A Study on the Factors that Hinder the Implementation of the Nursing Process by Nurses in the Saint Elizabeth Catholic General Hospital Shisong

: The nursing process is the bench mark of quality care and needs to be implemented in all health institutions. This research project was triggered by the fact that nurses do not really implement the nursing in patient care as expected despite the nursing profession autonomy it gives. This study therefore was designed to identify factors that hinder the implementation of the nursing process by nurses of the St Elizabeth‟s catholic general hospital Shisong”.The age distribution revealed that 20(83.3%) out of the 26 in the adult age group of 31-40, used the nursing process more than the older nurses. The findings revealed 49(70%) participants did not know all the components of the nursing process while only 21(30%) knew , this being the major factor that hindered its use as 38(54.3%) acknowledged that lack of adequate knowledge of the nursing process is a factor that hinders its implementation. Other factors identified by 52(74.3%)of the participants was hindrances to using the nursing process were administrative factors such as shortage of staff and no job description, lack of supervision by head nurses as identified by 35(50%) of the participants. The research concluded that there was no implementation of the nursing process by nurses of this institution.


Introduction
The nursing process is basically a systematic, patient Centred and scientific method of problem solving for structuring the nursing care in order to achieve a maximum level of change towards the expected out comes (kozieret al., 2008). Hence the nursing process demonstrate nursing functions through the use of science, humanities, arts and skills, a combination that is unique and un-replicated (nwonu,2002). The five components of the nursing process include Assessment, diagnosis, planning, implementation and evaluation. This process focuses on quality services and today"s society demands for quality services in all areas than what more of our delicate healthcare system (include references).
The nursing process is the essential core of practice for the nurse to deliver holistic patient focused care. The nursing process has been used for over 25 years as a systematic approach to nursing practice. Although it has been undergoing constant reevaluation and revision, the concepts within the process still remain central to nursing practice. The nursing profession in Cameroon strives to see that the quality needed in professional practice is acquired through the implementation of the nursing process (include references).
According to the American and German practice standards, nursing profession demands the efficient use of the nursing process and professional methodology (Barthlomew 2007). It is important to establish nursing process to practice care in every health institution within hospitals as well as community as a whole (Barthlomew 2010). The nursing process uses judgment to strike a balance of epistemology (a physiological theory of knowledge) between personal interpretation and research evidence in which critical thinking may play a part to categorize the client issue and course of action (Wikipedia 2015). No matter where a nurse is working, the nursing process is always the same. The aim of this work was to identify factors that hinder the implementation of the nursing process by nurses of the St Elizabeth"s catholic general hospital shisong".

METHODS AND MATERIALS 2.1 Study design.
It was a quantitative and qualitative study design in which an exploratory cross sectional strategy was applied.

The study
The study was carried out in the St Elizabeth Catholic General hospital Shisong with more than 200 nurses. The hospital has many departments including inpatient and out-patient departments. Shisong is at the outskirts of Kumbo and about 400km north of Douala which is the economic/industrial capital of Cameroon. It is also about 450km North West of Yaoundé which is the political capital of Cameroon and 110km north east of Bamenda which is the capital of the North West region. It is 3km east of Kumbo/Tobin the capital of Bui division.

Study population
The study population included nurses working in the following units; medical units, surgical units, paediatric unit and general unit and the maternity.

Sample size and sampling technique.
A sample size of 70 nurses was used. A convenient random sampling method was used and all the nurses working in the paediatric unit, medical units, general units" surgical units and the maternity that were present at the time of the study all participated. A structured questionnaire was used based on the specific objectives. Data was analysed using Microsoft SPSS (Storage package for statistical software) version 17 and results were presented on frequency tables , pie charts and bar charts.

Ethical clearance.
An ethical clearance was obtained from the ethical review board of the Catholic University of Cameroon (CATUC) Bamenda. Confidentiality, voluntary participation and anonymity were assured as participants were asked not to disclose their identities. The ethical clearance from the Director of the hospital was given to the heads of the departments. Also an informed consent was given to all participants to read through and then sign before participating in answering the questionnaire.   Table 2 shows that majority of the respondents were those who had work as from 0 -5years scoring 23 (33.0%), 6(9%) worked from 6-10 years,10(14%) of them had longevity in service from 11   The table above shows that 20(54.1%) nurses find it difficult implementing the nursing process because of too much work load and 10 with 27% being not conversant with the N.P thus finds it difficult using it. Then 7 nurses with 19.9% found it difficult to implement the nursing process due to challenges from the patients. Table 5: Comparing Age and use of the nursing process.   The above table 5(35.7%)participants above 50 years use the nursing process (N.P) pt. care while 9(64.3%) do not. Table 6: Comparing Qualification and use of the N.P.   The above table data reveals that 6(66.7%) participants with HND do use the N.P in patient care while 3(33.3%) do not.  Table 7: Comparing longevity in service and the use of the nursing process. The table above shows that 17(73.9%) participants who had worked from 0-5 years uses the N.P in pt. care while 6 of them do not. The table above shows that 6(100%) participants with longevity of service from 6-10years all use the N.P in pt. care.   The above table reveals that 2(25%) participants who worked within 21-30years uses the N.P while 6(75%) do not. The above table shows that 2(20%) participants who had worked above 31years uses the N.P while 8(80%) do not. From the above table 20(87%) participants who are nurse assistant faced difficulties using the N.P while 3(13%) did not face any difficulty. The table above shows that 10(32.3%) participants SRN had difficulties using the N.P while 21 of them do not face any difficulty The above table data reveals that 6(66.7%) participants with HND did not find the N,P difficult to use while 3(33.3%) did find the N.P difficult. From the above table 1(17.7%)participant found it difficult using the N.P while 5(83.3%) did not.

Factors That
Hinder the Use of the Nursing Process 4.3.0 Table 9: Frequency Distribution of the factors that hinders the implementation of nursing process (options) The above table shows that 21 nurses with a percentage of 30% thinks that its lack of interest by nurses that hinders nursing process implementation while 49 of them with about 70 do not think it"s because of lack of interest by nurses. The above table data reveals that 38(54.3%) nurses thinks that one of the nurses" factors that hinder the implementation of the nursing process is lack of adequate knowledge on the nursing process by nurses and 32(46.7%) nurses do not think so.   The above table shows that 21(30%) nurses see no supply of nursing process materials as one of the administrative factors that hinders nursing process implementation and 49(70%) of them do not see it as a militating factor that hinder N.P implementation The above table data shows that 22(31.4%) nurses think that no motivation from the administration is one of the factors hindering nursing process implementation while 48(69.6%) of them do not think so.  Table 11: Frequency Distribution of the strategies that will ensure nursing process implementation/sustenance (options to choose). From the above table data shows that 45(64.3%) nurses are the fact that more staff should be employ for the nursing process to be fully implemented and 25(35.6%) of them are not for this fact. The above table data shows that 40(57.8%) nurses thinks that paying of satisfactory salaries will encourage full implementation of the nursing process in patient care and 30(42.9%) of them do not hold the same view. Data from the above table reveals that 35(50%) nurses think that regular supervision of the N.P by head nurses will ensure its implementation and sustenance while 35(50%) of them do hold the same view. The table above data shows that 40(57.1%) nurses are of the opinion that one of the strategy to ensure nursing process implementation and sustenance is organizing N.P workshops to enlightened nurses and 30(42.9%) of them are not for this opinion.

Demographic Data
The majority of the nurses were mostly females (60.0%) with age groups of between 31 to 40years making up 34%. This is the active age group as 20(83.3%) participant of this age group had good knowledge on the Nursing Process as well as its good implementation. It can also be seen that educational level influences the implementation of the nursing process as 19(82.6%) participants were nurse assistants and had a very poor knowledge as well as poor implementation of the nursing process which is in accordance with Saba(2002)said it is impossible to provide nursing care without processing knowledge in some way. By implication it means that the higher the educational status the better the quality of care offered to patients.
The findings on the level of education revealed that the higher the qualification the better knowledge and implementation of the nursing process, this is substantiated by the fact that the BNS had good knowledge (100%) of the N.P and all of them except one had no difficulties in implementing it and the lone person stated that "I initiate the nursing care plan but there is no continuity" which is contrary to Nwonu(2002) who said the nursing care plan is very important in the continuity of patient care.
The findings from the study show that longevity in service had no significant impact on the knowledge and use of the nursing process as most people who had worked for long were nurse assistants with little knowledge on the implementation of the Nursing process.

Factors That Hinder the Use of Nursing Process
The majority of the 70 nurses sampled faced difficulties in implementing the nursing process as 53% acknowledged that the nursing process was difficult to use. The lack of adequate knowledge and competence was the major reason advanced by 38(53.4%) of the participants among the various factors that were seen to hinder the effective implementation of the nursing process. This is substantiated by the fact that a significant number; 23(33%) of staff were Nurse Assistants who are not conversant with the N.P and also has poor knowledge on it. This was not in line with Ezeh, (2002), who carried out a study in a hospital and the findings of the study showed that competence and knowledge in the use of the concept is a militating factor against Nursing Process implementation. The lack of knowledge by implication means lack of implementation of the NP. The lack of interest by 21(30%) of nurses was also seen as a factor that hindered N.P implementation and this goes to support a similar study carried out by Marener (2008) who commented that nurses" attitudes toward the nursing process is bad. According to the findings of this study, shortage of nursing staff was also seen as the highest factor contributing to the inadequate implementation of the nursing process at the St Elizabeth Catholic General Hospital-Shisong by 52(74.2%).This supports a study carried out by Laryea (2008) who concluded that the reasons why the N.P is not implemented due to low staffing and too much workload. One factor identified by a significant number of respondents 28(40) % was that the nursing process is time consuming which was also identified by potter and Perry (2008).

Strategies That Will Ensure Nursing Process Implementation/Sustenance
The findings from the study showed that majority of the nurses sampled 45(64.3%), indicated that more staff should be employed to enhance the implementation of the nursing process. This is similar to the findings of Zeemat (2009), which emphasized that hospital authority must collaborate with the implementing staff in terms of stationary supply, finance and personnel for a lot of writing is done in the nursing care plan approach.

Conclusion
The nursing process is the bench mark for nursing care, and nurses should in this time of globalization use it in the care of patients. After interpretation of the above findings, it was concluded that the following factors; lack of interest by nurses on implementation of the nursing process, lack of adequate knowledge on the nursing process, Nursing process is time consuming, negligence, lack of cooperation among nurses on the use of the nursing process, lack of supervision and insufficient number of nurses could hinder the effective implementation of the nursing process. In order to improve upon the implementation of the nursing process and further improve on the general health of patients, health care institutions should ensure the employment of more staffs, regular supply of nursing process materials, employment of more qualified staffs, and the use of the nursing process in patient care should be made obligatory for all nurses. It could be concluded from the study that majority of the nurses of St Elizabeth Catholic General Hospital-Shisong do not implement the nursing process in patient care.