RESEARCH & EDUCATION
Factors influencing implementation
of the nursing process in Naivasha
District Hospital, Kenya
By Linet Nyatichi Mangare, Lilian Omondi, Antony Ayieko, Sabina Wakasiaka, Grace Omoni and Dalton Wamalwa
T
he nursing process (NP) is a systematic and dynamic
way to deliver nursing care. It is made up of five
interrelated steps: assessment, diagnosis, planning,
implementation and evaluation (Munro, 2004). According
to Altman (2003), the NP is systematic, and nurses and mid-
wives who use this framework make clinical decisions and
delineate a course of action based on analysis of available data.
Much research has been undertaken to explore how the
NP affects nursing practice and the profession, and its effect
on nurses and midwives. Urquhart et al (2009) agree that
the NP can facilitate progress in the nursing profession,
research and case management, while de Andrade and
Vieira (2005) report that failure to use the NP leads to
low-quality health care, disorganisation in nursing care
and conflicting roles. Takahashi et al (2008) reported that
a lack of sufficient knowledge about the NP is a barrier to
nurses’ and midwives’ compliance to implementation of the
NP. Thoroddsen and Ehnfors (2007) also found out that
many nurses and midwives have not been educated in the
use of standardised language in the NP, while Mwarangu
and Makau (2009) reported that nurses and midwives had
inadequate knowledge on the NP.
Alves et al (2008) found that, although the NP was seen
as a form of professional recognition, it was also viewed
with feelings of anger, dissatisfaction and frustration. Varcoe
(1996) found that nurses and midwives perceive the NP to
be too time-consuming, while Rossi and Casagrande (2001)
reported that nurses and midwives viewed the nursing proc-
ess as a documentation activity. A study by Fernández-Sola
et al (2011) identified lack of time and shortage of resources
as obstacles to use of the NP, whereas nurses’ involvement
and support from management were enabling factors.
According to Gatere (1993), shortage of staff is a major fac-
tor, while time and stationery are minor factors hindering
nurses and midwives from using the NP in a Kenyan teach-
ing and referral hospital. There was no information about
implementation of the NP in district hospitals in Kenya.
The current study was, therefore, aimed at identifying fac-
tors influencing the implementation of the NP in one of the
district hospitals.
© 2016 MA Healthcare Ltd
Theoretical framework
This study was based on the theory of planned behaviour
(Ajzen, 1991) which suggests that behaviour is dependent
AFRICAN Journal of Midwifery and Women’s Health, April–June 2016, Vol 10, No 2
Abstract
Background: The nursing process (NP) is a framework that
is applicable in all clinical settings to provide quality nursing
care. Training curricula for nurses and midwives in Kenya have
incorporated the NP as a framework for nursing care. However,
nurses and midwives find it difficult to implement it. This
contributes to poor-quality care.
Aims: This study was aimed at determining factors influencing
implementation of the NP in Naivasha District Hospital.
Methods: A quantitative cross-sectional study was conducted
between May–June 2012 on 83 nurses and midwives selected
using quota sampling. A structured questionnaire was used to
collect data then analysed using the statistical package for
social sciences. Descriptive statistics were used to summarise
the data and Pearson’s correlation coefficient was used to
establish correlation between variables.
Results: Training, practical experience, adequate time, reference
materials, administrative support, supplies and adequate staffing
were the major factors influencing implementation of the NP.
Conclusions: Implementation of the NP can be promoted through
focusing on beneficial factors such as adequate staffing, training,
administrative support, and providing resources.
Keywords: Nursing process, Health care, Nurses, Midwives,
Training, Support, Barriers, Implementation
Linet Nyatichi Mangare, Lecturer, Department of Nursing,
Kisii University, Kenya; Lilian Omondi, Lecturer, School
of Nursing Sciences, University of Nairobi, Kenya; Antony
Ayieko, Lecturer, School of Nursing Sciences, University
of Nairobi, Kenya; Sabina Wakasiaka, Lecturer, School
of Nursing Sciences, University of Nairobi, Kenya;
Grace Omoni, Director and Senior Lecturer, School of
Nursing Sciences, University of Nairobi, Kenya/President,
Confederation of African Midwives Association/Chair,
Lugina Africa Midwives Research Network; Professor
Dalton Wamalwa, Senior Lecturer, Department of
Paediatrics and Child Health, University of Nairobi, Kenya
67
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RESEARCH & EDUCATION
on one’s intention to perform the behaviour. Intention is
determined by an individual’s attitude (beliefs and values
about the outcome of the behaviour) and subjective norms
(beliefs about what other people think the person should
do, or general social pressure). Behaviour is also determined
by an individual’s perceived behavioural control, which is
an individual’s perception of their ability or feelings of self-
efficacy to perform the behaviour.
Statement of the problem
According to the Kenya Institute of Public Policy Research
and Analysis (Kimalu et al, 2004), the quality of health
care in Kenya is low. Nurses and midwives make up 51.5%
of health workers in public hospitals (Republic of Kenya,
2009). This implies that nursing services contribute a large
proportion of overall health care. It has been reported that
patients in Kenyan public hospitals are dissatisfied with
nursing care (Ministry of Health, 2010). Therefore, to
improve the overall quality of health care, nursing services
must be improved.
A study by Lee et al (1999) has shown that the quality
of nursing care improves when the NP is used. This implies
that use of the NP can be a major strategy for improving
the quality of nursing care. This framework is incorporated
into all the nursing curricula in Kenya. However, in most
hospitals the NP is not implemented (Ministry of Health,
2010). This leads to lack of prioritisation of patient care and,
subsequently, low-quality nursing care. There are no known
studies undertaken in a district hospital to indicate the reason
for these difficulties. The current study, therefore, set out to
determine the factors influencing use of the NP in Naivasha
District Hospital (NDH).
Aims
The broad objective was to determine factors influencing
the implementation of the nursing process by nurses and
midwives working in NDH. The specific objectives were:
„„ To determine nursing and non-nursing factors that could
promote the use of the NP
„„ To determine nursing and non-nursing factors hindering
the use of the NP.
Methodology
This was a quantitative cross-sectional study involving
83  nurses and midwives, conducted between May and
June  2012. The sample size was determined using the
Cochran's formula (Israel, 2009). The sample was selected
using quota sampling. The quotas included paediatric,
male and female wards, theatre, maternity, neonatal unit,
outpatient, and maternal and child health/family planning
clinics. Purposive sampling was used to select the required
sample from each quota. A  list of nurses and midwives
working in each department was obtained from the
nursing officer in charge and used as the sampling frame.
A  structured questionnaire was used to collect data. The
data were entered in Microsoft Excel and analysed using
the Statistical Package for Social Sciences (SPSS) version
20.0. Pearson’s correlation coefficient was used to establish
correlation between variables.
68 AFRICAN Journal of Midwifery and Women’s Health, April–June 2016, Vol 10, No 2
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Findings
Based on the existing literature considering the NP, two
categories of factors were developed: nursing-related and non-
nursing-related. Participants were asked to rate the extent to
which factors listed in each category could promote or hinder
the implementation of the NP on a five-point Likert scale.
Factors that could promote the use of the
nursing process
The majority of the respondents felt all the listed factors
could promote use of the NP. Training on the NP, practical
experience  and adequate time were the major nursing-related
factors (Table  1), while administrative support, reference
materials, supplies and adequate staffing were the major non-
nursing-related factors (Table 2).
Correlation between demographic characteristics
and nursing-related factors that could promote the
use of the nursing process
The study showed a statistically significant correlation
between qualification of participants and response to training
on NP (r = –0.228, P = 0.038); gender and response to drive to
appear professional (r = 0.234, P = 0.034); age and response to
drive to appear professional (r = 0.24, P = 0.029); and years of
clinical experience and response to drive to appear professional
(r = 0.285, P = 0.009). The rest of the characteristics had
statistically insignificant correlations (Table 3).
Factors hindering use of the nursing process
The main nursing-related factor hindering use of the NP
was inadequate time (92.7%) (Table  4), while the major
non-nursing-related factor was inadequate staffing (93.6%)
(Table 5).
Discussion
The majority of nurses and midwives in the study had a
diploma in nursing; this may be attributed to the nursing
council of Kenya’s efforts to ensure all the nurses and
midwives in Kenya are educated to at least diploma level
or higher, in order to improve the quality of nursing care
(Rakuom, 2010). This also implies that most of the nurses
and midwives in this hospital should be capable of adopting
the NP in the delivery of nursing care.
With regard to nursing-related factors, participants
reported that training on the NP, adequate time, a drive to
appear professional and practical experience of using the NP
promote use of the NP to a high extent.
The study showed statistically significant correlation
between certain sociodemographic characteristics and nursing-
related factors: qualification of participants and training on
the NP; gender and drive to appear professional; age and
drive to appear professional; and years of clinical experience
and response to drive to appear professional. This could be
attributed to the fact that the proportions of participants with
diploma qualification, females, age group 45–49  years and
© 2016 MA Healthcare Ltd
those with clinical experience of 21–25 years, were the largest
among all the participants.
The majority of participants agreed that non-nursing-
related factors that could promote use of the NP included:
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 RESEARCH & EDUCATION

Table 1. Nursing-related factors that could promote the use of the nursing process
Factor Extent to which factor could promote use of nursing process (n = 83)
Very low Low Moderate High Very high
n % n % n % n % n %
Training 0 0% 0 0% 2 2.4% 13 15.7% 68 81.9%
Practical experience 0 0% 3 3.6% 5 6.0% 25 30.1% 50 60.2%
Drive to appear professional 11 13.3% 4 4.8% 12 14.5% 32 38.6% 24 28.9%
Adequate time 6 7.2% 5 6.0% 2 2.4% 21 25.3% 49 59.0%
Others 0 0% 0 0% 0 0% 0 0% 0 0%

Table 2. Non-nursing-related factors that could promote the use of the nursing process
Factor Extent to which factor could promote use of nursing process (n = 83)
Very low Low Moderate High Very high
n % n % n % n % n %
Policy on use of the nursing process 6 7.2% 4 4.8% 9 10.8% 36 43.4% 28 33.7%
Support from other health workers 4 4.8% 5 6.0% 7 8.4% 24 28.9% 43 51.8%
Reference materials on Nursing Process 7 8.4% 2 2.4% 3 3.6% 21 25.3% 50 60.2%
Administrative support 2 2.4% 3 3.6% 6 7.2% 23 27.7% 49 59.0%
Performance contracts 10 12.0% 4 4.8% 8 9.6% 37 44.6% 24 28.9%
Incentives (rewards) 13 15.7% 5 6.0% 11 13.3% 11 13.3% 43 51.8%
Availability of supplies (pharmaceutical & non-pharmaceutical) 4 4.8% 1 1.2% 1 1.2% 24 28.9% 53 63.9%
Adequate staffing 6 7.2% 3 3.6% 2 2.4% 9 10.8% 63 75.9%
Availability of patient charts 4 4.8% 1 1.2% 14 16.9% 13 15.7% 51 61.4%
Printed assessment forms 3 3.6% 4 4.8% 16 19.3% 19 22.9% 41 49.4%
Printed nursing care plans 3 3.6% 2 2.4% 11 13.3% 15 18.1% 52 62.7%
Others Adequate linen and writing space on nursing care plan, n = 2 (2.4%)
(This response was given by two respondents, who did not rate it according to the Likert scale)

Table 3. Correlation between demographic characteristics and the participants’ rating of the extent
nursing-related factors could promote the use of the nursing process
Characteristics Test Training on Practical Drive to appear Adequate time
nursing process experience professional
Professional qualification Pearson correlation –0.228* –0.122 0.033 –0.035
P value 0.038 0.271 0.768 0.752
Gender Pearson correlation –0.182 –0.163 –0.234* –0.066
P value 0.100 0.140 0.034 0.552
Age Pearson correlation 0.102 0.024 0.240* 0.134
P value 0.358 0.833 0.029 0.226
Clinical Pearson correlation 0.100 0.098 0.285* 0.152

P value 0.369 0.377 0.009 0.170

Current work station Pearson correlation 0.144 0.144 0.186 0.196
P value 0.193 0.195 0.093 0.076
*Correlation is significant at the 0.05 level; n=83

policy on use of the NP; support from other health plans and assessment forms. This supports earlier findings
© 2016 MA Healthcare Ltd

workers; reference materials on NP; administrative support; (Fernández-Sola et al, 2011) showing that nurses’ involvement
performance contracts; incentives (rewards); availability of and institutional support promoted use of the NP.
supplies (pharmaceutical and non-pharmaceutical); adequate The study indicated that nursing-related factors that
staffing; availability of patient charts; and printed care hinder use of the NP included inadequate time, inadequate

AFRICAN Journal of Midwifery and Women’s Health, April–June 2016, Vol 10, No 2 69
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RESEARCH & EDUCATION

Table 4. Nursing-related factors hindering use of the nursing process

Factor Extent to which factor could hinder use of nursing process (n = 83)
Very low Low Moderate High Very high
n % n % n % n % n %
Inadequate time 4 4.8% 1 1.2% 1 1.2% 9 10.8% 68 81.9%
Inadequate knowledge 9 10.8% 5 6.0% 14 16.9% 16 19.3% 39 47.0%
Nursing diagnosis terminologies 19 22.9% 8 9.6% 16 19.3% 17 20.5% 23 27.7%
Lack of experience using the nursing process 7 8.4% 14 16.9% 11 13.3% 24 28.9% 27 32.5%
Working in specialised unit 34 41.0% 14 16.9% 15 18.0% 9 28.9% 11 13.3%
Working in a clinic 28 33.7% 9 10.8% 10 12.0% 14 16.9% 22 26.5%
Others 0 0% 0 0% 0 0% 0 0% 0 0%

Table 5. Non-nursing-related factors hindering use of the nursing process

Factor Extent to which factor could hinder use of nursing process (n = 83)
Very low Low Moderate High Very high Total*
n % n % n % n % n % n %
Lack of policies on use of the nursing 13 15.7% 14 16.9% 9 10.8% 18 21.7% 29 34.9% 83 100%
process
Lack of reference materials on the nursing 7 8.4% 5 6.0% 6 7.2% 25 30.1% 40 48.2% 83 99.9%
process
Performance contracts 19 22.9% 18 21.7% 15 18.1% 12 14.5% 17 20.5% 81† 97.7%
Lack of incentives (rewards) 21 25.3% 11 13.3% 7 8.4% 11 13.3% 32 38.6% 82‡ 98.9%
Inadequate supplies (pharmaceutical and 6 7.2% 5 6.0% 8 9.6% 21 25.3% 43 51.8% 83 99.9%
non-pharmaceutical)
Inadequate staffing 1 1.2% 2 2.4% 2 2.4% 8 9.6% 70 84.3% 83 99.9%
Resistance from other disciplines 24 28.9% 7 8.4% 15 18.1% 17 20.5% 20 24.1% 83 100%
Lack of patient charts 13 15.7% 8 9.6% 15 18.1% 14 16.9% 33 39.8% 83 100.1%
Lack of printed assessment forms 15 18.1% 17 20.5% 14 16.9% 9 10.8% 28 33.7% 83 100%
Lack of printed nursing care plans 19 22.9% 8 9.6% 13 15.7% 10 12.0% 33 39.8% 83 100%
*Percentages may not sum to 100 due to rounding. †2 participants did not respond. ‡1 participant did not respond

knowledge, nursing diagnosis terminologies, and lack of
experience in using the NP. The study further revealed that
working in a specialised unit and working in a clinic hinder
use of the NP, but only to a low extent. This implies that
participants require more training and practical experience
on the use of the NP.
Non-nursing-related factors that hinder use of the NP to a
high extent included lack of policies, lack of reference materials,
lack of incentives (rewards), inadequate supplies, inadequate
staffing, lack of patient charts, and a lack of printed assessment
forms and printed nursing care plans. A lack of performance
contracts and resistance from other disciplines also hindered use
of the NP to a low extent. These findings agree with those of
Gatere (1993).
NP. According to the findings, implementation of the NP can
be promoted through adequate staffing, training of nurses on
clinical use of the framework, administrative support, and
providing adequate supplies and reference materials to nurses
and midwives. AJM
Acknowledgement: The project described was supported by the
Linked-Strengthening Maternal, Newborn and Child Health
Research Training in Kenya through a grant from the US
National Institutes of Health (Number 5R24TW008907).
The content is solely the responsibility of the authors and does
not necessarily represent the official views of the US National
Institutes of Health.

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The target population was small, hence the findings may not Ajzen I (1991) The theory of planned behavior. Organizational Behavior
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© 2016 MA Healthcare Ltd

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AFRICAN Journal of Midwifery and Women’s Health, April–June 2016, Vol 10, No 2
RESEARCH & EDUCATION
Key Points
The nursing process is a framework that can be used in all
„„
clinical settings to provide quality nursing care
Nurses and midwives working in Naivasha District Hospital
„„
reported finding it difficult to use the nursing process
Training on nursing process, adequate time and practical
„„
experience could promote use of this framework
Inadequate staffing hinders use of the nursing process
„„
Republic of Kenya (2009) National Human Resources for Health Strategic
Plan 2009–2012. Ministry of Medical Services, Nairobi
Takahashi AA, de Barros ALBL, Michel JLM, de Souza MF (2008)
Difficulties and facilities pointed out by nurses of a university hospital
when applying the nursing process. Acta paul enferm 21(1): 32–8.
doi: 10.1590/S0103-21002008000100005
Thoroddsen A, Ehnfors M (2007) Putting policy into practice: pre-
and posttests of implementing standardized languages for nursing
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Urquhart C, Currell R, Grant MJ, Hardiker NR (2009) Nursing
record systems: effects on nursing practice and healthcare outcomes.
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Varcoe C (1996) Disparagement of the nursing process: the new dogma?
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