Clinical Utilization of Nursing Process in Improving Patient’s Outcome and Its Associated Factors: A Cross-Sectional Study among Nurses and Midwives Working at Njombe Regional Referral Hospital, Tanzania

Background: Improvement of patient care in any hospital depends primarily on the quality of nursing care. Nursing care is enhanced by the nursing process, which outlines the nursing activities to be provided for a patient. Methods and Materials: A cross sectional design employing quantitative methods was conducted in Njombe RRH in December 2021. Quantitative data were collected from nurses and midwives from all wards by simple random sampling techniques using a sample-size calculator. SPSS version 26.0 was used to analyse data whereby a p-value of 0.05 was considered a decision mark for the significance of the result; Chi-square and Logistic regression respectively were used to find out the association and its strength between variables. Result: Majority of the respondents, 41 (85.4%), had inadequate knowledge and 33 (68.8%) found them people with a negative attitude to the nursing process. Significantly, there is an association between knowledge and clinical utilization (AOR 2.24; 95% CI: 1.6 - 2.5; P 0.04), attitude and clinical utilization (AOR 4.32; 95% CI: 1.8 - 3.7; P < 0.001). Conclusion: A knowledge gap in relation to the utilization of the nursing process and a negative attitude were noted to be associated significantly with the utilization of the nursing process among nurses and midwives. It is recommended on-job training, supportive supervision, and Value Clarification and Attitude Transformation (VCAT) Evaristus


Introduction
The nursing process is the gold standard for nursing care provision and the only guide that enables nurses to adequately communicate patients' general conditions for the purpose of continuity of care within nursing and interdisciplinary health care teams [1]. It has been adopted in many developed countries and there is evidence that it is actually being used by nurses with positive patient outcomes [2].
The nursing process has been defined as a series of critical thinking activities that are used by nurses as they care for their patients [3]. These activities define a nursing model of care, differentiating nursing from other helping professions.
The nursing process consists of interconnected steps, and it is an organized and self-motivated way of giving nursing care to patients. It encourages humanistic, outcome focused, cost-effective care; and it is based on the belief that, as we plan and convey care, we must also consider the exceptional values, concerns, and desires of the consumer, who may be an individual, a family, or a community [4].
The nursing process as a systematic approach intended to guide nursing practice with a view to improving the quality of care. It helps nurses to establish and maintain a certain standard of care that enhances quality over time while facilitating the provision and management of care [5]. Nurses use the nursing process at all levels of care to guide their interventions depending on the health care problems identified in the client [6]. The nursing process requires both human and non-human resources as well as ample institutional organization to enable successful execution in all settings with the objective of improving health outcomes for all groups of persons [2].
The utilization of the nursing process and a nursing diagnosis has been identified as critical to nursing practice [7]. Some of the factors affect the use of nursing.
The process has been studied among nurses working in various health institutions. Several factors were found to impede the efficient implementation of the nursing process. Operational difficulties involved in the systematization of nursing care in practice, such as a lack of knowledge of the steps involved in the process, too large number of tasks assigned to the nursing team, the poor quality of professional education, and inadequate reports on the physical examination related to the disease, are among these factors (Pokorski, et al., 2009). The nursing process and the resulting written plan of care pick up communication through the allotment of knowledge and information between departments and shifts, as well as ensuring better communication with the multidisciplinary team [8].
Although the nursing process is a major element of nursing education in sub-Saharan Africa [9], most countries face major issues with its effective implementation in almost all health care settings and the extent to which it is implemented is still very unclear. The present study will justify a follow up of the status of implementation of the nursing process. Hence, the ultimate purpose of the current study is to dig deep into the factors contributing to why nurses and midwives did not utilize the effectively nursing process in caring patients during their daily working shift, and these will focus on staffing level, knowledge, attitude and other enabling and enabling factors.
Research questions 1) What are the enabling factors impede the implementation of nursing process? 2) Do nurses and midwives have adequate knowledge to implementation of the nursing process?
3) What are the attitude of nurses and midwives towards nursing process? 4) Is there significant association between knowledge, attitude and clinical utilization of the nursing process?

Methods and Materials
Study Area and duration of the study The study was conducted in all departments and units whereby nurses and midwives are working in Njombe Regional Referral Hospital from November 2021 to December 2021. The Hospital has a total of 59 available Beds, with an average OPD attendance of 56 Patients per day, the average in patient's admissions per day is 10 Patients; this makes total annual OPD attendance at 33,181 patients and total in-patients at 5603. The catchment area of Njombe RRH is 732,578 people and receives referrals from both public and Private Health Facilities including District Hospitals, Health Centers and Dispensary. From the regional Hospital, the patients are referred to Mbeya Zonal Hospital. Apart from the referral services, the hospital also provides service of curative, preventive and rehabilitative services in all these services nurses and midwives are keyworkforces.

Study designs and population
The facility-based cross sectional study with a quantitative approach was employed to take off the study to 48 nurses and midwives working at Njombe Regional Referral Hospital at a single point of time mid-exposures and outcome of interest; it has been selected because it is relatively cheap and less time consuming and the current study is not going neither to establish cause-and-effect relationship nor analyses behaviour over a period of time or long terms trends. A total of 48 nurses and midwives were involved in the study. A simple random sample of 48 nurses and midwives were selected from a population of 54 nurses and midwives currently working at the Hospital. Using a list of all 54 participants.
Each participant was given a number (1 to 54), and these numbers are written on small pieces of paper. All the 54 papers are kept in a box, after which the box is shaken vigorously, to ensure randomization. Then, 48 papers are taken out of the box, and the numbers are recorded. The nurses and midwives belonging to these numbers constituted the sample of the study (n = 48)

Data Collection methods and Tools
Administering written questionnaires and reviewing documents are the two methods employed in the study for data collection, whereas Self-administered structured questionnaires for determining the enabling and reinforcing factors and attitude was adopted from the study done by Hagos with his friends [10], and knowledge assessment was adapted and modified from the study of Mwangi with his friends [11]. Documentary review of Guideline for ISS and EHPA the 2019, DHIS2 and HRMIS were used as tool for reviewing staffing level for nurses and midwives and number of patients served and admitted in the hospital (See Table 1).

Validity and reliability of the questionnaire
Checking the reliability of likert scale questions made up of twenty dimensions, the Cronbach's alpha was computed for overall and each sub-dimensional item to check the internal reliability and consistency of results prior to the actual study, in order to determine the reliability of modified questionnaires. According to George & Mallery [12] (2003:231), these authors provided the following rules of thumb on Cronbach's Alpha value; ≥0.9 Excellent, ≥0.8 Good, ≥0.7 Acceptable, ≥0.6 Questionable, ≥0.5 Poor and ≤4 Unacceptable. The Cronbach's alpha ranges between 0 (denoting no internal reliability) and 1 (denoting perfect internal reliability). Table 2, Cronbach's alpha result was acceptable for analysis with Table 1. Sources of research instruments.

Specific Research Objectives
Tool Analysis To determine the enabling and reinforcing factors Self-administered structured questionnaire Descriptive analysis To assess knowledge on nursing process among nurses and midwives Self-administered structured questionnaire

Descriptive and Binary Logistic analysis
To assess attitude of nurses and midwives on nursing Self-administered structured questionnaire Likert analysis a score of 0.76. This indicated that the items were reliable and the item statistics released meant they didn't exceed 1 and, therefore, all items were analysed. Inter-item correlation using SPSS version 26.0 was also computed and observed to detect whether the items on the Likert-type scale and items for trapped's attitude are trapped into the same underlying concept. This conclusion was made based on a rule of thumb for similar fair means and any items that have scores that are quite a lot higher (or lower) than the others were thought to be removed from the questionnaire to make it reliable [12].

Research Variables
The current papers consist of dependent variables; clinical utilization of the nursing process and several independent variables, including knowledge, attitude, administration support, resource allocation, time, nurse-patient ratio, feedback, motivation, on-job training and professional educational level. Knowledge and attitude variables were operationalised to make them measured by choosing appropriate indicators as shown in Table 3.

Data collection procedure
Data was collected by one trained diploma nurse and one-degree holder of Nursing research assistant from the respondents in their working areas after clearly filling out an informed consent form and providing instructions on how to attempt the administered questionnaire. Attempted questionnaires were then collected for a while and this was taken as a matter of agreement between data collectors (research assistants) and respondents about the convenient time for collection and giving ample time for attempting.

Data processing and analysis
Data was checked for the completeness, missing values, and coding of questionnaires was done; then, the data was entered into the computer and processed (data cleaning) and analyzed using SPSS version 26.0. The data was summarized and described using descriptive statistics and chi-square and binary logistic regression was used to determine the relationship of socio-demographic characteristics Ethical approval was granted by Njombe RRH Research Ethic Committee with an approval letter (NRRH/REC/2022/01). Study participants were assured privacy, confidentiality and anonymity to be observed throughout the study, informed about the purpose of the study, the assortment of information needed from them and they can refuse or stop.

Response Rate
Total of 48 participants were involved in the study which is 100% of all sampled participants as shown in Table 4.

Social demographic characteristics among respondents
The findings of the study as presented in Table 5 show that it accounts for 16 (33.3%) and females, 32 (66.7%). The demographic age of the age of the nurses and midwives were found that a large sample falls between the ages of 31 -40 years, which shows 24 (50%), whereby the sample mean of age was 30.9 and 33. More nurses and midwives attained a technician certificate in Nursing, which accounts for 24 (50%).

Clinical utilization of Nursing Process
Of total study participants, 15 (31.3%) were effectively utilized nursing process in their Daily working when caring patients as shown in Figure 1.
As reported in Table 6, Individual response on application of nursing process was also analysed to identify distribution of participants with their response.
As revealed in Table 7, individual response on the most difficult area in implementing the nursing process revealed that, 31 (64.6%) agreed that implementing nursing intervention is the most difficult area in the nursing process and 29 (60.4) reports for nursing diagnosis as the most difficult area while 34 (70.8%) did not agreed that documenting is the difficult area in nursing process.

Enabling and reinforcing factors for clinical utilization of nursing process
Of the total study participants, 32 (66.7%) participants said hospital administration do not support the application of nursing process and 29 (60.4%) said there is no appreciating feedback available for application of nursing process as shown in Table 8.

Knowledge on Nursing Process among nurses and midwives
The results of knowledge of the nursing process revealed that 41 (85.4%) of the study participants had inadequate knowledge of the nursing process and only 7 (14.6%) were found with adequate knowledge. Table 9 presents general knowledge whereby 28 (58.3% were unable to identify parties involved in developing the  nursing process. The knowledge of participants on individual question was also considered to highlight the most area in which participants were conversant or not. Result shows, 44 (91.7%) participants were unable to define assessment in the context of nursing process and only 9 (18.8%) were able to differentiate between nursing and medical diagnosis (See Table 10).

Attitude of Nurses and Midwives on nursing process
The study intended to assess attitude of nurses and midwives in application of nursing process. Out of study participants, 15 (31.3%) had positive attitude on nursing process and 33 (68.8%) found with negative attitude and as shown in Table 11 presents response on individual items.

Association between knowledge, attitude and clinicalutilization
As revealed in the Table 12, presents the results on influence of knowledge and attitude on nursing process in relation to its clinical utilization. Result from the Chi-square test and binary logistic regression showed that, there is a statistically significant association between knowledge and clinicalutilization (AOR 2.24; 95% CI: 1.6 -2.5; P 0.04), attitude and clinical utilization (AOR 4.32; 95% CI: 1.8 -3.7; P 0.000).

Discussion
The result of this study showed that most of the enabling and reinforcing factors did not egg on nurses to apply to the nursing process. For instance, more than half (66.7%) of the respondents said that the administration of the hospital did not support the application of the nursing process; 64.6% said the nurse/patient ratio is not optimal for applying the nursing process; 60.4% said there is no monitoring and evaluation for application of nursing process and 66.7% said there is no appreciating feedback available for application of nursing but more than half (64.6%) of the respondents did not agrees if salary and motivation can motivating for application of nursing process even though 62.5% said they did not get on-job training on nursing process. Findings of study are parallel to that. of Hagos with his friends [10], who found slightly less than half (47%) of the respondents said that the administration of the hospital supported the application of the nursing process these similarities and 75% said there was an imbalance between the nurse/patient ratio.  The findings revealed that although the nurses were taught the nursing process at school, more than a third quarter of the nurses and midwives had inadequate knowledge, especially in the steps of assessment, planning and evaluation. This could be due to tutors who taught the nursing process not understanding the nursing process themselves, as observed by Mwangi with his friend in their study [11]. These findings support that of Agyeman-yeboah with her colleagues [13], who found nurses not having a better understanding of the nursing process, and that of Hugoz with his friends [10], who also found the majority of nurses   associated with the utilization of the nursing process, which found that lack of knowledge on the nursing diagnosis prevented nurses from effectively using these nursing diagnoses. This difference could be due to the scope of the study, as the current study focused on the entire nursing process whilst the comparison was focused on only nursing diagnosis. The findings from this study revealed that the nurses and midwives did not utilize the nursing process in the ward; this was supported by the study of Agyeman-yeboah with her colleagues [13], who found nurses did not implement it in the ward because they did not really understand it. In the case of the current study, this is not only for understanding of the nursing process, but also due to negative attitudes to the application of the nursing process. The author confirmed that nurses and midwives with a positive attitude towards the nursing process are two times more likely to apply to the nursing process than those with a negative attitude. This result was dissimilar to the study of Hagos, Alemseged, Balcha, Berhe and Aregay [10]. The majority of the respondents had a positive attitude towards the nursing process. This difference could be due to a couple of reasons, including teaching and learning strategies at school, the working environment and management process and supportive supervision approaches.

Strengths and Limitation of the Study
The study was strong enough as it used tools and standardized tools. But it was limited to knowledge, attitude and enabling and reinforcing factors; the study also did not find out the relationship between socidemographic characteristics and the independent variables of the study; knowledge and attitude.

Conclusions and Recommendation
The study concludes that the number of nurses and midwives was insufficient, hence increasing workload, which in turn affects clinical utilization of the nurs-ing process. From the enabling and reinforcing factors, administration support, nurse/patient ratio, lack of appreciating feedback and monitoring and evaluation were the factors noted for enabling and reinforcing the implementation of the nursing process.
The majority of the study participants had inadequate knowledge of the nursing process and more than half of the study participants had negative attitudes towards the nursing process. Conclusively, knowledge and attitude are the significant factors in the clinical utilization of the nursing process. Training intervention to address knowledge gaps followed by supportive supervision and attitude transformation through VCAT were the recommendations to hospital management in facilitating effective clinical utilization among nurses and midwives working at Njombe RRH as these two interventional approaches will upgrade their knowledge and attitude to the nursing process.

About the Authors
Evaristus P. Makota is a hospital research and training coordinator, Winfred P. Kyambile is a medical officer in-charge, Vinogelaki Seif is a nursing officer incharge, Ashery Mwalukolo is a quality improvement focal person and Emmanuel Ulomi is a clinical service coordinator.