed as shown by Figure

4.6. This means that there was minimal support provided by the hospital

administration towards the implementation of NP at MNTRH. The interviewees

Yes No

91%

unanimously agreed that the hospital administration provided minimal to no support

at all to the implementation of NP. This was indicated to result in no motivation

among the nurses to continuously implement NP in the daily routines in the patient

management care.

Figure 4. 6 Support of NP Implementation by Hospital Administration

On monitoring of implementation of nursing process by hospital administration, the

findings obtained as shown by Figure 4.7 indicated that 64% (n=72) of the

respondents disagreed with 36% (n=40) negating the statement. This implies that

there was low monitoring geared towards ensuring effective implementation of NP at

MNTRH.

Figure 4. 7 Monitoring of NP Implementation by Hospital Administration

36%

Yes No

64%

43%

57%

Yes

A Likert Scale was further employed in establishing the extent hospital-related factors

that influence NP implementations at MNTRH. The findings obtained as presented by

Table 4.8 indicate that majority of the respondents 77% (n=86) agreed on no follow

up by the authorities, having a mean of 4.02. On failure of the hospital administration

to prioritize the NP formulation and implementation plans, majority of the

respondents 77% (n=86) also agreed with a mean of 4.17. Majority of the respondents

86% (n=96) also agreed on there is no adequate budgetary and financial allocation

towards the NP implementations with a mean of 4.37. The respondents 48% were

neutral on the nurses not being well trained and developed with a mean of 3.54.

However, majority of the respondents disagreed 59% (n=66) on neglect being given

towards the psychiatric nurses as compared to the general nurses having a mean of

2.49. The respondents also disagreed 47% (n=53) on the hospital ruling on non-

implementation of NP with a mean of 3.18.

Overall, Hospital-related factors of NP implementation had an average mean score of

3.79 and standard deviation of 0.8463 which implied a large extent (mean>3.75) of

influence on NP implementation at MNTRH. The results of the Chi square test of

significance as shown by Appendix VII further indicated that hospital-related factors

had a p-value of 0.000<0.05 which implies it had a positive and significant influence

on implementation of Nursing Process at MNTRH as the p-value was less than 0.05.

Therefore a unit change in these hospital-related factors will translate in a unit change

in the level of NP implementation at MNTRH.

Table 4. 5 Hospital-related determinants to NP implementation

Hospital related Factors S

D N A

Std.

Dev

No follow up by the authorities 4 7 13 34 42 4.0 0.89

% % % % %

2 14

Hospital rules in non-implementation of NP 1 47 16 30 5 3.1 0.97

% % % % %

8 78

Failure to priorities the NP formulation and 4 7 11 22 55 4.1 1.12

implementation plans

% % % % %

7 99

The nurses are not well trained and developed 4 7 48 24 16 3.5 0.62

% % % % %

4 24

Neglect is given towards the psychiatric nurses 30 29 20 13 8 2.4 0.24

as compared to the general nurses

% % % % %

9 11

There is no adequate budgetary and financial 1 5 8 28 58 4.3 1.21

allocation towards the NP implementations

% % % % %

7 48

Mean Score 3.7 0.84

9 63

SD=Strongly Disagree, D=Disagree, N=Neutral, A=Agree and SA=Strongly Agree

4.4.2 Patient-related determinants to NP implementation

The study investigated the various patient-related factors which influenced NP

implementation including the patient-nurse ratio, patient compliance and variation of

NP outcomes amongst patients. From the interviews, it was found out that the patient-

nurse ratio ranged from 1 nurse: 20 patients to 1 nurse to 30 patients with the number

increasing at night. This shows a high workload regarding the number patients to be

attended to. The interviewees stated that patient-nurse ratio is a huge determinant on

the amount of time spent per patient as well as the extent of individualized treatment

provided. It was also noted that patient compliance was one of the major factors

determining the implementation efficiency of NP at MNTRH. Patient compliance

refers to the willingness and corporation of the patient towards assistance or medical

intervention by the nurses. Without patient compliance, the respondents unanimously

agreed that NP implementation was not possible. It was therefore indicated that prior

to the start of the NP it was essential for the nurse to establish a rapport with the

patient and gain their trust failure to which they would experience difficulties in

executing all the phases of the nursing process.

On the variations of NP outcomes amongst patients, 27% (n=30) stated an above

moderate extent, 33% (n=37) stated a moderate extent while 40% (n=45) stated a

below average extent as shown by Table 4.6. This shows that there was still

inconclusiveness on the exact extent of NP outcomes amongst patients from the

respondent’s perspective.

Table 4. 6 Variation of NP outcomes amongst patients

Extent Frequency Percentage

Very great extent 12 11%

Great extent 18 16%

Moderate extent 37 33%

Small extent 16 14%

Very small extent 29 26%

Total 112 100%

A Likert Scale was further employed in establishing the extent patient-related factors

that influence NP implementations at MNTRH. The findings obtained as presented by

Table 4.7 indicate that majority of the respondents 53% (n=59) strongly agreed on

evaluation of the patient could be difficult to perform if the steps of the nursing

process are not well followed with a mean of 4.35. On a high number of patient

causing a challenge in ensuring adequate time allocation for the NP implementation,

42% (n=47) of the respondents agreed and 35% (n=39) strongly agreed having a mean

of 4.12. On every patient being unique and needing an individualized care plan thus

causing problems in the NP implementation, 29% (n=32) of the respondents agreed

and 43% (n=48) strongly agreed having a mean of 4.04. On difficulties in collecting

and recording all the patient’s information 30% (n=33.6) of the respondents agreed

and 31% (n=34) strongly agreed having a mean of 3.77.

On barriers in evaluating progress towards goals, 32% (n=35) of the respondents

agreed having a mean of 3.25. On patients do not make progress because NPs are not

well implemented, 32% (n=35) of the respondents agreed and 16% strongly agreed

having a mean of 3.51. However, on patient refusal to cooperate, 46% (n=51) of the

respondents were neutral. Overall, the patient related factors were established to have

a large extent of influence (mean >3.75) on the implementation of nursing process at

Mathari National Teaching and Referral Hospital having a mean of 3.76 and standard

deviation of 0.7271. The results of the Chi square test of significance as shown by

Appendix VII further indicate that patient-related factors had a p-value of 0.000<0.05

which implies it had a positive and significant influence on implementation of

Nursing Process at MNTRH as the p-value was less than 0.05.

Table 4. 7 Patient-related determinants influencing NP implementation

Patient Related S

DNAS

Std.

Dev

Difficulties in collecting and recording all the 6 4 2 3 3 3. 0.67

patient’s information % % 9

77 46

Every patient is unique and will need an 1 8 2 2 4 4. 0.86

individualized care plan, causing problems in the NP

implementation

% % 0

04 59

Patients do not make progress because NPs are not 2 1 4 3 1 3. 0.57

well implemented. % 0

51 62

High number of patient causes a challenge in 0 0 2 4 3 4. 0.85

ensuring adequate time allocation for the NP

implementation

% % 3

12 81

Patient refusal to cooperate 5 1 4 2 1 3. 0.53

% 2

29 02

Evaluation of the patient could be difficult to 0 0 1 2 5 4. 1.09

perform if the steps of the nursing process are not

well followed

% % 8

35 91

Barriers in evaluating progress towards goals 1 1 3 3 1 3. 0.48

25 52

Mean Score 3. 0.72

76 71

SD=Strongly Disagree, D=Disagree, N=Neutral, A=Agree and SA=Strongly Agree

Theme: Structural factors influencing NP implementation

Based on the responses from the interview, the main structural related factors that

influenced NP implementation at MNTRH were grouped into the following sub-

thematic areas which included patient-nurse ration, patient compliance, varying

patient needs and corporation with the patient family members, hospital

administration, under staffing of the nurses, inadequate resources and lack of

appropriate frameworks for monitoring and evaluation of NP implementation.

Sub-theme: Patent-Nurse Ratio

From the interviews, it was found out that the patient-nurse ratio ranged from 1 nurse:

20 patients to 1 nurse to 30 patients with the number increasing at night. This shows a

high workload regarding the number patients to be attended to. The interviewees

stated that patient-nurse ratio is a huge determinant on the amount of time spent per

patient as well as the extent of individualized treatment provided. An interviewee

further added that;

“The high patient-nurse ratio at MNTRH tends to discourage most of the

nurse from utilizing the NP in patient care. This is attributed to the fact that

the large number of patients required to be attended to make it impossible to

follow all the steps of NP at all the times. Though the number reduces

substantially when there are RN/MH students around, the number is still high.

This results in only the steps of NP which are perceived to be most

„beneficial‟ being followed by the nurses.” (Respondent 2)

Sub-theme: Patient Compliance

It was noted that patient compliance was one of the major factors determining the

implementation efficiency of NP at MNTRH. Patient compliance refers to the

willingness and corporation of the patient towards assistance or medical intervention

by the nurses. Without patient compliance, the respondents unanimously agreed that

NP implementation was not possible. It was therefore indicated that prior to the start

of the NP it was essential for the nurse to establish a rapport with the patient and gain

their trust failure to which they would experience difficulties in executing all the

phases of the nursing process.

Sub-theme: Varying Patient Needs

From the interviews, it was established that the patient have varying medical needs

based on the degree and severity of the medical conditions. An interviewee indicated

that;

“Some patients require very minimal medical interventions due to their

medical conditions being less severe. They therefore tend to be less demanding

medical wise which makes it easier for the nurses to extensively utilize the NP

in coming up with the appropriate medical diagnosis. However, others may

have complicated or more demanding medical condition which require prompt

interventions with the NP not being able to provide any fast assistance. ”

(Respondent, 10)

Sub-theme: Corporation with the Patient Family Members

The respondents further argued that some of the family members of the patients may

not be willing to cooperate with the nurses in ensuring prompt recovery of the

patients. As such, it was noted that;

“Family members of some patients may tend not to provide no additional

support to the family members. They see the role of patient management to be

the sole responsibility and do not perceive any relevance in providing

assistance. In this regard, they do not offer to do basic activities such as

advising the patient to be compliant to the nurse‟s interventions, bringing the

patient to the facility in time and ensuring completing of the recommended

treatment which tends to be a huge drawback towards NP implementation.”

(Respondent, 7).

Hospital Administration Support

The interviewees unanimously agreed that the hospital administration provided

minimal to no support at all to the implementation of NP. This was indicated to result

in no motivation among the nurses to continuously implement NP in the daily routines

in the patient management care. Specifically, an interviewee noted;

“When Nursing Process was first introduced at MNTRH, the management was willing

to fully support its implementation in whichever way possible. However, as the time

progresses the support given towards NP has diminished substantially which acts a

discouraging factor for both the nurses and the nursing officers as its relevance in

improving patient care is not fully appreciated.”(Respondent, 6)

Sub-theme: Staffing of Nurses

The respondents all agreed that the number of nurses recruited and deployed into the

wards for patient management and care was a huge contributing factor for the success

of NP implementation. This was argued to be largely because it determines not only

the attention given to each patient but also the nurses’ output and burnout. Low

staffing was therefore established from the interviews to be a great barrier but yet a

common occurrence at MNTRH which acts to reduce effectiveness of NP

implementation. An interviewee indicated that;

“The number of nurses employed by the national government is really small

compared to the huge patient number. This has been going on for several years now

(since when I joined the hospital in 2010) with most of the nurses constantly

complaining. Due to the low number of nurses present, most of the nurses tend to

forego the NP and adopt „shortcuts‟ which enable them serve more patients within a

shorter time. Also others practice the NP minimally so as not to tire out faster and

prevent themselves from being overwhelmed by their duties.”(Respondent, 2)

Sub-theme: Resources Provided

From the interview responses it was revealed that the amount of resources provided or

channeled towards the nursing process implementation is a huge contributor towards

the extent of implementation. An interviewee explained that;

“Equipment such as stationary for the documentation process and adequate drugs for

patient treatment are one of the most basic requirements for NP implementation to

take place. However, in most cases, these resources are not always provided by the

hospital administration. Even in instances when they are provided, it‟s in only limited

quantities and only for a short period of time. The question then that rises among us

nurses is that if the hospital is really interested in achieving high and effective

implementation of the nursing process, why is there no adequate provision of

resources despite funds being allocated by the Ministry of Health?”(Respondent, 1)

Sub-theme: Monitoring and Evaluation of NP

The researcher also found out from the interviews that the extent of monitoring and

evaluation of NP was also another main factor influencing the implementation of the

process. Monitoring and evaluation entail the process of not only ensuring that the NP

was implemented but also accessing whether the intended outcomes of NP are

attained. An interviewee argued that;

“Regarding Monitoring and Evaluation of NP, there is minimal monitoring and

supervision towards the process. Even if happens, it is always periodically after a

very long time. This results in reluctance among the nursing staff to always adhere to

the NP as they perceive to face no dire consequences if they don‟t strictly follow it.

Without proper monitoring and evaluation it is hard to tell whether Np has been

comprehensively implemented at MNTRH and whether it has had any positive

significance to patient care and outcomes.”(Respondent, 5).

4.5 Process factors influencing the implementation of nursing process in

management of patients with mental disorders in Mathari National Teaching

and Referral Hospital

The study sought to determine the process factors influencing the implementation of

nursing process in management of patients with mental disorders in Mathari National

Teaching and Referral Hospital. Specifically, the study investigated nurse related

factors which included the respondents’ understanding of NP, training on NP and

general attitude of the staff on NP.

4.5.1 Respondents understanding of NP

On the respondents’ understanding of NP, the findings obtained indicated that only

minority of the respondents 28% (n=31) indicated an above average extent of

understanding of NP with 46%(n=52) stated a below average extent of understanding

as shown by Table 4.8 This implies that most of the respondents at MNTRH were yet

to fully understand the relevance and application of NP in patient management and

care.

Table 4. 8 Respondents understanding of NP

Extent of understanding Frequency Percentage

Very good 12 11%

Good 19 17%

Average 29 26%

Poor 37 33%

Very poor 15 13%

Total 112 100%

4.5.2 Respondents training on NP

On whether the respondents had undergone trainings on nursing process, majority of

the respondents 60% (n=67) were affirmative while only 40% (n=45) negated as

shown by Figure 4.8. This shows that a considerable number of the respondents were

well equipped in NP training. The trainings were stated by the respondents to be

undertaken during their course work studies, on job trainings, and workshops.

Figure 4. 8 Nursing Process Training

4.5.3 General attitude of the nurse staffs towards NP

Regarding the general attitude of the nurse staffs towards NP the results obtained

revealed that only a small proportion of the respondents 33% (n=34) had a good and

very good attitude towards the NP while 47% (n=53) had poor and very poor attitude

towards NP as shown by Table 4.9. From the responses from the interviews, it was

Nursing Process

Training

40% Yes

60%

revealed that majority of the nurses at MNTRH portrayed negligence towards NP

implementation which had a negative adverse effect.

Table 4. 9 Attitude of the nurse staffs towards NP

Frequency Percentage

Very good 12 11%

Good 22 20%

Average 25 22%

Poor 33 29%

Very poor 20 18%

112 100%

4.5.4 Nurse-related Factors that influence NP implementations

This section sought at determining the nurse-related factors that influence NP

implementations at MNTRH. To achieve this, a Likert Scale analysis of 1-5 was

employed in rating the responses whereby; 1=Strongly Disagree, 2=Disagree,

3=Neutral, 4=Agree and 5=Strongly Agree. The findings obtained are presented by

Table 4.10.

Table 4. 10 Nurse-related Factors influencing NP implementation

Nurse Related SD

D N A

SA Mea

Std.

Dev

Care plans are not usually discussed 6% 9% 6% 36 43 4.00 0.935

with the patient

% %

Formulating nursing diagnosis 9% 20 45 18 9% 2.98 0.470

should not be mandatory

% % %

In patient care there should be less 45 11 7% 25 13 2.50 0.328

writing and more action.

% % % %

Nursing care plan should be drawn 29 19 23 17 12 2.63 0.181

for the very sick patients only

% % % % %

Nursing instructions on a care plan 15 29 21 19 17 2.94 0.267

often bear very little relation to what

the nurse actually does

% % % % %

Nursing process is cumber some 8% 11 6% 21 54 4.02 1.091

% % %

Nursing process is not be applied to 20 9% 14 21 36 3.45 0.671

all patients

% % % %

The care plan plays no significant 30 29 11 21 9% 2.50 0.226

part in the provision and evaluation

of care.

% % % %

The nurses have adequate expertise 3% 30 38 19 10 3.03 0.408

to undertake the NP

% % % %

There has been well acceptance of 6% 10 53 29 2% 3.11 0.708

the NP practices

% % %

Use of nursing care plans enables a 7% 11 7% 28 47 3.97 0.970

nurse to establish priorities of care

% % %

Writing a care plan is a burden 4% 9% 20 30 38 3.87 0.755

% % %

Mean Score 3.25 0.548

SD=Strongly Disagree, D=Disagree, N=Neutral, A=Agree and SA=Strongly Agree

As shown by Table 4.10, majority of the respondents 54% (n=60) strongly agreed on

the nursing process being cumbersome with a mean of 4.02. On Care plans not

usually being discussed with the patient, 36% (n=40) of the respondents agreed while

43% (n=48) strongly agreed with a mean of 4.00. On use of nursing care plans

enables a nurse to establish priorities of care, 28% (n=31) of the respondents agreed

while 47% (n=53) strongly agreed with a mean of 3.97. On writing care being a

burden, 30% (n=33) of the respondents agreed while 38% (n=42) strongly agreed

having a mean of 3.87. On the Nursing process not being applied to all patients, 21%

(n=24) of the respondents agreed and 36% (n=40) strongly agreed having a mean of

3.45.

The respondents were neutral on nurses having adequate expertise to undertake the

NP, there has been well acceptance of the NP practices, nursing instructions on a care

plan often bear very little relation to what the nurse actually does and formulating

nursing diagnosis should not be mandatory having means of 3.03, 3.11, 2.94, and 2.98

respectively. On in patient care there should be less writing and more action, 45%

(n=50) of the respondents strongly disagreed, On Nursing care plan should be drawn

for the very sick patients only, 29% (n=32) of the respondents strongly disagreed and

19% (n=21) agreed with a mean of 2.63.

While on care plan plays no significant part in the provision and evaluation of care

30% (n=33) of the respondents strongly disagreed and 29% (n=32) disagreed with a

mean of 2.50. Overall, nurse-related factors were established to have a moderate

effect (mean>3.0) on nursing process implementation at MNTRH having a mean of

3.25 and standard deviation of 0.5487. The results of the Chi square test of

significance as shown by Appendix VII further indicate that nurse-related factors had

a p-value of 0.035<0.05 which implies it had a positive and significant influence on

implementation of Nursing Process at MNTRH as the p-value was less than 0.05.

Theme: Process factors influencing NP Implementation

Based on the responses from the interview, the main nurse-related factors which

influenced nursing process implementation at MNTRH was organized into four sub-

thematic areas including, experience of the nurses, attitude and perception, negligence

of NP and Nursing Process Training.

Sub-theme: working experience of the nurses

The working experience of the nurses was noted to be a main determinant on the

nurses’ knowledge ability, ease of use and applicability of the nursing care in patient

management. It influenced the frequency of use of NP and the patient outcomes

obtained. An interviewee argued;

“The more experienced nurses are more familiar with the NP and therefore will tend

to more frequent utilize it to the latter without the need for any references. As

compared to the less experienced and recently graduated ones who though may have

the NP knowledge in most instances are not able to fully implement it. However, the

experienced nurses due to long durations of practice, may perceive some of the steps

of NP to be more important than others, hence tend to give more priority and time

towards these steps.” (Respondent, 3).

Sub-theme: Attitude and perceptions of Nurses towards NP

According to the respondents, the attitude and perception of the NP was also another

main factor contributed towards implementation of NP. This is attributed to the fact

that a positive perception towards the NP due to the benefits accrued from the process

was indicated to translate to higher levels of NP implementation. On the contrary,

poor attitude and bad perception towards NP was argued to lead in minimal utilization

and avoidance of the NP translating to low implementation levels of the NP at

MNTRH.

Sub-theme: Negligence of NP by Nurses

From the responses from the interviews, it was revealed that majority of the nurses at

MNTRH portrayed negligence towards NP implementation which had a negative

adverse effect. Specifically, an interviewee described;

“Some of the nurses tend to neglect the NP and its importance at MNTRH. This may

occur either intentionally or non-intentionally based on the situation. Intentional

negligence occurs when the nurse refrains from utilizing the NP such as when they

are fatigued while the unintentional negligence mostly occurs when there is a high

number of patients that ought to be attended to hence to save time. Also due to their

minimal support and supervisor on the NP implementation by the hospital

management, the nurses may see an avenue to avoid from using it in patient care.”

(Respondent, 12).

Sub-theme: Nursing Process Training

On the influence of nursing process training on nursing process implementation at

MNTRH, it was indicated that;

“The importance of Nursing Process cannot go unnoticed. It not only helps the nurses

understand the relevance of the nursing process in patient management but also be

aware with best ways to execute all the stages of NP. Though majority of the nurses

have undergone training of NP at one point of their careers, others still remain not to

be fully trained especially those who began the practice before the introduction of the

NP in the nursing curriculum. It is therefore important that more additional training,

workshops and seminars on NP to be frequently undertaken.”(Respondents 1, 11, 3

and 8).

CHAPTER FIVE: DISCUSSION

5.1 Utilization of nursing process in management of patients

The study sought to determine the utilization of NP in management of patients with

mental disorders in Mathari National Teaching and Referral Hospital. Specifically,

three aspects were used in determination of NP utilization namely; patient assessment,

availability of a nursing care plan and proper documentation. Out of the 30 patient

files examined, only 18 had at least 50% of the assessment measures investigated.

This translate to a 60% assessment level which implies an above average extent of

utilization of NP which tends to contradict Barasa, et al, (2017) who conducted a

study on nursing process in county hospitals in Kenya and established that patient

assessment was very low at less than 40%.

Availability of a nursing care plan (NCP) was used in assessing the utilization of the

other phases of NP including diagnosing, planning, implementing, and evaluation.

The patients had been in the wards for a period of not less than 48 hours. Out of the

30 patient files examined only 12 of them had well completed nursing care plans

translating to 40% which is a very low extent of utilization of nurse care plans.

Information on goal setting/outcome identification, evaluation data and incomplete

assessment cues were missing in most of the patients files. This compares with

Ndambuki, (2015) who studied NP implementation in Msambweni district hospital,

Kwale County and found out that practice of NP was still very low.

The interviewees further pointed out NP implementation at MNTRH was not fully

successful with the only approximately 25-40% success levels. This compares with

Aseratie, Murugan, and Molla, (2014) who assessed the Factors Affecting

Implementation of Nursing Process among Nurses in Selected Governmental

Hospitals, Addis Ababa, Ethiopia. They found out that utilization of NP in patient’s

care using NCP was still low in most of the government hospitals. This confirms that

most public hospitals were still faced with a challenge in NCP use.

Documentation on the other hand was measured using appropriate completion of

patient charts, flow sheets and NCP for inclusion of all relevant information stated as

implements in the NCP. Out of the 30 patient files investigated only 16 of them were

found out to have proper and complete documentation. This translates to a frequency

percentage of 53% implying a moderate extent of documentation of the NP. Most the

constructs were observed to be missing and only present in few files showing that

completion of NP documentation by the nurses at MNTRH was still relatively low.

Similarly, Mahmoud and Bayoumy (2014) established that the proper documentation

was a challenge still facing most nurses in implementing NPs in the hospitals.

5.2 Structural factors influencing the implementation of nursing process

The study aimed in establishing the structural factors influencing the implementation

of nursing process in management of patients with mental disorders in Mathari

National Teaching and Referral Hospital. The study found two main structural factors

influencing nursing process implementation namely patient-related factors and

hospital-related factors.

5.2.1 Patient related factors influencing implementation of nursing process

The study found out that high patient-nurse ratio, patient compliance and variation of

outcomes among patients were huge determinant of the utilization and

implementation of NP at MNTRH. Similarly, Mahmoud and Bayoumy (2014) in

their study observed most nurses complained that high patient workload was the most

significant barrier to NP implementation. These patient related factors were

established to have a large extent of influence (mean >3.75) on the implementation of

nursing process at Mathari National Teaching and Referral Hospital having a mean of

3.76 and standard deviation of 0.7271. This was supported by the results of the Chi

square test of significance where patient-related factors had a p-value of 0.000<0.05

was obtained which implies it had a positive and significant influence on

implementation of Nursing Process at MNTRH as the p-value was less than 0.05.

The positive influence is supported by Fisseha, et al, (2014) who indicated that the

patient’s compliance and corporation are the key factors to implementation of NP and

its success. In a similar way, Yeboah, (2017) in his study established that some

patients, may not be completely willing to provide the necessary information

pertaining to their medical condition causing difficulties in the diagnosis. Habermann

and Uys (2006) further established a significant effect and postulates that the NP may

not only be time consuming, due to specialized needs of the patients but also interfere

with the care of the patients’ needs.

5.2.2 Hospital-Related Factors influencing implementation of nursing process

The study found out that on the Hospital administration support towards the

implementation of NP, 64(57%) of the respondents disagreed while 48(43%) agreed

implying that there was minimal support provided by the hospital administration

towards the implementation of NP at MNTRH. This concurs with Munroe, Duffy and

Fisher (2010) also identified lack of administrative support as one factor affecting the

NP implementation. The study also found out that there was inadequate monitoring

and resource allocation geared towards NP implementation which was considered as a

huge barrier to the success of the implementation. Prince, Comas-Herrera, and

Karagiannidou (2016), also found out that the shortage of resources, inadequate

support from the hospital management and high workload among nurses are among

the critical obstacles to NP implementation in the management of patients with mental

disorders.

Overall, Hospital-related factors of NP implementation had an average mean score of

3.79 and standard deviation of 0.8463 which implied a large extent (mean>3.75) of

influence on NP implementation at MNTRH. This was supported by the Chi square

test of significance that indicated that hospital-related factors had a p-value of

0.000<0.05 which implies it had a positive and significant influence on

implementation of Nursing Process at MNTRH as the p-value was less than 0.05.

In a similar way, studies conducted have also established a positive effect of hospital

related factors on nursing process implementation. Provi Brown, Wickline, Eccof and

Glaser (2009) in their study discovered that organizational barriers such as lack of

nursing autonomy were top barriers to the use of evidenced base practice while

knowledge factor is a facilitator. This is similar to Schaefer (2010) who studied

nursing process and its determinant factors and established that the number of

workforce dedicated to wards nursing and management of the patients also acts to

greatly affect its level of implementation and sustainability (Marnseri, 2012). While

according to Prince, Coma-Herrera and Karagiannidou (2016), inadequate resources

acts a main determinant to NP implementation especially in the developing states.

These resources are in terms of insufficient finances, high workload, inadequate

workforce and shortage of physical resources.

5.3 Process factors influencing implementation of nursing process

The study sought to determine the Process factors influencing implementation of

nursing process in management of patients with mental disorders in Mathari National

Teaching and Referral Hospital. Findings of the study revealed that the main process

factor influencing NP implementation was the nurse related factors. The study found

out that most of the respondents at MNTRH were yet to fully understand the

relevance and application of NP in patient management and care. Regarding the

general attitude of the nurse staffs towards NP the results obtained revealed that only

a small proportion of the respondents 34(33%) had a good and very good attitude

towards the NP while 53(47%) had poor and very poor attitude towards NP. This

indicates that not all the nursing staffs fully accepted and had a positive perception of

NPs at MNTRH.

The experience of the nurses was noted to be a main determinant on the nurses’

knowledge, ease of use and applicability of the nursing care in patient management. It

influenced the frequency of use of NP and the patient outcomes obtained. According

to Alburquerque-Sendín and Palacios-Ceña (2018), the lack of experience tends to

hinder greatly the implementation of the NP especially on management of patients

with mental disorders. This coincides with Agunwah, (2010) who also found out that

lack of experience of practical use of the nursing process tends to negatively affect its

utilization. This tends to limit its feasibility in the daily nursing practice (Baraki, et al,

2017).

The respondents all agreed that the number of nurses recruited and deployed into the

wards for patient management and care was a huge contributing factor for the success

NP implementation. This compares with Agunwah (2006) who concluded that the

shortage of nurses influenced the utilization of the nursing process. In a similar way,

Fernandez-Sola et al. (2012) also reported that the high work overload was recognized

as one of the main obstacles encountered by the nurses, while implementing the

nursing process. The findings from this current study are in line with those of

Bjorvell, Wredling and Thorell-Eksstrand (2008), who reported lack of time as a

major issue in relation to documenting and updating the nursing-care plan.

Overall, nurse-related factors were established to have a moderate effect (mean>3.0)

on nursing process implementation at MNTRH having a mean of 3.25 and standard

deviation of 0.5487.The results of the Chi square test of significance as shown by

indicated that nurse-related factors had a p-value of 0.035<0.05 which implies it had a

positive and significant influence on implementation of Nursing Process at MNTRH

as the p-value was less than 0.05.The positive effect of nurse related factors on

implementation of nursing process concurs with Agyeman-Yeboah, et al, (2017) who

found out that clinical utilization of the Nursing Process at clinical settings was

influenced by lack of clear understanding on the Nursing Process and Care Plans.

Also Huguchi, Dulburgen and Duff (2012) in their study on the factors associated

with the utilisation of nursing diagnoses found that the lack of knowledge on the

nursing diagnosis prevented nurses from effectively using these nursing diagnoses.

While Florance and Adenike, (2013) confirm this by indicating that the nurses

significantly determined the use NP in patient management.

CHAPTER SIX: CONCLUSIONS AND RECOMMENDATIONS

6.1 Conclusions

6.1.1 Utilization of nursing process in management of patients with mental

disorders in Mathari National Teaching and Referral Hospital

The study findings revealed that though there was awareness of nursing process

among the nurses and recognition of nursing process as a crucial tool in patient

management, utilization of nursing process in patient assessment, NCP and

documenting in Mathari National Teaching and Referral Hospital was still low. The

study therefore concludes that Mathari National Teaching and Referral Hospital is yet

to fully attain complete implementation of NP in management of patients with

evidence of nursing process implementation gaps in the facility.

6.1.2 Structural factors influencing the implementation of nursing process in

management of patients with mental disorders in Mathari National Teaching

and Referral Hospital

Findings of the study revealed that the main structural factors included the hospital

related factors and the patient-related factors. These hospital related factors were

found out to determine the support offered to NP implementation, resource allocated

and supervision of NP implementation. The patient related factors on the other hand

were found to influence the time spent on each patient and compliance towards NP.

The study thus concludes that structural factors have a positive and significant effect

on NP implementation in MNTRH. These factors are concluded to either enhance or

hinder the NP implementation based on their effectiveness.

6.1.3 Process factors influencing implementation of nursing process in

management of patients with mental disorders in Mathari National Teaching

and Referral Hospital

The study findings revealed out that the main process factors influencing NP

implementation was nurse related factors which included the nurses’ experience,

attributes, perceptions, training and perceptions regarding nursing process. The nurse-

related factors were established to a have a strong positive effect on nursing process

implementation. The study therefore concludes that nurse-related factors influence the

level and extent of implementation of NP at MNTRH. Hence, the perceived benefits

of the NP by the nurse as well as their skills and attributes are concluded to affect NP

utilization and application.

6.2 Recommendations

6.2.1 Recommendation for Practice

It is recommended that the management at MNTRH to highly prioritize

implementation of nursing process as a key function of the hospital. The management

should formulate better policies and frameworks which will ensure that the barriers to

the NP are minimized. There should be periodic workshops and seminars on the

nursing process, in order for nursing tutors to equip them with the needed skills and

confidence to value and teach the nursing process. There should also be regular in-

service training on to continually update knowledge and skills on the nursing process.

The nursing process committees and the nurse managers at MNTRH should conduct

routine supportive supervision on NP. This is recommended to be conducted either

after two weeks or monthly so as to provide direction and motivation of the nursing

staff on the utilization of nursing process. This will make the task of assessing and

managing the mental disorders of patients to be systematic and organized. Therefore,

proper implementation of the NP will ensure that the patient needs are all catered for

with a good patient outcome.

6.2.2 Recommendation for Policy

It is also recommends that the National Government to employ more nursing staff so

as to reduce the poor nurse-patient ratio that was established to be present in the

hospital facility.

The Ministry of Health, regional health bureau, zonal health desks and other Non-

Governmental partners should ensure that the institutions are well empowered on

importance of nursing process. The Ministry of Health should also strengthen national

policy frameworks and interventions aimed at improving nursing process training and

implementation at clinical setting in Kenya. This will act to greatly boost the overall

effectiveness of the NP in the institution thus promoting better patient care.

6.3 Suggestion for further research

The study has provided a starting point for further research on the factors influencing

implementation of nursing process in patient management in hospital facilities.

However, there are certain areas which have emerged from the study necessitating

further research to be conducted. The study was limited by the methodology used

whereby it was institutionalized focusing entirely on Mathari National Teaching and

Referral Hospital. This may not be actual representation of the nursing process

implementation phenomenon in other hospitals. Further studies are thus suggested on

other hospitals in other regions of the country to enable comparison and

generalizability.

The study also investigated only three factors influencing the implementation of NP

namely patient-related factors, nurse-related factors and hospital related factors which

is not an exhaustive list of the available factors. Its therefore suggested further studies

be conducted on factors other than these so as to enable generalization of the study

findings. In addition, further studies are suggested on the barriers and enhancers of

NP implementation in details to facilitate comprehensiveness of the findings. A

similar study should be also conducted at a different time frame so as to determine

whether there would be any changes on the extent of NP implementation.

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APPENDICES

APPENDIX I: MATHARI TEACHING AND REFERRAL HOSPITAL MAP

Source; Google Maps 2018

APPENDIX II: TIME FRAME (GANTT CHART)

Duration in Months May

2018

Jun

2018

July

2018

Aug

2018

Sep

2018

Oct

2018

Nov

2018

Problem Identification

Proposal Writing

Seeking consent from

Ethical committees

Recruitment and

training of research

assistants

Pre-testing and

administration of tools

Data cleaning and

analysis

Report writing and

presentation,

Compilation of final

report and

dissemination

APPENDIX III: BUDGET

Item Unit cost Quantity Cost Total cost

HUMAN RESOURCE

Training of research assistants 1000 2 2,000

(a)Pre-testing of questionnaire

Principal researcher 2,000 1 2,000

Research assistants(2) 1,000 2 2,000

(b)Data collection

Principal researcher 20,000 1 20,000

Research assistants(2) 10,000 2 20,000

Data analysis and production 25,000

Sub-total 71,000

MATERIALS AND SUPPLIES

Biro pens(1 dozen) 180 1 180

Field books 65 3 195

Folders 100 3 300

Sub-total 675

PROPOSAL AND THESIS

Photocopying final report (5 copies) 3 250 750

Proposal typing and printing (50

pages)

35 50 1750

Research result book binding

(5copies)

600 5 3000

Sub-total 5500

Total 77375

Contingency 10% of total 7737.50

Grand TOTAL 85,112.50

APPENDIX IV: PARTICIPANT INFORMATION SHEET AND CONSENT

FORM

Introduction:

This study is a Master’s thesis by Mary Mueni Isika, a mental health and psychiatric

nursing student under the supervision of Dr. Irene Mageto and Dr. Mirriam C.A

Wagoro of Nairobi University.

The purpose of this information is to give you details about the study that will enable

you to make an informed decision regarding your participation. You may ask

questions to clarify any doubt about what we will discuss in this information and

consent form. I will also ask you questions regarding the study before you sign the

consent form to ascertain your understanding of the information provided.

Background and objective: The purpose of this study is to “Explore factors

influencing implementation of nursing process in Mathari National Teaching and

Referral Hospital.”

Significance: Findings from this study could be used for furthering knowledge about

how implementation of the nursing process could be utilized in improving patient care

and management among patients with mental disorders.

Participation: The participation in the study will involve answering of questions

which will be administered through a semi-structured questionnaire.

Benefits: There is no direct monetary benefit in participating in this study. However,

the results of the study will be useful in facilitating the understanding of the

importance of nursing process and underlying factors to its implementation.

Risks: The study poses no physical or economic risks. You may skip any questions

which you may not be in a position to provide answers to. The researcher will also be

present for approximately 20-30 minutes to enable the data collection process to

proceed.

Confidentiality: The study will maintain outmost confidentiality with the information

provided to be used solely for academic purposes. Additionally, anonymity of the

respondents will be maintained with no form of name or identification required.

Voluntary participation: Participation in the study is entirely voluntary and refusal

to participate will not attract any negative consequences. In case you may not be

comfortable in providing answers to any particular question, feel free not to answer.

Compensation: The study provides no form of compensation for participation in the

study.

Conflict of interest: The researcher and the supervisors confirm that there is no

conflict of interest amongst them.

CONSENT FORM

If you agree and fully consent to participate in this study, please sign below;

I hereby offer my consent to undertake this study. The nature of the study, potential

risks and benefits have been fully explained to me. I am also aware that my

participation is on voluntary basis and may choose to withdraw from the study at any

particular time without any consequences or explanations. I have also been assured

that anonymity will be maintained and all the information provided will be strictly

confidential. I confirm that all my concerns pertaining to the study have been

adequately addressed and understood.

Participants Signature………………………………………………………

Date…………………

I consent that have fully explained the nature and contents of the study in details and

the participant has voluntarily agreed to participate without any form of pressure or

coercion.

Investigator Signature……………………………Date.……………………………...

For any Clarification, please contact

APPENDIX V: RESPONDENTS’ QUESTIONNAIRE

Questionnaire Serial Number Questionnaire Status (1=complete; 2=

partially complete)

Interviewer ID Date of Interview / /2018

Introduction

You are hereby invited to participate in a questionnaire for a study on ‘Explore

Factors Influencing the Implementation of Nursing Process (NP) In Management

of Patients with Mental Disorders in Mathari National Teaching and Referral

Hospital’. Be honest, free and active in your participation in responding to the

questions given. Please tick or write in the spaces provided.

SECTION A: SOCIO-DEMOGRAPHIC CHARACTERISTICS

1. Please indicate your gender

Male [ ] Female [ ]

2. Please indicate your age bracket

Less than 20 [ ] 21-30 [ ] 31-40 [ ]

41-50 [ ] 51-60 [ ] more than 60 [ ]

3. Please indicate your marital status

Single [ ] Married [ ]

Widowed [ ] Divorced [ ]

Others [ ] Specify………………………………………………………….

4. Please list your academic qualification(s)

………………………………………………………………………………………

………

5. How many years of work experience do you have?

Below 5 [ ] 5-10 [ ] 11-15 [ ] 16-20 [ ]

21-25 [ ] 26-30 [ ] Above 30 [ ]

6. Please indicate your designation(s)

…………………………………………………………………………………………

7. Which activity are you mainly involved in?

Patient care [ ] Care planning [ ] Administration [ ]

Others [ ]

Specify………………………………………………………………

8. Are you aware of Nursing Process (NP) initiatives in the

hospital? Yes [ ] No [ ]

PART B: PROCESS FACTORS INFLUENCING NP IMPLEMENTATIONS

a) Nurse-related Factors

9. How do you rate your understanding of NP?

Very good [ ] Good [ ] Average [ ] Poor [ ] Very poor [ ]

10. Have you ever been trained on NP?

Yes [ ] No [ ]

If yes where? Please specify ……………………………………………….

11. How do you rate the general attitude of the nurse staffs towards NP?

Very good [ ] Good [ ] Average [ ] Poor [ ] Very poor [ ]

12. Using a scale of 1-5, where 1 is strongly agree, 2 is agree, 3 is neutral, 4 is

disagree and 5 is to a strongly disagree, please rate the following in relation to

Nurse-related Factors that influence NP implementations.

Statement 1 2 3 4 5

Care plans are not usually discussed with the patient

Formulating nursing diagnosis should not be mandatory

In patient care there should be less writing and more action.

Nursing care plan should be drawn for the very sick

patients only

Nursing instructions on a care plan often bear very little

relation to what the nurse actually does.

Nursing process is cumber some

Nursing process is not be applied to all patients

Statement 1 2 3 4 5

The care plan plays no significant part in the provision and

evaluation of care.

The nurses have adequate expertise to undertake the NP

There has been well acceptance of the NP practices

Use of nursing care plans enables a nurse to establish

priorities of care

Writing a care plan is a burden

b) Patient-Related Factors

13. What is general effectiveness of NP towards patients’

outcomes? Very effective [ ] Effective [ ]

Moderate [ ] Minimal effect [ ] Not effective [ ]

14. To what extent is the variation of NP outcomes amongst patients?

Very great extent [ ] Great extent [ ] Moderate extent [ ]

Small extent [ ] Very small extent [ ]

15. Please rate the following statement that relate to the patient-related factors to NP

implementation using a scale of 1-5, where 1 is strongly agree, 2 is agree, 3 is

neutral, 4 is disagree and 5 is to a strongly disagree.

Statement 1 2 3 4 5

Difficulties in collecting and recording all the patient’s

information

Every patient is unique and will need an individualized

care plan, causing problems in the NP implementation

Patients do not make progress because NPs are not well

implemented.

High number of patient causes a challenge in ensuring

adequate time allocation for the NP implementation

Patient refusal to cooperate

Statement 1 2 3 4 5

Evaluation of the patient could be difficult to perform if the

steps of the nursing process are not well followed

Barriers in evaluating progress towards goals

PART C: STRUCTURAL FACTORS INFLUENCING NP

IMPLEMENTATION

16. What is the ratio of nurse to patients in your ward?

……………………………………………………..………………………………

……

17. Does the hospital administration recognize nursing process as a framework of

nursing care delivery?

Yes [ ] No [ ]

18. Does the hospital administration support the implementation of

NP? Yes [ ]No [ ]

If yes what form of support is given to you by hospital administration?

…………………………………………………………………………………………

……………

19. Does the management monitor implementation of nursing

process? Yes [ ] No [ ]

If yes how does the administration monitor the implementation of NP?

…………………………………………………………………………………………

20. Please rate the following statement that relate to the hospital-related factors to NP

implementation using a scale of 1-5, where 1 is strongly agree, 2 is agree, 3 is

neutral, 4 is disagree and 5 is to a strongly disagree.

Statement 1 2 3 4 5

No follow up by the authorities

Hospital rules in non-implementation of it

Failure to priorities the NP formulation and implementation

plans

The nurses are not well trained and developed

Neglect is given towards the psychiatric nurses as

compared to the general nurses

There is no adequate budgetary and financial allocation

towards the NP implementations

21. To what extent would you rate the level of implementation of NP in the

institution?

Very great extent [ ] Great extent [ ] Moderate extent [ ]

Small extent [ ] Very small extent [ ]

22. Please rate the following statement that influence the implementation of NP

negatively using a scale of 1-5, where 1 is strongly agree, 2 is agree, 3 is neutral, 4

is disagree and 5 is to a strongly disagree.

Statement 1 2 3 4 5

Lack of proper NP Policy Frameworks

Inadequate hospital guidelines on NP use

Poor perception on the usability of the NPs

There is minimal monitoring and follow ups towards NP

implementation

Some nurses experience problems in adaptability of NP

There is low acceptance of NP by the nurses

23. Are there any other factors that negatively influence implementation of nursing

process in the Hospital?

………………………………………………………………………………………

………………………………

24. In your opinion, which measures should be put in place so as to mitigate these

factors that negatively influence implementation of nursing process?

………………………………………………………………………………………

End

Thank you for your cooperation

APPENDIX VI: KEY INFORMANT INTERVIEWS GUIDE

Dear participant,

You are hereby invited to participate in a Key Informant Interview for a study on

Factors Influencing Implementation of Nursing Process (NP) In Management of

Patients with Mental Disorders in Mathari National Teaching and Referral

Hospital. Be honest, free and active in your participation in responding to the

questions given for due response. Participation will be guided by use of Key

Informant Interviews Guide. There will be an observer, moderator and note taker for

your Key Informant Interview information. Recordings will also be made by use of

tape recorders to store information as presented. All information gathered will be held

under strict confidentiality and will be used only for purposes of the research.

Questions

1. Are you aware of NP in Mathari National Teaching and Referral Hospital?

2. Briefly describe the stages adopted in the NP used

3. What are the benefits accrued in the utilization of NP?

4. In your opinion, has the NP implementation in Mathari National Teaching and

Referral Hospital been successful?

5. Which factors have hindered/facilitated NP implementation in Mathari

National Teaching and Referral Hospital

6. What measures should be undertaken so as to ensure successful

implementation of NP in Mathari National Teaching and Referral Hospital?

7. Do you have additional regards as pertains to the entire NP at Mathari

National Teaching and Referral Hospital?

APPENDIX VII: OBSERVATION CHECKLIST

Comments

Work environment

Floors cleanliness

Patient hygiene

Hygiene of patient lockers/ incubators

Availability of patient linen

Presence of caretakers

Comprehensive assessment

Identification data

History of presenting illness

Current health state/treatments

Data on physical examination

Summary of investigations ordered

and done

Appropriate nursing diagnosis with

three parts

Appropriate completion of patient

charts/records

Identification data

TPR & BP charts

Fluid charts

Nurses cardex

Nursing care plans

Others

APPENDIX VIII: TEST STATISTICS FOR STUDY VARIABLES

Implementation

Nurse

Det.

Patient

Det.

Hospital-Related

Det.

Chi- 7.288a45.469b61.937c57.469d

Square

df 54 30 25 22

Asymp. 1.000 .035 .000 .000

Sig.

a. 55 cells (100.0%) have expected frequencies less than 5. The minimum

expected cell frequency is 1.2.

b. 31 cells (100.0%) have expected frequencies less than 5. The minimum

expected cell frequency is 2.1.

c. 26 cells (100.0%) have expected frequencies less than 5. The minimum

expected cell frequency is 2.5.

d. 23 cells (100.0%) have expected frequencies less than 5. The minimum expected

cell frequency is 2.8.

APPENDIX IX: KNH-UON ERC APPROVAL LETTER

APPENDIX X: REQUEST FOR APPROVAL TO CONDUCT A STUDY

APPENDIX XI: MATHARI HOSPITAL APPROVAL LETTER

EXPLORING FACTORS INFLUENCING IMPLEMENTATION OF NURSING PROCESS

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