Factors Affecting Implementation of Nursing Process
Among Nurses Working in Governmental Hospitals,
Oromia Region, Ethiopia, 2016: Cross Sectional Study
Abstract: Background: Nursing process used in clinical practice worldwide to deliver quality individualized care to patients
and lack of its application can reduce the quality of care. Nursing Process is a systematic problem-solving approach used to
identify, prevent and treat actual or potential health problems and promote wellness. It has five steps- assessment, diagnosis,
planning, implementation, and evaluation. Applying nursing process requires understanding of factors affecting its
implementation from the perspective of nurses. Nursing process implementation could be highly influenced by different factors
that can lead to poor quality of nursing care, disorganization of the service, conflicting roles, medication error, poor diseases
prognosis, readmission, dissatisfaction with the care provided, and increased mortality. These problems are manageable if a
nurse can properly implement nursing process. Objective: The main aim of this study was to assess factors affecting
implementation of nursing process among nurses in governmental hospitals of Arsi Zone. Materials and Methods: A cross-
sectional study was used to conduct on governmental hospitals in Arsi Zone from December- June 2016. Both quantitative and
qualitative methods were used. All governmental hospitals in Arsi Zone was used since they were convenient for the study.
Numbers of the participants were small, so all those who full fill inclusion criteria were participant in the study. Tools were
given to nurse out of the study to check for its validity and adjustment was made according to the feedback obtained before
actual data collection. Data was collected using self-administered questionnaire and in-depth interview. Data was analyzed
using SPSS 21.0 version. Result: Findings revealed that organizational factors have the highest predictive value in the use of
nursing process, followed by practice related factors. Conclusion and Recommendation: The result concluded that the
organizational factors have the most important influence on the use of nursing process. It is recommended that the organization
should fulfill needed materials which are necessary to provide nursing care. This will enhance nurses’ ability to use nursing
process to improve the quality of patient’s care.
Keywords: Nursing Process, Nurses, Factors
1. Introduction
Nursing process is one of the standardized nursing cares in
which professional nurses are accountable and responsible. If
professional nurses implement nursing process in
standardized way, quality of nursing will be increased.
The nursing process is an organized and systematic process
of giving goal oriented and humanistic nursing care that is
both effective and efficient.
It is consisting of five sequential and interrelated steps-
Assessment, Diagnosis, Planning, Implementation, and
Evaluation. Nursing Process is based on the assumption that
professional nursing practice is interpersonal in nature. [1]
The nursing process is based on a nursing theory
developed by Ida Jean Orlando. She developed this theory
in the late
29
1950's as she observed nurses in action. All nursing
personnel take part in the nursing process. The RN has the
primary responsibility however. [2]
Implementation of the nursing process as identified in this
Nursing Standard should allow for the delivery of quality
nursing care within a systematic, goal-directed framework
and a reasonable assurance that the individual’s course along
the health/illness continuum is predictable and progressive.
[3] By providing quality care, safe and free of risk, it is
understood that nurses make a nursing diagnosis assessment,
elaborate the clinical evolution in every work shift, provide
complex care demanding specific skills and knowledge, and
manage technological equipment. [4]
The nurse practitioner’s role involves responsibility for
meeting the health care and nursing needs of individual
patients, their families and significant others. This dominant
role of nurses could be achieved by the proper application of
the nursing process. [5]
Effective implementation of the nursing process leads to
improved quality of care and stimulates the construction of
theoretical and scientific knowledge based on the best
clinical practice. [6] So this study attempts to find out factors
that affect the implementation of the nursing process.
2. Methods and Materials
Health Institution based quantitative and qualitative study
was conducted in three governmental hospitals of Arsi Zone
Oromia reign from December to June 2016. A total of 111
BSc nurses were included in the study.
To select study participants’, for quantitative study all BSc
nurses in Arsi zone hospitals that were going to be included in
the study was taken from the respective coordinator of
nursing unit and head nurse. Data was collected from all who
were fulfilling the inclusion criteria. Purposive sampling
method was used for qualitative method.
For data collection structured questionnaire was used. Data
was collected by self-administered questionnaire. Before the
actual data collection, data collectors had two days training
about the aim of the study and the content of the instrument.
There are two types of questionnaire for quantitative and
qualitative. For quantitative method of data collection
structured questionnaire was used. It includes five main parts
about nurses ‘socio demographics, organizational, knowledge
of nursing process, attitude and skill of nurses. For qualitative
aspect of the study, open-ended questions were prepared to
guide an in-depth interview.
The questionnaire was pre tested for the relevance of
dependent and independent variables to avoid any confusion
during actual data collection period. The principal
investigator was checked 5 (5%) nurses’ response one week
prior to the actual data collection period in Adama Medical
college hospital, Adma.
Correlation analysis was used to see the association of
independent with the dependent variable. Finally, the results
were interpreted as statistically significant association if
p<0.05 and 95% of CI, and some of the results was compared
with results of other studies available. Data from an in-depth
interview was transcribed by arranging the record according
to forwarded questions.
Letter of ethical clearance was obtained before the
beginning of data collection from Arsi University College of
health sciences research Publication office (RPO).
Permission letter was provided to selected hospitals for
proceeding data collection.
3. Results
Socio-demographic Characteristics of the Study Population
Out of 82 sampled respondents were participate in the
quantitative study during the study period a total of 43
(52.4%) were females and 39 (47.6%) were males. Fortify five
(54.9%) of the respondents were in the age range from 25-29
years, 13 (42.2%) were in 20-24 years, 10 (12.2%) were 30-
34years and
6 (7.3%) were 35-39 years. Regarding Work experience
twenty-seven (32.9%) of respondents had 5-9 years of work
experience. (Table 1)
Table 1. Socio demographic characteristics of BSc nurses in governmental
hospitals of Arsi Zone, Ethiopia, 2016.
Variables Frequency Percentage
Female 43 52.4
Sex Male 39 47.6
Total 82 100.0
<20 1 1.2
20–24 13 15.9
25–29 45 54.9
30–34 10 12.2
Age 35–39 6 7.3
40–44 4 4.9
45–49 2 2.4
≥50 1 1.2
Total 82 100.0
< 1 year 19 23.2
1 – 4 years 19 23.2
Work experience 5 – 9 year 27 32.9
10 years and above 17 20.7
Total 82 100.0
Institution Governmental 69 84.1
/organization NGO/Private 13 15.9
graduate from Total 82 100.0
Current job title/
position
Head nurse
Staff nurse
Total
18
64
82
22.0
78.0
100.0
Medical Ward 8 9.8
Surgical Ward 16 19.5
Department/
units giving
service
Gynaecology Ward
Paediatrics Ward
OPD/Emergency
OPD
7
13
20
8.5
15.9
24.4
Others 18 22.0
Total 82 100.0
According to the current study, 56 (68.3%) of respondents
were implemented nursing process in their hospital. Among
the respondent, 47 (57.3%) of them known as there were
support from administration to implementation of nursing
process and regarding the resource for implementation of
nursing process 50 (61.0%) were not adequate. According to
respondents nurse patient ratio 41 (50.0%) and time
allocation 40 (48.8%) to implement the nursing process was
not matches. Regarding appreciating feedback available 42
(51.2%) for the nursing process implementation was low.
Sixty nine (84.1%) were working over time with low
payment 54 (65.9%). (See table 2 below).
Table 2. Percentage distribution of organizational related factors affecting
implementation of nursing process among nurses in governmental hospital
of Arsi Zone, Ethiopia, 2016.
Variables Numbers Percentage
Hospital implement nursing Yes 56 68.3
No 21 25.6
process I do not know 5 6.1
Administration support the Yes 47 57.3
implementation of nursing No 21 25.6
process I do not know 14 17.1
Resource for Yes 22 26.8
implementation of nursing No 50 61.0
process adequate I do not know 10 12.2
Nurse patient ratio optimal Yes 34 41.5
to implement the nursing No 41 50.0
process I do not know 7 8.5
Allocated time sufficient Yes
No 37
40 45.1
48.8
to apply the nursing process
I do not know 5 6.1
Appreciating feedback Yes 30 36.6
available for the nursing No 42 51.2
process implementation I do not know 10 12.2
worked over time Yes 69 84.1
No 13 15.9
Over time is with payment Yes 54 65.9
No 15 18.3
The payment enough Yes 15 18.3
No 54 65.9
The salary adequate Yes 12 14.6
No 70 85.4
School practice the Yes 24 29.3
implementation No 51 62.2
nursing process adequate I do not know 7 8.5
Instructors practice Yes 36 43.9
the implementation nursing No 39 47.6
process I do not know 7 8.5
Job training on nursing Yes 26 31.7
process No 56 68.3
Regarding the knowledge assessment of nurses few of
respondents 16 (19.5%) have answered the correct for
nursing theorists who was developed nursing process and
majority of them 66 (80.5%) have wrongly answered. Sixty
one (74.4%) have answered correctly what the nurse should
do one at the first step of nursing process and the rest of them
21 (25.6%) have wrongly answered. More than half of
respondents 41 (50%) answered human response towards
physiological disturbance is the focus of Gordon approach
which is the correct answer whereas the remaining 41 (50%)
have wrongly answered. Fifty six 56 (68.3%) of respondents
have correctly answered as nursing diagnosis for a problem
to be manifested in the future is potential nursing diagnosis
while the remaining
26 (31.7%) have wrongly answered. Fifty one (62.2%)
respondents have chosen the correct answer that the major
difference between nursing diagnosis and medical diagnosis
is the focus of nursing diagnosis towards human response
than the disease process while 31 (37.8%) of them answered
wrongly. Twenty one (25.6%) of respondents have chosen
the correct answer that was, data base of the patient could not
be recorded in the planning phase of nursing process where
as the remaining 61 (74.4%) of respondents have wrongly
answered. Forty three 43 (52.4%) of respondents correctly
answered that implementing the proposed interventions in the
planning phase is the expected activity to be performed in the
implementation phase of nursing process and 39 (47.6%)
have wrongly answered. (Table 3).
Table 3. Percentage distribution of nurses’ knowledge about nursing process
among nurses in governmental hospitals of Arsi Zone, Ethiopia, 2016.
step of nursing process
targeted
mellitus chronic complication in
medical approach
sign/symptom
As it is shown in the table below 16 (19.5%) of
respondents were highly knowledgeable and 39 (47.6%) were
moderately knowledgeable while 27 (32.9%) had poor
knowledge.
Table 4. Percentage distribution on level of knowledge among nurses working
in governmental hospitals of Ars zone, Ethiopia, 2016.
Level of knowledge of respondents Frequency Percentage
Highly Knowledgeable 16 19.5
Moderately Knowledgeable 39 47.6
Low Knowledgeable 27 32.9
Total 82 100.
Thirty five (42.7%) of the respondents agreed and 22
(26.8%) strongly agreed while few of them 10 (12.2%) were
disagree that the nursing process works well in practice.
Twenty nine (35.4%) of the respondents agreed and 16
(19.5%) strongly agreed as nursing process can be used in any
settings. Around 30 (36.6%) of the respondents agreed and 22
(26.8%) where disagree as there is no enough time to apply
nursing
Correct Incorrect
Answer No (%)Answer No (%)
Knowledge area
developed nursing
process
31
process during pt care. Around 21 (25.6%) of the respondents
agreed and 19 (23.2%) disagreed to the statement “nurse
staffs
have no willingness to apply the nursing process” (Table 5)
Table 5. Percentage distribution of application of Attitude among nurses on caring patients in governmental hospitals of Arsi Zone, Ethiopia, 2016.
Attitude area Strongly
agree No (%)
Agree No
(%)
Disagree
No (%)
Strongly
disagree No (%)
I don’t know
No (%)
The nursing process works well in practice 22 (26.8%) 35 (42.7%) 10 (12.2%) 5 (6.1%) 10 (12.2%)
The nursing process can be used in any settings 16 (19.5%) 29 (35.4%) 12 (14.6%) 12 (14.6%) 13 (15.9%)
There is no enough time to apply Nursing process during pt care 19 (23.2%) 23 (28.0%) 22 (26.8%) 11 (13.4%) 7 (8.5%)
The Nursing process simplifies the awareness of needs 25 (30.5%) 30 (36.6%) 11 (13.4%) 4 (4.9%) 12 (14.6%)
I’m ready for the implementation of nursing process 32 (39.0%) 23 (28.0%) 7 (8.5%) 7 (8.5%) 13 (15.9%)
Nursing process enables to provide quality nursing care to pts 38 (46.3%) 18 (22.0%) 10 (12.2%) 7 (8.5%) 9 (11.0%)
I’m willing implement nursing process during pt care 24 (29.3%) 34 (41.5%) 9 (11.0%) 3 (3.7%) 12 (14.6%)
Nursing process is a waste of time 12 (14.6%) 12 (14.6%) 19 (23.2%) 32 (39.0%) 7 (8.5%)
I’m fed up with hearing about the nursing process 14 (17.1%) 24 (29.3%) 14 (17.1%) 25 (30.5%) 5 (6.1%)
The nursing process involves too much of paper work 15 (18.3%) 24 (29.3%) 22 (26.8%) 11 (13.4%) 10 (12.2%)
I think introduction of NP will cause a problem 10 (12.2%) 17 (20.7%) 29 (35.4%) 20 (24.4%) 6 (7.3%)
I think the nursing staff have no willingness implement to nursing 14 (17.1%) 21 (25.6%) 19 (23.2%) 18 (22.0%) 10 (12.2%)
process
I think the staff will never accept the nursing process 13 (15.9%) 10 (12.2%) 21 (25.6%) 24 (29.3%) 14 (17.1%)
Regarding the ability to follow the steps of nursing process
during provision of care (as shown in table 6) thirty seven
(45.1%) of the respondents were use always while 23
(28.0%) used sometime. Fifty (61.0%) always ability to
developed nursing diagnosis from assessment while 22
(26.8%) able develop sometime. fifty (69.5%) always able
to safely
administer medicine and other therapies. Forty nine (59.8%)
respondents have practiced always the principles of health
and safety, including moving and handling, infection control;
essential first aid and emergency first aid and emergency
procedures very much where as 19 (23.2%) were practiced it
Sometimes.
Table 6. Percentage distribution of application of Practices among nurses on caring patients in governmental hospitals of Arsi Zone, Ethiopia, 2016.
Practices area Not at all No
(%)
Sometimes No
(%)
Undecided No
(%) Always No (%)
Ability to follow the steps of nursing process during provision of care 14 (17.1%) 23 (28.0%) 8 (9.8%) 37 (45.1%)
Ability to developed nursing diagnosis from your assessment 3 (3.7%) 22 (26.8%) 7 (8.5%) 50 (61.0%)
Ability to arranged in order of priority of problem statements 5 (6.1%) 27 (32.9%) 7 (8.5%) 43 (52.4%)
Identified and documented nursing interventions in the care plan 8 (9.8%) 17 (20.7%) 14 (17.1%) 43 (52.4%)
Maintenance of patient dignity, privacy and confidentiality 8 (9.8%) 24 (29.3%) 6 (7.3%) 44 (53.7%)
Ability to practice principles of health and safety 3 (3.7%) 19 (23.2%) 11 (13.4%) 49 (59.8%)
Safely administer medicine and other therapies 6 (7.3%) 17 (20.7%) 2 (2.4%) 57 (69.5%)
Objective measures of patient progress towards the identified goals 6 (7.3%) 21 (25.6%) 18 (22.0%) 37 (45.1%)
The care plans used both day and night as a basis for giving care 7 (8.5%) 25 (30.5%) 11 (13.4%) 39 (47.6%)
The evaluation recorded in the care plans or progress notes 9 (11.0%) 15 (18.3%) 11 (13.4%) 47 (57.3%)
Association of implementation of nursing process
Regarding association of implementation of nursing process
with selected variables with correlation analyses as shown in
table 7 there is no association with socio-demographic
characteristics. There is association of implementation of
nursing process with some of the organizational factors.
Hospital administration support has correlation, for
implementation of nursing process (r=. 494**,.000
Correlation is significant at the 0.01 level (2-tailed)). Nurse
patient ratio has association (r=.366**.001; Correlation is
significant at the 0.01 level (2-tailed).) Time sufficient,
feedback available, adequacy of school practice and
adequacy of training from instructor was significantly
associated with implementation of nursing process r=.378**,.
236*,. 236*,. 227*,. 354**) respectively. (Table 7) Regarding
association of implementation of nursing process with factors
related to knowledge and attitude; there is no association. But
one of the practice related factor; the ability to follow the
steps of nursing process has an association with
implementation of nursing process. (r=.047).
Table 7. Association of implementation of nursing process by selected variables among nurses working in selected governmental hospitals of Arsi Zone, Ethiopia,
2016.
VARIABLES IMPLEMENT NURSING PROCESS
SOCIO-DEMOGRAPHIC Pearson Correlation Sig. (2-tailed) Level of significant
Sex .010 .926
Age -.195 .079
Work experience -.113 .312
Institution from gradated .061 .588
ORGANIZATIONAL FACTORS
Support from administration .494** .000 **. Correlation is significant at the 0.01 level (2-tailed).
VARIABLES IMPLEMENT NURSING PROCESS
SOCIO-DEMOGRAPHIC Pearson Correlation Sig. (2-tailed) Level of significant
Allocation of resource .018 .872
Nurse patient ratio .366** .001 **. Correlation is significant at the 0.01 level (2-tailed).
Time sufficient .378** .000 **. Correlation is significant at the 0.01 level (2-tailed).
Feedback available .236* .033 *. Correlation is significant at the 0.05 level (2-tailed).
Salary adequate -.084 .450
Adequacy of School practice .227* .041 *. Correlation is significant at the 0.05 level (2-tailed).
Adequacy training from instructor .354** .001 **. Correlation is significant at the 0.01 level (2-tailed).
Job training .212 .056
KNOWLEDGE FACTORS
Level of knowledge .110 .324
ATTITUDE FACTORS
Works well in practice .055 .625
Enables to provide quality nursing care -.073 .515
Nursing process is a waste of time -.010 .926
Never accept the nursing process -.048 .670
SKILL FACTORS
Ability to follow the steps of NP -.220* .047 *. Correlation is significant at the 0.05 level (2-tailed).
Ability to developed nursing diagnosis -.195 .079
The data collected from interviewees was summarized
thematically by identifying the core ideas they have
responded. The whole information is summarized into three
themes.
Organizational Factors
Most of interviewees have described that hospital‘s
environment was not suitable for implementation of nursing
process. Hospitals were not able to afford supplies needed
for caring. For example, nursing process formats were not
available. The available format was not the correct format to
register all the components of nursing process. Low nurse to
patient ratio was the other problem that participants were
described. Nurses were obligated to care for many patients
beyond their capacity. In the contrary they were not
obligated to record their activities in a formal way. Simply
they were allowed to perform their activities following the
instruction of physicians. Higher officials were not informed
the role of nurses and the benefit of nursing process on the
patients ‘outcome. They were only working for the
successful accomplishment of medical services leaving
nursing services apart. Low salary and duty payments
created negligence among most of nurse to enforce nursing
process. Knowledge
Most of the respondents agreed that knowledge is a
determinant factor that could influence implementation of
nursing process. Some respondents believed that nurses have
obtained adequate amount of knowledge for caring their
patients. But as nurses stayed for long time without
implementing nursing process their knowledge might be
depreciated.
Attitude and skills
Most of the respondents described that nurses were not
committed to implement nursing process. There were several
reasons that make nurses to become negligent about their
responsibility. The first reason was their experience. From
their experience they were recording their activities and
fighting for the betterment of nursing but nothing was
changed rather the value of nursing was declining. The
second reason was absence of recognition for the highly
devoted nurses. They were advocating for the patient from
the beginning
history of nursing in Ethiopia yet they were not considered as
they could contribute anything for the health of the country.
The third reason was poor payment.
The nursing process is a widely accepted method and has
been suggested as a scientific method to guide procedures
and qualify nursing care. In Ethiopia, quality of health care
was poor and to improve the quality of health service,
application of nursing process may contribute a lot. [9]
Regarding resources related factors, this study revealed that
50 (61.0%) of nurses agreed upon several resources’ barriers,
which included inadequate staff in the unit, lack of specified
nursing care document and education budget, insufficient
equipment and absence of supplies and materials. These
results were in line with the previous studies. Another most
challenging factor was nurses to patient’s ratio in which one
nurse giving care for more patients in their hospital. Half 41
(50%) of the respondent said that the nurse to patient ratio
was not optimal to apply the nursing process; whereas only
37 (45.1) said that the allocated time was sufficient. There is
lack of time to apply the nursing process. Forty 40 (48.8%) of
the respondents believes that as there is shortage of time to
implement nursing process.
Forty two (51%) of the respondents said that there is no
available appreciating feedback for the nursing process
implementation. Majority of the nurses 69 (84.1%) worked
over time with payment 54 (65.9%) which was not enough
payment 54 (65.9%). This is with lower than research
conducted in Addis Abeba city hospitals which is Only 9
(5.7%) of the respondents were satisfied with the over time
payment where as 148 (94.3%) were not satisfied with the
payment. [7]
Sixteen 16 (19.5%) of respondents were highly
knowledgeable and 39 (47.6%) were moderately
knowledgeable while 27 (32.9%) had not knowledgeable.
These results were almost in line with study conducted at
College of Medicine and Health Sciences, Arbaminch
University, Arbaminch, Ethiopia in which 23.34% of
respondents were highly knowledgeable and 44.9% were
moderately knowledgeable while 31.63% had not
33
knowledgeable. [5] According to both the qualitative and
quantitative findings nurses of the study sites have positive
attitude towards the nursing process. A survey on the
attitudes of nurses toward the nursing record revealed that
Nursing process enables to provide quality nursing care to
pts. Thirty seven (45.1%) of respondents reported that they
followed the nursing process in the provision of care to their
clients. This is lower than research conducted in Bale zone
hospitals which was 52.1%of respondents reported that they
followed the nursing process in the provision of care to their
clients. (15) Fifty seven (69.5%) respondents were safely
administer medicine and other therapies very much but 6
(7.3%) were not at all administered. This is somewhat
similar with research conducted in Addis Abeba which was
57.8% respondents were safely administer medicine and
other therapies very much but 1.6%) were not at all
administered. [7]
This study showed that organizational factor influence the
implementation of nursing process more than other variables.
One of the biggest problems currently facing the nursing
profession is that of implementing the nursing process was
lack of equipment’s, formats for formulating nursing care
plan and lack of administration supports were identified.
Practice factor ranks the second highest predictive value in
the use of nursing process but currently, many institutions do
not use nursing process for the care of their clients. Lack of
application of the nursing process as a standard of care can
reduce job satisfaction, incorrect evaluation, reduction in the
quality of care, neglecting of some of the authorities to this
field, devaluation of this profession by nurses themselves and
their excessive dependency to the physicians, indisputable
obedience, doing routine activities without thinking,
conducting one dimensional care, reduce in patients
independence and costing heavy expenses due to doing
repeated acts.
It is well known that nursing process implementation is
very essential to maintain nursing as profession. The
following measures should be taken to minimize the
burdensome of factors affecting implementation of nursing
process. In order to achieve quality health care service,
quality nursing care is the key element and to fill this
demand application of the nursing process have a
significant role, but in practice application of the nursing
process is not well developed. Based on these facts the
principal investigator would like to give the following
recommendations:
1. Hospitals should provide the appropriate supply of
instruments for nursing care.
2. Hospital managements including the medical directors
should be enlightened on the benefits of the process in
terms of patients’ outcome. This will enhance regular
supply of the needed materials for the practice of the
nursing process and motivate the staff nurses.
3. Hospital officials should get the right information about
nursing.
4. Health facilities must provide in-service education or
periodical training to update the knowledge of nursing
process.
5. There should be regular supervision of nurses by head
nurse / matron
6. Change the training/practice system to make nursing a
well recognized profession by the society and
professionals themselves.
List of Abbreviations
BSC: Bachelor of Science
NANDA: North America Nursing Diagnosis Association
NP: Nursing Process
OPD: Outpatient department
RN: Registered Nurses
SPSS: Statistical Package for Social Science
Conflict of Interests
The authors declare that there is no conflict of interests
regarding the publication of this paper.
Acknowledgements
I give a great appreciation and opportunity to thank Arsi
University and College of health sciences for initiating this
research program and financial support. The deepest thanks
go to college of health sciences community and research
coordination office for spent their valuable time during
enquiry of this study. My gratitude also goes to my friends
for their direct or indirect contribution to the development of
this study. I am pleased to thank MR. Aliye Kediro (MSN)
Arsi University) for his expertise comment on my research
questionnaire. I am grateful to show my appreciation to Mr.
Mesfin Tafa (MPH, lecturer, Arsi University) for his
supporting during data analysis and use of some software. I
wish to express my sincere thanks to all people who were
involved interview, and those responded to the questionnaires
for devotion of their time and energy. I would like to extend
my gratitude to supervisors, data collectors, Asella teaching
and referral hospital, and Robe and Abomsa hospitals for
their cooperation in the realization of the study. The last but
not the least I am thankful to my wife and three sons for their
moral support and patience.
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