Adoption of Theory-Based Nursing Care in Clinical Practice

Adoption of Theory-Based Nursing Care in Clinical Practice; a study conducted among 20 selected nurses of various specialties of a tertiary hospital in Ondo state

ABSTRACT:Several concepts have been developed over the years in an attempt to improve nursing practice; efforts are being made daily to base nursing care on evidences that have proven to withstand test of time and not mere traditions passed from generation to generation which is not helping the profession in achieving the desired global image. Amongst efforts put in place is evidences from Nursing Research and application of Nursing Theories.

The study aimed at exploring into the level of knowledge of nurses about nursing theories, exploring into the extent to which nurses are willing to adopt theory-based nursing practice, ascertaining the influence of level of education on knowledge of theory based nursing care and influence of work experience on adoption of theory based nursing care.

Results showed that greater proportion (60.0%) of the respondents had fair knowledge about theories, almost all (90.0%) the nurses had positive perception about theories, greater proportion (85.0%) of the nurses are currently not practicing theory-based nursing care, almost all (90.0%) the nurses were willing to adopt theory-based nursing care practice. Hypothesis testing revealed that there is no significant relationship between Educational Level and Knowledge of Theory-Based Nursing Care (P value 0.775) and there is no significant relationship between Work Experience and Willingness to adopt Theory-Based Nursing Care (P value 0.311). Factors affecting adoption of theory-based nursing care were itemized to include poor insight, stereotype way of practice, workload. Recommendations were made to ease the barriers.

In conclusion, adopting theory-based nursing practice is beneficial to the profession as it enhances reliable care.

Key words: evidence-based practices, theory-based practice, adoption, willingness, quality of care, practice  

INTRODUCTION

Several concepts have been developed over the years in an attempt to improve nursing practice; efforts are being made daily to base nursing care on evidences that have proven to withstand test of time and not mere traditions passed from generation to generation which is not helping the profession in achieving the desired global image. Amongst efforts put in place is evidences from Nursing Research and Theory-based Nursing Care. Nursing theories are being embraced globally as a mean to explain nursing care, guide nursing practice and give meaning to the profession. Practicing with evidences portray nurses as professionals with difference as nursing theories provide nurses with sense of identity and make their roles in healthcare delivery a unique and incomparable one¹. It helps to pinpoint what should form the foundation of practice by explicitly describing nursing as nursing strives to establish a unique body of knowledge²

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A researcher in her article written to support evidence-based nursing practice pinpointed estimates of nearly 200,000 patients die from avoidable healthcare errors every year and 40% of patients do not receive scientifically proven treatments, hence the need for greater emphasis on evidence-based practice which could only be best gotten from knowledge of theories and nursing researches³; it is said that this knowledge is becoming more complex day-in-day-out such that the amount of medical knowledge that a nurse practitioner must know today doubles every three years.

There is dearth of data to specifically explain the perception, knowledge and attitude of nurses on adoption of theory-based nursing care in clinical practice in several countries in Africa. However, in Nigeria,a study conducted on Knowledge and Utilization of Evidence-Based Nursing Practice among Nurses of Offa Specialist Hospital, Kwara State revealed that a greater proportion (77.3%) of the nurses were rated high in knowledge of evidence-based nursing, 95.5% affirm that they are aware of the concept of practicing based on evidences, only 30.9% of the nurses base their practice on evidence although the source of evidence was not defined and 57.3% of the nurses have made efforts to write protocols/guidelines that will promote implementation of evidence-based nursing practice⁴.

In a strive to improve quality of care, nursing profession has evolved globally over the years to come to what it is today; an evidence-based practice profession. Studies have shown that nursing theories guide nurses in acting more proactively, making concrete and directive plan of care and tactfully carrying out nursing care in a way that it gives efficient nursing care⁵. In our local settings, evidence-based nursing care is being encouraged but anecdotal observations have it that this is not being totally complied with all over and no studies have been able to successfully measure accurately the extent of compliance in trying institutions. While some of the studies reviewed opined that theory-based nursing care has proven to be highly effective in institutions that have adopted them and showed factors that work against adoption of Nursing Process; a nursing theory, in nursing care of patients^{6, 7}, there is paucity of data to ascertain whether nurses actually understand and accepts the concept of theory-based nursing care as a whole.

Objective of the study

General objective: To assess the compliance of nurses with evidence-based practices and to explore into the extent to which nurses are willing to adopt theory-based nursing practice.

Specific objectives:

1. To explore the level of knowledge of nurses about theories
2. To ascertain how nurses perceive nursing theories
3. To assess the extent to which nurses practice theory-based nursing care
4. To assess the willingness of nurses in adopting theory-based nursing care
5. To identify the factors affecting adoption of theory-based nursing care
6. To identify ways through which adoption of theory-based nursing care can be improved

Hypothesis

1. There is no significant relationship between level of education and knowledge of theory-based nursing care
2. There is no significant relationship between work experience and willingness to adopt theory-based nursing care   

MATERIALS AND METHODS

The study was conducted in Owo among nurses working in the tertiary hospital in Owo (Federal Medical Centre, Owo) though they were met outside the premises of the institution as there was industrial action among the workers during the time of data gathering. The study adopted the mixed method of research design. The total population of nurses in the institution was 367 as of time of data gathering. The study population was the selected nurses based on their area of specialty. Sample size was 20 and research elements were chosen purposively on area of specialty and posting.

Inclusion criteria

• Nurses that are on permanent appointment with the tertiary institution
• Nurses that have area of specialty
• Nurses that have spent at least 1 year in practicing his/her specialty

Exclusion criteria

• Nurses who did not give consent
• Nurses that are less than a year in the institution
• Nurses that are under disciplinary action(s)

Instruments for data collection

Research questionnaire which was developed by the researchers based on the current related literatures was used to get the necessary information. The questionnaire was a structured self administered one. The questionnaire consisted of different sections; section A was about the demographic data of the respondents, section B tested the level of knowledge about nursing theories, section C assessed the perception of nurses about theory, section D assessed the current practices and willingness to adopt theories in rendering nursing care, section E looked into the factors affecting adoption of theory-based nursing care, section F addressed the ways through which theory-based nursing care can be improved. Interview guide was also used to gather information about personal opinions on pertinent issues on theory-based nursing care.

Sample and Sampling technique

Sample was purposively selected based on their area of specialty and present posting in the institution. The interview session was a major determinant in sample size. A major stop was put to selection of samples when saturation was reached on the eighteenth respondent.

Analysis of data

After completion of the field work, questionnaires were given serial numbers and variables coded before data entry. Data were entered and analyzed by using STATA (SE 12.0) whereby frequency tables were run, mean and standard deviation was calculated. Test of relationship to determine the probability that the hypothesis was true or not was also done.

Outcome measure

Knowledge scoring: knowledge was classified as good, fair, moderate or poor knowledge. To determine the level of knowledge, the response to questions on knowledge was scored as follows: there were ten questions in this section and each of them carried one point making a total of ten points. This was translated to percentage (i.e ten points is equal to one hundred percent). Therefore, the number of correct answer was based on percentage. Below fifty percent was classified as poor knowledge, fifty to sixty percent was classified as fair knowledge, sixty one to seventy percent was moderate knowledge while above seventy percent was good knowledge.

Perception scoring: perception was classified as positive or negative perception. This section has ten questions and each question is equal to a point, this will be converted to percentage as well. Score of sixty percent and above was classified as positive perception while score below sixty percent was classified as negative perception.

Ethical consideration

Consent was gained from each respondent; they were informed about the objectives of the study, that their participation was voluntary and that there was no kind of force that would be employed to have them participate. All information gathered was treated with confidentiality.

Limitation of the study

There were errors due to bias of respondents, sample size used was too small compared to the total population of nurses in the institution though sample selection was stopped due to saturation of data. This could be a reason for the failure to identify a difference in tested relationships if one truly existed.

RESULTS

The results revealed that greater proportion (80.0%) were females. With respect to marital status, almost all (95.0%) were married. All (100%) of the respondents are Nigerians. Out of the respondents, the rank that has the highest (25.0%) number is SNO. Most (65.0%) of the respondents had work experience of between 11-20 years, quite a number (70.0%) had first degree as the highest educational level. Medical/Surgical field made up the highest (40.0%) number of respondents. The minimum age of respondents recorded was 33 years, maximum age was 52 years, mean age was 41.2 and standard deviation was 5.46.

Table 1: Respondents’ socio-demographic characteristics (n = 20)

Greater proportion (60.0%) of the respondents had fair knowledge about theories.

Table 2: Knowledge about theory (n = 20)

Almost all (90.0%) the nurses had positive perception about theories.

Table 3: Perception about theory (n = 20)

Greater proportions (85.0%) of the nurses are currently not practicing theory-based nursing care.

Table 4: Theory-based nursing care practice (n=20)

It can be seen that almost all (90.0%) the nurses were willing to adopt theory-based nursing care practice.

Table 5: Willingness to adopt theory-based nursing practice (n = 20)

Hypothesis 1: revealed that there is no significant relationship between Educational Level and Knowledge of Theory-Based Nursing Care (P value 0.775).

Table 6: there is no significant relationship between Level of Education and Knowledge about Theory-Based Nursing Care

Pearson Chi2(4) = 1.7857  Pr = 0.775

Hypothesis 2: revealed that there is no significant relationship between Work Experience and Willingness to adopt Theory-Based Nursing Care (P value 0.311). 

Table 7: there is no significant relationship between Work Experience and Willingness to adopt Theory-Based Nursing Care

Pearson Chi2(2) = 2.3362  Pr = 0.311

Reports/observations from the interview session

1. Though good scores were recorded for knowledge among the selected nurses, but it was noted that a good number of them actually went home with the questionnaires so as to read up before answering them (as confessed by them)
2. Just three (3) nurses answered the questionnaire on-site and one (1) of the three actually googled to answer about three of the questions
3. Quite a number of them do not recognize nursing process as a theory
4. A good number of the nurses want to adopt theory-based nursing care at all times if the following basic things are put in place in their institution

-          Regular update training

-          Monitoring and Evaluation to ensure the appropriate use of theory in practice

-          Availability of equipments

-          Motivation/giving of incentives as reward for hard work

-          Collaboration of those in academics with clinicians in research studies

-          Encourage academic advancements among clinical nurses as better skills come with higher education

-          Improvement in manpower sources

-          Proper funding of health institutions

-          Each health care agency should adopt and enforce use of specific theories in their institutions

Factors affecting adoption of theory-based nursing care

• Poor insight which has made laziness and improvisation to thrive
• Stereotype way of practice
• Workload
• Poor dissemination of research outcome information
• Non availability of equipments, equipped library and update training in the practice
• Lack of motivation
• Poor in-depth knowledge about nursing theories
• Inability to integrate theory into practice appropriately
• Complexity of health- illness continuum

DISCUSSION

Good knowledge of the nurses about theory-based nursing practice is quite low (20%), a greater proportion (90%) of them have positive perception about theory-based nursing practice, lower percentage (15%) are presently practicing theory-based nursing care, however, majority (90%) of the nurses are willing to adopt theory-based nursing practice in comparism to a study conducted by nurse-researchers⁴ on Knowledge and Utilization of Evidence-Based Nursing Practice among Nurses of Offa Specialist Hospital, Kwara State, Nigeria which revealed that a greater proportion (77.3%) of the nurses were rated high in knowledge of evidence-based nursing, 95.5% affirm that they are aware of the concept of practicing based on evidences, only 30.9% of the nurses base their practice on evidence and 57.3% of the nurses have made efforts to write protocols/guidelines that will promote implementation of evidence-based nursing practice.

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Nursing profession is a scientific corporate entity with specific, identifiable discrete body of knowledge that is made up of paradigms, frameworks, models and theories. Unification of nursing theories and practice brings to the fore front the scientific nature of nursing. In view of this, each agency should designate a specific nursing theory they will adopt in specific cases; this is in line with the work of Thompson⁸ in which she said choice of theory that fits best in any line of practice can be arrived at by considering the purpose i.e. is it for quality care, to improve a system or process, to frame a research study that will contribute to quality care or to educate patients?  

The factors highlighted to have impaired constant practice of theory-based nursing care shared similarities with the work of Adeleke⁶, wherein he noted that there are barriers to effective evidence-based practice. He highlighted them to include insufficient organizational support from administration and physicians, lack of time, lack of resources, lack of authority, lack of incentives and lack of relevance. Inability to integrate theory into practice appropriately: is in accordance with the statement of Hugh⁹, wherein it was affirmed that certain models and theories are not infallible and as such there may be difficulties in applying theories appropriately to practice. This has called for looking into strategies for bridging the gap between theory and practice. The complexity of health- illness continuum which will warrant use of multiple theories on a single patient; is in line with the work of Meleis¹⁰, where she dealt thoroughly with barriers to theory development and pinpointed that each theory in itself is not capable of holistically dealing with nursing phenomena and theories were not perceived to reflect the complexities of nursing practice. Poor in-depth knowledge about nursing theories: in the study of Agbedia, Okoronkwo, Onokayeigbo and Agbo¹¹, it was affirmed that though certain theories (Roy and Orem) are being used by nurses in Nigeria, others were neglected due to their difficulty in being indoctrinated in our settings as a result of differences in culture. But it can be said that situations like this call for adapting the theories while we adopt the fully applicable ones.   

RECOMMENDATIONS

Enrichment of our various curricula of training and procedural manuals with nursing theories and their applications; this helps in introducing the idea/practice early enough. To fully deliver on issues of evidence-based practice, initiatives such as education and curricular realignment, model and theory development, scientific engagement in new fields of research with development of a national research network needs to be done¹².

Regular update training for clinical nurses; diffusion and synthesizing of necessary information to get clinical nurses up to date in nursing theories that aid their practice. The available medium for these are Mandatory Continuing Professional Development Programme (MCPDP), Continuous Education Unit programs in institutions, conferences etc  

Monitoring and Evaluation to ensure the appropriate use of theory in practice

Encourage collaborative nursing research between nurse clinicians and academics; this fastens application of results in practice

Provision of modern equipments to ease nursing care

Motivation

Encourage creativity / innovations among nurses

Encourage academic progress among nurse clinicians

Improve manpower resources

Proper funding of nursing departments

Each agency should designate a specific nursing theory they will adopt in specific cases

Leaders/mentors should be Supportive in their behaviors and practices; there should be shared visions and articulated ideas. They should prioritize goals and help to institutionalize evidence-based practices in various organizations

There should be clinical autonomy. This allows professionals to act autonomously and avoid the constraints of professional control and standardization.

CONCLUSION

The study concluded by saying that systematic accumulation of knowledge is essential to progress in any profession; adopting theory-based nursing practice is beneficial to the profession as it enhances reliable care. And in spirit of true professionalism, theory-based nursing practice should be taught, encouraged and adopted. Hence, the need for individual regular updates on current issues in nursing. There should be personal / organizational strives to improve quality of care.

REFERENCES

1. Colley, S. (2003). Nursing Theory: its importance to practice. Journal of Nursing Standard’s Art & Science, 17(46), 33 – 37.
2. D.Elakkuvana, B. (2011). Nursing Theories; a practical view. India: Jaypee Brothers Medical Publishers.
3. DeCapua, M. (2018). NursePractitionerSchools. Retrieved December 11, 2018, from nursepractitionerschools.com: https://www.nursepractitionerschools.com/blog/guide-to-evidence-based-nursing-practice/
4. Famutimi E. O, Eke J. H and Fowomola B. (2015). Knowledge and Utilization of Evidence-Based Nursing Practice among Nurses of Offa Specialist hospital, Kwara State. IOSR Journal of Nursing and Health Science, 4(4), 51 – 62.
5. Raudonis M. B and Acton G. J. (1997). Theory-Based Nursing Practice. journal of Advanced nursing, 26(1), 138 – 145.
6. Adeleke, A. (2010). The Challenges of Best Practices and Standards in Nursing in Nigeria. Inaugural Lecture Series, Igbinedion University (pp. 27-28). Okada: Igbinedion University Press Limited.
7. Onyemenam, C. (2013, June 4). Articlesng. Retrieved December 9, 2018, from www.articlesng.com: http://articlesng.com/factors-hinder-implementation-nursing-process/
8. Thompson Cathy J (2017). How to choose a theory for Nursing Practice https://nursingeducationexpert.com/theory-for-nursing-practice/
9. Hugh, M. (1997). Nursing Theories and Models. London: Routledge Publishers.
10. Meleis, A. (2012). Theoretical Nursing: development & progress (5th ed.). Pennsylvania: Wolter Kluwer, Lippincott Williams & Wilkins.
11. Agbedia, Okoronkwo, Onokayeigbo and Agbo. (2014, January 24). Nurses’ perspective of the research – practice gap in Nursing. Open Journal of Nursing , 95 – 100. doi:http://dx.doi.org/10.4236/ojn.2014.42013
12. Stevens, K. (2013, May 31). The Impact of Evidence-Based Practice in Nursing and the Next Big Ideas. Online journal of Issues in Nursing, 18(2). doi:10.3912/OJINvol18No02Man04