The nursing process is a scientific and systematic method of solving the numerous patient’s problems, which promotes problem solving in professional practice, and is useful because it promotes congruency and uniformity in practice.
This study was carried out evaluate the impact of a training programme on utilisation of nursing process among community health nurses in primary health care centres in Ijebu-Ode LGA. A thorough review of literature was done on the subject under study. The study design was a quasi-experimental study and a total of 32 female participants took part in this study. They were purposively assigned into the two treatment groups – intervention group (participants who were trained on the use of nursing process) and the placebo control group (participants who were not trained) using the relevant inclusion and exclusion criteria. The intervention group had 18 (56.3%) participants while the control group had 14 (43.7%) participants. Data was collected using close-ended structured questionnaires and performance observation check-lists. A statistical package for social sciences (SPSS 24.0) was used to analyse data, descriptive statistics was used to present data, and inferential statistics such as chi-square test was used to test the relationship between different variables of the study at 0.05 significant levels.
The results of analysed data showed that participants had fair knowledge towards the utilization of nursing process, participants also showed negative attitude towards the utilization of nursing process for health care delivery. Further findings revealed low level of practice of nursing process among community health nurses in primary health care centres in the study area. The results of t-test statistic showed that the post-implementation impact of the training programme was significant on the knowledge of community health nurses (t= -1.565; p < .05), attitude of community health nurses (t= -3.699; p < .05), and on the performance of community health nurses (t= – 16.194; p <.05) in primary health care centres. The univariate test of effect showed that there was a significant effect of the training programme on participants’ post-test performance (F = 267.628; p < 0.05) with Least Square Difference (LSD) comparisons indicate that the post implementation performance of participants who were not trained and those who were exposed to training programme were statistically different (MD = -19.158; Std error = 1.171; p < 0.05). Years of experience of the participants were not significantly associated with the assimilation of the training programme, χ2(12) = 12.125.
The study concluded that the intervention group exerted a greater effect over the control group, with overall improvement in their knowledge, attitude and practice of the nursing process. It is recommended that community health nurses should attend periodic workshops to enhance their ability to use nursing process to improve the quality of patient’s care. Nurse educators should also constantly reflect on the nursing curricula to strengthen the role of registered nurses on the utilisation of the nursing process when implementing elements of PHC in their daily practice.
Keywords: Impact, training programme, utilisation, Nursing process, Primary Health Care
Word Count: 497
TABLE OF CONTENTS
Title Page i
Letter of Certification ii
Table of Contents viii
List of Tables x
List of Figures xi
CHAPTER ONE: INTRODUCTION
- Background to the Study 1
- Statement of the Problem 3
- Objective of the Study 4
- Research Questions 4
- Hypotheses 4
- Significance of the Study 5
- Operational Definition of Terms 5
CHAPTER TWO: REVIEW OF LITERATURE
- Introduction 7
2.1. Theoretical Framework 8
2.2. The Concept and Strategies of Primary Health Care 12
2.2.1. Definitions of Primary Health Care 13
2.2.2. Strategies of primary Health Care 14
2.3. Nursing Process 17
2.3.1. The Phases of the Nursing Process 20
2.3.2. Assessment 21
2.3.3. Diagnosis or problem identification 22
2.3.4. Planning 24
2.3.5: Implementation 25
2.3.6: Step 5: Evaluation 26
2.4. Critical Thinking and Nursing Process 27
2.4.1. Introduction 27
2.4.2. Definitions of Critical Thinking 28
2.4.3. The relevance of Critical Thinking in Nursing Process 28
2.4.4. Critical Thinking Skills needed in Nursing Process 30
2.5. Barriers to the successful implementation of Nursing Process 31
CHAPTER THREE: METHODOLOGY
3.0. Introduction. 33
3.1. Research Design 33
3.2. Population 33
3.3. Sample and Sampling Technique 34
3.3.1. Inclusion and Exclusion Criteria 35
3.4. Instrumentation 35
3.4.1. Validity of Instrument 36
3.4.2. Reliability of Instrument 36
3.5. The Training Module 36
3.6. Data Collection Procedure 37
3.6.1. Selection of Research Assistant 37
3.6.2. Design of Intervention. 38
3.7. Method of Data Analysis 38
3.8. Ethical Consideration 39
3.8.1. Post Research Benefits 39
CHAPTER FOUR DATA ANALYSIS, RESULTS AND
DISCUSSION OF FINDINGS
4.0. Introduction 41
4.1. Data Presentation 41
4.1.1. Demogrgraphic characteristics 41
4.2. Analysis of Research Questions 42
4.2.1. Research Question One 43
4.2.2. Research Question Two 45
4.3. Testing of Hypotheses 50
4.3.1. Hypotheses One 51
4.3.2. Hypothesis Two 54
4.4. Summary of Findings 55
4.5. Discussion of Findings 56
4.5.1. The demographic presentation of the participants 56
22.214.171.124. Research objective one (Knowledge needs of participants) 57
126.96.36.199. Attitude of the Community Health Nurses. 58
188.8.131.52. The performance (practice) of community health nurses 58
4.5.3. Discussion on research objective two: 59
4.5.4. Discussion on research objective three 60
4.5.5. Discussion on Hypothesis one 60
4.5.6. Discussion on Hypothesis two 62
CHAPTER FIVE SUMMARY, CONCLUSION AND RECOMMENDATIONS
5.0. Introduction 63
5.1. Summary 63
5.2. Conclusion 64
5.3. Recommendations 65
5.4. Suggestions for further studies 66
LIST OF APPENDICES
- The research questionnaire 73
- Pre and Post Performance Check-list 75
III. Informed Consent Form 77
- Letter of Introduction
- Ethical Clearance Certificate
- Pictures of events
LIST OF TABLES
3.1. The distribution of the community health nurses in the study area 34
3.2. Timeline of Activities 35
3.3. Outline of Intervention 38
4.1. Age Distribution of Respondents 41
4.2a. Assessment of Knowledge Needs of Participants on nursing process 43
4.2b. Assessment of the participants’ attitude towards nursing process 44
4.2c. Assessment of Participants’ Level of Practice of Nursing Process 45
4.3a. Summary of Descriptive and inferential statistics of pre-test knowledge
of Community Health Nurses on Nursing Process 45
4.3b. Summary of Descriptive and inferential statistics of post-test knowledge of
Community Health Nurses on Nursing Process 46
4.3c. Summary of Descriptive and inferential statistics of pre-test Attitude
of Community Health Nurses towards utilization of Nursing Process 47
4.3d. Summary of Descriptive and inferential statistics of post-test
Attitude of Community Health Nurses towards utilisation of Nursing Process 47
4.3e. Descriptive and inferential statistics of pre-intervention performance
(practice) of community health nurses in the control and experimental groups 48
4.3f. Descriptive and inferential statistics of post-intervention performance
of community health nurses in control and experimental groups 49
4.4. Descriptive statistics of pre and post-intervention performance
scores of participants 40
4.5. ANCOVA summary showing the effect of programme on the utilisation
of nursing process 51
4.6. Estimates of control and intervention treatments 51
4.7. Univariate test of the effects of control and intervention training
on participants’ post-test scores 52
4.8. Pairwise comparison of treatments on participants’ implementation
of nursing process 52
4.9. Cross tabulation of years of experience and performance rating 54
4.10. Chi-square test showing relationship between experience and
assimilation of training programme 54
4.11. Adjusted and Unadjusted Treatment Means and Variability for Post
Implementation Performance of Nursing Process with Pre-test as a Covariate 56
LIST OF FIGURES
- Nursing Process Model 8
- Pre and post knowledge of the participant on the use of nursing process 46
- Pre and post attitude of the participant on the utilisation of nursing process 48
- Pre and post implementation practice of nursing process by participants 49
- Estimated marginal means of post-performance scores 53
- Background to the Study
Primary Health Care (PHC) describes the basic tenets and values that guide professional nurses as the continuous practice of health promotion, illness prevention, prompt diagnosis/care of ailments and restoration of sick people to their pre-illness state (Iita, Small and Van, 2011). According to WHO (2010), the utmost priority and objective of primary health care is to ensure improved health for everyone. The organisation has identified five basic principles for this as reducing segregation and inequalities in social health (global coverage); designing health care services around people’s health needs and aspirations (service delivery); integrating health into all sectors (public policy); the pursuing collaborative ideals of policy dialogue (leadership); and the increasing stakeholders’ involvement. In other words, PHC focuses on a strategy that surpasses the orthodox health care arrangement which stresses on health uniformity-yielding social policy; but rather includes all aspects that directly influence health. This include; prompt and timely access to health services, suitable environment and lifestyle. Hence, primary healthcare and public health strategies may together be considered as the fundamentals of universal health system (Daisy, 2009).
In order to achieve these goals, the core attributes of primary health care which are first contact (accessibility), longitudinality (person focused preventive and curative care overtime), patient-oriented comprehensiveness and coordination (including navigation towards secondary and tertiary care) are factors that should be put in place and to also enhance effective health care delivery (WHO, 2008). Besides taking care of the needs of the individuals, primary health care teams also look at the community, especially when addressing social determinants of health. This is achievable through a community oriented primary care (COPC) experience which integrates public health focus and primary health care. The interaction of the primary health care team with different networks (education, work, economy, and housing) are also important. By using all these methods, the primary health care team promote health equity, increase social cohesion and empowerment through its contribution (Daisy, 2009).
According to Chukwu and Momoh (2010), the nursing process which is a universal phenomenon is fundamental for making nursing a unique profession. Consequently, the process of implementation of the components and attributes of primary health care can be best achieved through the use of this process, being a broadly acceptable, systematic method of planning and delivering individualized care for clients in any state of health or illness; and a scientific means of solving the numerous and dynamic nursing problems (Chiarelli, Costanzi, Moraes, Pokorski, and Rabelo, 2009). The nursing process is made up of a global standard through which nursing problems are identified and solved (Elder and Paul, 2005). It is also a method of thinking critically to solve patient problems within the professional practice. The nursing process is a series of steps taken to fulfil the goals and objectives of nursing practice” (Walsh and Yura 1983). The nursing process is a dynamic and an organised pattern for rendering nursing care through six interrelated and overlapping phases of assessing, diagnosing, identifying outcome, planning, implementing and evaluating nursing actions. It is an actual task adopted by professional nurses to identify/ solve patient’s problems and deliver a top quality levels of care among families, groups and communities (American Nurses Association, 2009). At the assessment phase, a thorough exploration of the needs of the individual, family, group or community that are of importance to them are made by the nurse in order to arrive at a diagnosis from the numerous data collected.
At the planning phase, nurses’ judgment of the individual, family, or community’s responses to the important life’s activities; or to specific or potential health needs are identified and planned for. This also provide a basis for the choice of appropriate nursing actions (North American Nursing Diagnosis Association, 2007). The implementation phase addresses the problems identified using the most relevant nursing actions and finally assessed for effectiveness at the evaluation phase (Alfaro-LeFerve, 2004).
However, the Implementation of the nursing process in the community and primary health care settings can be achieved through the principles of action research which requires knowledge and understanding of the major aspects of the nursing process, and the platform through which this knowledge can be applied in practical settings (Good and Savett, 2005). If this is implemented, it will amount to good quality of care that enhances the development of scientific cum theoretical knowledge that rests on a quality clinical nursing care, (Almeida, Barra, Debétio, Marinho, Paese, Rios, and Sasso, 2013). Also, to promote and enhance the worth of nursing practice, the use of nursing process is advocated, because it advances, patterns and designs, in addition to promoting the continuous use of information. This gives nursing staff the opportunities to evaluate their work output/productivity as well as revamp the rate at which they perform their job in relation to their consumers’ responses to care (Dal Sasso, et al., 2013).This research implemented a training programme for community health nurses on the utilisation of nursing process, in primary health care in selected primary health care centres in Ijebu-Ode Local Government Area.
- Statement of the Problem
Nursing process is a universal phenomenon that is foundational to nursing as a profession. If correctly and effectively utilised, it will promote the quality of health care; and improve the worth of nursing care at all levels of health care including the primary, secondary and tertiary levels (Chukwu & Momoh 2010). However, despite this universal identification and acceptance of nursing process as the major tool for delivering quality health care services, its utilisation in the primary health care centres is still underrated, with the major obstacles being related to the management processes in health services, the resistance of nurses to change, shortage of manpower, administrative/political matters that antagonise the practice of nursing, the administrative design and programme of healthcare institutions, the lack of autonomy of the professional nurse, centralisation of power in institutions; and lack of willingness on the part of nurses to accept and face the tasks of modelling themselves to acquiring new skills and education in nursing practice (Alemseged, Aregay, Balcha, Berhe & Hages, 2013).
The World Health Organisation (2008) has registered this as a concern; and submits that since health is a fundamental human right, the community has a role to play in contributing to the health of its members and divers groups in the community. Most communities today have at least one health care facility located as close as possible to where they live or work, in all the districts or local government areas of many of the states in Nigeria. Nonetheless, it has been discovered that the establishment of these health care facilities has not in any way led to its utilisation; with the record that one of the major contributory factors to high mortality rate in Nigeria is lack of access to; and non-utilisation of health care services due to unfair treatment of patients and their relatives by the nurses and lack of competencies in providing quality nursing care (Achi, Amos & Olayinka, 2014).
The researcher has noted from clinical practice that most members of the communities where primary health care centres are located, bypass these health centres to seek for health care in secondary or tertiary institutions, when there are primary health care centres in their neighbourhoods which are meant to serve their health needs. Also, when patients are referred from Primary Health Care centres to secondary or tertiary institutions for better and continued health management, they often report at these institutions with more grievous complications than they were originally before they sought care in these Primary Health Centres; with reasons ranging from inhumane and rigid attitude of the community health nurses to lack of competencies in providing quality care, mismanagement of the conditions by care providers, exorbitant prices charged on services when they felt primary health care should be relatively cheap and affordable among other reasons. These has often led to increase mortality, morbidity and irreversible damages on the patients’ lives. Chianca, Miranda, Silveira & Vaz, (2013) support this evidence and affirm that a mismanaged patient in a primary health care or faith-based organisation is often a reason for opening a death record in either a secondary or tertiary health institution.
1.3. Research Objectives
The main objectives of the study is to evaluate the impact of a training programme on utilization of nursing process among community health nurses in primary health care centres in Ijebu-Ode LGA and the specific objectives of the study are to:
- conduct a need assessment on knowledge, practice and attitude of community health nurses towards the utilization of Nursing Process.
- design and Implement a training programme on the utilisation of nursing process in primary health care delivery and
- measure the post implementation impact of the training programme on the participants.
- determine the relationship between the years of experience of the participants and assimilation of the nursing process training programme
1.4. Research Questions
- What are the required needs of community health nurses on knowledge, attitude and practice towards the utilisation of nursing process?
- What is the post implementation impact of the training programme on the community health nurses towards the utilisation of Nursing Process?
1.5. Research Hypothesis
Ho1. There is no significant effect of training programme on the utilization of nursing process among community health nurses in primary health care centres in Ijebu-Ode LGA
Ho2. There is no relationship between the years of experience of the participants and the assimilation of the training programme.
1.6. Significance of the Study
This study would help to stimulate the interest of community health nurses to utilise the nursing process in delivering quality-individualised care to patients and members of the community. It would also promote professionalism and autonomy in work place; thereby making their work more visible and highly valued by the broader society. It is expected to contribute to minimising healthcare costs by less delays, reducing the length of hospital stay, task duplication and promote the implementation of evidence-based practice; to drive the use of information that supports the continuous practice of quality and safe care. As part of the importance of the nursing process, it would support collaboration on decision making among health care providers based on contributory knowledge from them as led by nurses who are the primary care givers in any clinic or community setting.
Since the development of nurse leadership is considered as one of the key stones for enforcing the retainership and productivity improvement at the primary health care level, the study may contribute some importance for stakeholders and policy makers in the primary health care board to provide an atmosphere for nursing care practice template on scientific grounds, which stem from the pattern of the service delivery framework, and the inclusion of nursing care into every institution’s goals and mission statements. This enhancement geared towards the implementation of organisational-oriented techniques which seek to tailor the practice framework, offer nurse professionals a concrete platform which promote the intense commitment their involvement in the correct application of the nursing process in various settings.
1.7. Operational Definition of Terms
Outcome: Information, event, object or state of being produced as a result or consequence of a plan, process, accident, effort or other similar action or occurrence (Oxford English Dictionary).
Training: The activity of imparting and acquiring skills or the action of teaching a person or animal a particular skill or type of behaviour (Oxford English Dictionary).
Community: A group of people or a social unit living in the same place or having a particular characteristic in common and sharing certain attitudes such as norms, values and identity (Merriam Webster Online Dictionary).
Community health nurse: Community health nurses are the primary care providers in most communities, home care and public health services working in an expanded nursing role with other health care professionals to provide community health promotion services which include prevention of disease, maintenance of health and the overall wellbeing of the community in a designated region in accordance with the philosophy and objectives of the authority (Northwest Territories).
Nursing Process: It is a series of organised steps designed for nurses to provide excellent care, offer framework for thinking through problems and provide some organisation to a nurse’s critical thinking skills (American Nurses’ Association, 2005).
Selected Primary Health Care Centres: These are the basic structural and functional units of the public health services in the community who provide accessible, affordable and available primary health care to people and have met the inclusion criteria for the research study from among several options.
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