Abstract
Context: Nursing process is the systematic method of thinking used by nurses to develop an individualized plan of care for patients. Effective use of the nursing process depends on a nurse's familiarity with the standardized nursing language.
Aim: This study evaluates the utilization of nursing process on the day of admission and within 24 h of patient admission in a teaching hospital. Setting and Design: Descriptive and Retrospective design was utilized.
Materials and Methods: Systematic sampling technique was adopted to evaluate 959 patients' records from 2014 to 2016 in 2 medical and 2 surgical wards over 3 months period using a self designed checklist.
Statistical Analysis Used: Data collected was analyzed using SPSS version 21 and presented as frequencies and percentages. T test was used to test the significant difference between variables with P value set at ≤ 0.05.
Results: Only 24.9% of the medical records contained the nursing process form. On the day of admission, <25% of the charts included a complete record of nursing assessment, nursing diagnoses, nursing intervention, and the evaluation. The highest phase of nursing process recorded is nursing diagnosis followed by patient assessment. At 24h postadmission, no significant increase was noted in the phases of nursing process recorded. There was a significant difference between the frequencies of documentation of nursing diagnosis and the nurses' area of practice (P = 0.001).
Conclusions: Nursing process utilization remained poorly incorporated into the activities of nurses in this institution. Therefore, continuing professional education on nursing process and supervision should be mandated.
Keywords
Nursing assessment Nursing diagnosis Nursing process utilization
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© 2017, Author(s). This open-access article is available under the Creative Commons Attribution 4.0 (CC BY 4.0) International License (https://creativecommons.org/licenses/by/4.0/), which allows for unrestricted use, distribution, and reproduction in any medium, provided that the original work is properly cited.