Factors that Hinder the Implementation of Nursing Process (Case Study: Mater Misericordiae Hospital, Afikpo, Ebonyi State)
Nursing Process - Demand for “quality” in all areas seems to be a rallying point for today’s society. It has become a major concern in the agenda of service delivery. It is virtually impossible to be part of today’s health care system and not appreciate the quality revolution that is taking place (Adigwe, 2004). In addition to the demand for quality, the public wants health care delivered at a lower cost, with greater accessibility, accountability, efficiency and effectiveness.
Quality can be defined as a continuous striving for excellence and a conformance to specifications of guidelines (Adigwe 2004). Operationally, quality of care could be defined as the ability of the nurse to provide care that meets patients’ needs based on professionally agreed standard. The process of health care includes two major components, technical interventions and interpersonal relationships between practitioners and clients. Both are important in providing quality care and both can be evaluated (Okoronkwo, 2005). Traditional approaches to quality have included a focus on assessing or measuring performance, assuring performance conforms to standards and providing appropriate modification if those standards are not met. The Nursing profession must meet these challenges by implementing a process that addresses the multifaceted issues in providing quality health care. For the nurse to actually attain to the improved quality of service, she should be conversant with the application of Nursing process, which 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 outcome (Kozier et al, 2008). Hence, Nursing process demonstrates Nursing function through the use of science, humanities, arts and skill, a combination that is unique and un-replicated. (Nwonu, 2002).
The Nursing profession like other health care professions in Nigeria and beyond have recognized and accepted that quality care in health is necessary in the professional practice of the disciplines responsible for the delivery of health. The delivery of quality health care in health sector is linked with problem identification, resolution, prevention and drive for efficiency, effectiveness and maintenance of very high and sustainable standard of care (Adigwe, 2004). This unique professional goal is to offer good care.
The quest for quality care is as old as Nursing itself. Florence Nightingale first initiated quality Nursing care by the use of morbidity and mortality rates as a measure of quality during the Crimean war (Bassey, 2006). In addition, the author stated that this brought about reforms in the British health care system based on her reputation on the cycle of standard setting, observation, review and improvement in Nursing. Joint commission on accreditation of hospitals in North America was a corner stone in the work towards the setting of standard of nursing care. Moreso, in 1978, the Royal College of Nursing (RCN) commissioned a committee on the standard of Nursing care which recommended that nurses should imbibe to use the framework of the nursing process as a generic process of patients’ care.
A lot of improvements have been recorded in advanced countries, all geared towards meeting the satisfaction of consumers of Nursing service and health care. Programmes like Nursing audit, quality assurance and a review of nurses’ practice act all aimed at the improvement and sustenance of quality of nursing care. The need for this care was prompted due to recent great scientific and technological advances which brought about radical changes in the society and consequently, in the delivery of health care services in general and nursing practice in particular. Their efforts were channeled towards:
- Providing appropriate health teaching to patients and significant others in the areas of maintenance of wellness and rehabilitation.
- Utilizing the principles of Nursing process in meeting the specific needs of all ages in the areas of hygiene, safety, medication, etc.
In this part of the world, the effect is not much, despite numerous attempt that have been made to improve the quality of Nursing care, much have not been achieved. Several attempts have been made to improve the quality of Nursing service like the workshops organized by the west African college of Nursing in Accra with the theme. Quality Nursing care through Nursing process in 2003. Ghanian, Gambian, Nigerian nurses etc all participated in the sub-regional workshop. In Nigeria, committed efforts have been made to improve the quality of nursing care through the utilization of nursing process.
The Nursing and Midwifery Council of Nigeria in 1982 in order to bring the quality of nursing care to an enviable position reviewed Nursing education curriculum and fully integrated the Nursing process concept to ensure that newly qualified nurses will be able to utilize the nursing process in patient care.
Much concerted efforts have been put in place in areas like initial and continuing education through seminars, workshops and symposium with the upper-most view of improving the quality of nursing care and build capacity of professional nurses to adopt and use the nursing process programme in organizing, directing and implementing care. Examples of such hospitals include Ebonyi State University Teaching Abakaliki, Presbyterian joint Hospital Uburu and Mater Misericordiae Hospital [MMH], Afikpo.
Statement of Problem
Mater Misericordiae Hospital [MMH], Afikpo is a mission hospital in Afikpo and also a training institution for student Nurses since 1952. Nursing students and the professional nurses do not integrate the concept of Nursing process in directing patients’ care despite the concerted efforts of the ministry of health and Nursing profession to do so. As highlighted previously, nursing process is the major way to render quality nursing care to patients. It is hence, on the basis of giving undiluted, standard and quality nursing care that the researcher is motivated to identify factors hindering the implementation of Nursing process in Mater Misericordiae Hospital Afikpo, Ebonyi State.
Purpose/Objectives of the Study.
The purpose of this study is to identify the factors militating against Nursing process implementation and utilization in directing patient care in Mater Misericordiae Hospital, Afikpo, Ebonyi State.
The objectives of the study specifically are to:-
1. Identify the Nurses’ factors that are responsible for the non- implementation of the Nursing process in Mater Misericordae Hospital, Afikpo, Ebonyi State.
2. Determine the administrative factors that hinder the Nursing process implementation in the hospital.
3. Elicit strategies to ensure Nursing process implementation and sustenance.
Significance of the Study
The researcher is optimistic that the findings of this study will be of great benefits to the Government/management of health care in general and Nursing service in particular to formulate policies, implement, direct, organize and evaluate the effectiveness and efficiency of care provided to patients in Mater Misericordae Hospital Afikpo, Ebonyi State.
To the nurse: The paper provides a bench mark upon which individual or collective nurses will re-appraise their achievement/productivity over time mostly in areas of competence and uniqueness in job specialization.
To the patients/clients: It will help to enhance their health status tremendously.
Finally, this quality Nursing care will serve/form a basis for further research either to confirm or refute findings.
1. Are nurses knowledgeable on Nursing process (N.P)?
2. What nurses’ factors are responsible for non-implementation of Nursing process?
3. What administrative factors hinder the implementation of N.P?
4. What strategies ensure N.P implementation and sustenance?
Scope (Delimitation) of Study
The study is delimited to Mater Misericordae Hospital, Afikpo, Ebonyi State, one of the mission hospitals in the state. The study is confined to all cadres of nurses in the hospital. It is only investigating lack of adequate knowledge, skill and attitudinal factors that hinder Nursing process implementation in Mater Misericordae Hospital Afikpo, Ebonyi State.
Operational definition of terms
- Process:- on-going event
- Administrative factors:- Hospital issues/authority including policy , manpower development, material resources, stationeries, and facilities, etc that hinder the implementation of Nursing process.
- Nursing factors:- Nursing/ Nurses’ issues e.g educational status, attitude or lack of adequate knowledge of the total work environment hindering Nursing process’ implementation .
This chapter will review the related literature [from textbooks, journals, magazines and periodicals] in Nursing process and factors hindering its implementation by nurses under the following sub-headings:
- The concept of Nursing process
- Historical background/perspective of Nursing Process.
- Achievements/Advances in Nursing via Nursing process
- Problems facing/ militating against Nursing process implementation and sustenance
- Nurses’ factor
- Administrative factors
- Factors emanating from patients/clients
- Strategies/measures that will promote successful implementation of Nursing process and its sustenance.
The concept of Nursing Process
Nursing process has been defined by several authors.
Nwonu (2002) defined Nursing process as the systematic collection of patient care data for determining nursing care needs and evaluating patient care outcomes.
Whereas Potter and Perry (2007) stated that nursing process is a systematic problem-solving method for providing individualized care for clients in all states of health and illness. According to Laryea (2004) nursing process is a deliberate, problem-solving approach to meet the health care and nursing needs of patients. The author went further to state that the steps are interrelated, interdependent and recurrent.
Musa (2006) said Nursing process is a dynamic process that uses information in a meaningful way through problem-solving strategies to place the patient, family or community in an optimal health state.
Following from the above definitions, we can assert that Nursing process can be said to be a systematic and goal-directed set of activities which are interrelated and dynamic, used by the nurse to determine, plan and implement individualized nursing care, which is aimed at helping the patient to achieve integration of his whole being or optimal level of wellness.
Historical background/Perspective of Nursing Process.
Lydia Hall originated the term “Nursing process” in 1955 in a lecture entitled “the Quality of Nursing Care” delivered in New Jersey. United States of America and Johnson (1959), Orlando (1961) and Wiedenbach (1963) were among the first nurse theorists to use it to refer to a series of phases describing the process of Nursing. Since then, various nurses have described the process of Nursing and organized the phases in different ways.
Guzetta, Dossey and Kenner (2002) stated that Yura and Walsh in 1967 first identified the steps of the Nursing process as:
– Implementation; and
Fry in 1953 first used the term “Nursing Diagnosis”, but it was not until 1974, after the first meeting of the group now called the North American Nursing Diagnosis Association (NANDA), that Nursing Diagnosis was added as a separate and distinct step in the Nursing process. Prior to this, Nursing diagnosis had been included as a natural conclusion to the first step, assessment. Currently the steps in the nursing process are:
– Nursing Diagnosis
– Planning and outcome identification
– Implementation and
Furthermore, the integrated use of cognitive, interpersonal and psychomotor skills in client care is basic to the practice of professional Nursing. The Nursing process provides a logical and rational way for the nurse to organize information so that the care given is appropriate and effective. Although, the process is a scientific one, it is conducted by human beings who can carry it out in a sensitive and caring manner. Hence, the nursing process is both scientific and humane, just as nursing is perceived as both a science and an art. Saba (2002) stated that “it is impossible to provide nursing care without processing knowledge in some way”. Noting that theory is the knowledge or content for practice, Saba (2002) also said that “process is the way of using that content”.
The nursing process is an orderly process; it is not simply a quantitative approach. It has pervasive qualitative aspects that make the process vital. Actually, these qualitative factors (such as the time it takes for procedure-driven documentation).
Invariably, the nursing process is presented as a series of four or five phases, with a number of steps within each phase (Laoye, 2006). The net effect is a procedure that appears linear (or at best overlapping or circular) and cumbersome. Unfortunately, in many practice settings, there is a perception that the nursing process is desirable but too time-consuming to be practical. If it is not valued, it is not used and many nurses continue to intervene using standardized procedures based on medical diagnoses, rather, than a rationale based on nursing assessment, planning and evaluation feedback.
In today’s real world of nursing practice, it is probably true that many nurses do not use the nursing process as a deliberate method of practice. In a critique of nursing theories, Laryea [2004) stated that the nursing process can be described in two ways: as descriptive, the way nursing actually happens, and as normative, the way nursing should be performed. These authors argued that most nurses do not perceive that their care for their clients is based on the rational procedure of the nursing process: “Thus, the nursing process would appear not to be an accurate description of how nursing is actually performed” (Laryea, 2004)
Characteristics of Nursing Process
- It is systematic and goal-directed in the sense that it follows a sequential process and all the activities are directed at achieving some set goals.
- It is individualized in the sense that the product of the activities, that is, assessment, planning etc, that are carried out for one individual, is peculiar to that individual and cannot be used in totality for the care of another.
- The activities are interrelated and dynamic in the sense that they are carried out in each of the steps and are dependent on each other to achieve the overall goal, which is effective client care.
Importance of Nursing process
Nwonu, (2002) identified the following as reasons why nurses should adopt nursing process as a tool for patients’ care:
i. Nursing process is a means of unifying nursing practice.
ii. The nursing process demonstrates nursing function through the use of science, art, humanity and skills, a combination that is unique and unreplicated.
iii. It promotes consumer satisfaction.
iv. The nursing process restores nursing to its primary commitment, which is, determing care to people on a one-to-one basis and thereby eliminating the present tendency to relinquish this overall function to those who are not prepared to fulfill it.
v. It provides a means of assessing nursing’ economic contribution to the totality of client care.
vi. It enables the nurse to realize her potentials as an independent decision maker who has command over competencies, which before now were not used in carrying out predominantly assistance-type functions.
Nurses’ Factor responsible for non- implementation of Nursing Process:
Nurses are responsible to a reasonable extent for non- implementation of the nursing process in many ways. The factors from the nurses that hinder nursing process implementation may be considered in the following ways:
Laryea(2004) conducted a study in Ghana on “Barriers to nursing process implementation” and discovered that the nurses’ theoretical knowledge was high, however, majority lacked the practical skill in data collection, writing nursing diagnosis and objective. This indicated that there is a gap between theory and practice. Ezeh (2003) in his study conducted at Eagle General Hospital identified lack of competence and knowledge in the use of the concept as a militating factor against its implementation. The author therefore, suggested that more workshops should be conducted in the state particularly in the areas of nursing diagnosis and scientific rationale. He also found out that nurses do not have the will or the good spirit resulting from the hard-work to carry out the process. Also, Collaham (2006) discovered that while all nurses attended workshops and nurses’ training colleges where students are taught and examined on the nursing process, the nursing process was not being practised in the ward.
Bowman (2008) identified that many nurses do not have adequate skills to implement care plan. Block (2009) affirmed that when he conducted studies on nursing process implementation in three tertiary health institutions in Nigeria, he discovered that nursing process was not done accordingly, mainly due to the fact that some nurses have lower ability to process information based on intellectual, interpersonal and technical skills. Hence, for nursing process to be effectively implemented, nurses require to possess adequate cognitive, affective and psychomotor skills.
Wesley (2006), stated that for nursing process to be carried out effectively and efficiently, technical skill should be acquired in the use of equipment/machines and accurate manual dexterity in procedures. In addition, intellectual skills must be acquired such as critical thinking, evidence-based care and making thoughtful nursing decisions backed with scientific principles in every aspect of nursing process. It is mandatory that all nurses responsible for carrying out nursing process should have qualitative and comprehensive educational background in order to effectively explain and implement the concept of nursing process and be in the best position to give account or description at every stage of patient care (Bassey, 2006).
Ezeh (2004), in a study on knowledge and attitude of nurses towards nursing process discovered that 68.1% and 52.6% of nurses have correct information on nursing process and its components respectively. Only 50% of the nurses have correct information of the activities of each phase of the nursing process, nurses who had worked for 0-20 years have more correct knowledge of nursing process than those that have worked for more than 30 years.
Ezeh (2004) further commented that 99.1% of nurses have positive attitude as years of experience have little or no influence on their attitude towards nursing process.
Nurses’ attitude as one of the variables in this study was defined by White (2003) as mental or neural state of readiness organized through experience, exerting a dynamic influence upon the individuals’ response to all objects and situation with which is related. The author further stated that attitudes not only differ among people or societies but also vary across time for a given individual or societies. Bowman (2008) asserted that most of the problems of nurses with nursing process were caused by nurses’ attitude. The nurses had high anxiety level as a result of the criticism they received from other disciplines or profession.
Guesta (2003) observed that some nurses regard the nursing process as the United States’ culture and American concepts, hence, implementation of the idea could not be bought over completely to the African set-up with a different culture. The author said that nursing process implementation should differ from country to country, main barrier being cultural differences.
Carlson (2007), identified some other problems in the nursing process approach that deals with attitudes of nurses: the older/earlier graduate nurses never did nursing process in their days at school, rather medical practice was used then, so they functioned intuitively and their action was automatically responded to.
- Another fact was that the newer graduate nurses viewed nursing process as more of a student-learning tool which existed only for those patients as students were assigned to take care during examination.
- Also, nurses do not keep proper records of care plans to be used as a continuum in patient care during follow -up.
Mariner (2008) supported this idea that some nurses even abroad have innate incapabilities, therefore, they would not want to do anything about nursing process even with much administrative supports, many nurses still fail to write care plan. The author commented further that some nurses’ attitude towards the use of the concept was bad and gave the under-listed reasons for their action:-
• Nursing process is time-consuming; one spends too much time writing with a limited time for implementation.
• A nurse cannot see any purpose for writing the care plan.
• Nurses lack the ability to identify the contents of independent nursing functions and making nursing judgments.
• Nurses do not have the skill of assessment necessary to obtain input on which the care plan is developed.
Carlson (2007), further pointed out in his study that research into the application of the nursing process during the night was rarely done, 45% of the time, a patient spends in the hospital came under the care and responsibility of the night care/staff. The research carried out into the attitude of nurses over nursing process was mainly concentrated on the day shift, but was not done during night shift as the researchers too like to sleep at night.
Potter and Perry’s (2007) idea about the non- implementation of the nursing process by the nurses include the process, is time-consuming and difficult, high patient turnover and inadequate material resources.
Johnson (2003) opined that a major barrier to nursing process implementation is low level of staffing. This affects the effectiveness of the nurses as the few available ones are overworked invariably they get tired, despaired and eventually give up the attempts. In a study done by Laryea (2004) in Ghana as cited in Umunna (2006) noted that despite good theoretical knowledge among the studied nursing personnel, there are still obstacles to implementation of the nursing process due to inadequate staff especially during afternoon and night shifts, too much work- load as a result of poor staffing. The author further stated that individualized care plans were time-consuming and difficult to implement, low level of commitment, poor motivation and lack of role models among senior nurses are factors that militated against N.P implementation.
Moreseo et al (2007) pointed out that inter-personal relationship among staff is very pertinent because it allowed for open discussion, exploration of feelings and opportunities to laugh or be angry together. Qualities of patience, humour and magnanimity are vital ingredients among the staff. Whereas relationship among the staff is uncordial, when there is always a bridge in communication, delegation of duty is difficult and confusion and disorders will be coming from multi-foci directions and there is no unity in direction.
All these factors highlighted above and others are nurses’ factors that hinder/militate against implementation of Nursing process:
Yura and Walsh (2008), asserted that for nursing process to be effectively implemented, there must be collaboration of hospital authority with the implementing nurses as it regards finance, equipment and personnel. Wesley (2006) supported the above view, by stating that extremely disjointed care which is less comprehensive arises as a result of shortage of instrument and equipment in the hospitals. Laoye (2006) researched on problems inhibiting the use of nursing process in patient care. In his study, thirty eight (38) nurses were randomly selected from various hospital wards (male and female) wards out of 38, 28 (72.7%) complained of lack of power and equipment, 10 (27.3%) stated lack of motivation by hospital authorities. Nineteen (19) also complained of the process being cumbersome and time-consuming. They concluded that lack of personnel and equipment are hindering factors affecting the use of nursing process in client care.
Howe (2005) stated that poorly equipped hospitals or units, perennial shortage of drugs, non-training of nurses and unattractive service conditions including very low salaries led to non- implementation of nursing process. Inadequate/lack of conducive work environment as well as lack of job satisfaction and frustration among nurses are other factors for its non- implementation.
Factors emanating from the patients
Enim (2005) conducted a study to determine the satisfaction of patients with nursing process in University of Calabar Teaching Hospital, Calabar, in which 60 patients, both male and female were selected for the study. Out of this number, 41 patients said they were satisfied with the nursing process, the remaining (19) however complained of too much questioning during assessment, ignorance of what the process is all about, lack of finance to settle increased hospital bills as a result of new process and lack of detailed explanation of procedures. She concluded that clients need more enlightment on the new approach and that they should be fully involved in their care to gain their full cooperation. Wesley (2006), stated that long stay in hospital coupled with huge hospital bills could lead to patients leaving the hospital against medical advice. The author concluded by advising that social workers should be involved in client’s care in order to achieve successful and more satisfactory care.
Strategies to Ensure Full Implementation and Sustenance of the Nursing Process
Itah (2005) conceptualized strategies as specific major action or patterns for attainment of objectives. Strategies could also be seen as sets of action plans, mapped out to achieve specific objectives by guiding the behaviour of participants towards the attainment of the objective.
A pertinent role of nursing practice is the ability of the nurses to process information and to make sound and informed judgment. This information processing involves the various skill identified in this section. Successful implementation depends on cognitive, affective and psychomotor skills of the nurses that is, intellectual, interpersonal and technical skills (Yurah and Walsh, 2008). In the same vein as proposed to the project, 2002 document, a new preparation for practice, the nurse of the future should be “versatile in knowledge, able to marshal information, to make assessment of needs, devise a plan of care, implement, monitor and evaluate it. Thus, the nurses are expected to demonstrate favourabe skill to client and implicit in this is the duty of accountability for sound professional practice”. (Zemat, 2009). The author further indicated that the strategies to ensure nursing process implementation and sustenance is that the hospital authority must collaborate with the implementing nurses in terms of stationary supply, finance and personnel for a lot of writing is done in the nursing care plan approach. This can only be achieved if “out- of- stock syndrome” is completely removed from our hospitals; nurses will put their best to see that the nursing process is fully implemented and sustained. Itah (2005), commented that strategies are based on the concept of staff development, embracing continuing education and in-service training which is aimed at acquiring new knowledge and skill in nursing and other-related areas. Hence; it gives room for effective implementation of nursing process.
In addition Itah (2005), recommended that much workshop should be conducted in the state especially in the area of nursing diagnosis and scientific rationale. This will increase the knowledge and skill that nurses have about nursing process particularly diagnosis and scientific rationale as to make nurses more scientific. In these workshops, the practical skills to be stressed are in the area of data collection, writing nursing diagnoses and objectives. This will bring a balance between the nurses’ practical skill and high theoretical knowledge that Laryea (2004) discovered that nurses have but however, advised that nurses should put more effort in practising nursing process in the hospital wards as they were taught in the classroom.
Howe (2005) is of the opinion that poorly equipped hospital and unit, perennial shortage of drugs, shortage of staff, non training of the few employed and so on are factors that work against nursing process implementation. To really ensure strategies for its implementation and sustenance, all hospitals or unit should be well equipped with modern instruments and drugs. Adequate staff should be employed and sent for refresher courses as often as possible to update their knowledge, example continuing education/higher degrees. The services should be lucrative with updated salary scales, regular and prompt payment. This will give the nurses a comfortable, adequate and conducive work environment that will provide job satisfaction thereby changing the negative attitudes some nurses have about nursing process and its implementation.
Calloham (2006) identified in his study that adequate staffing was the most important element in nursing practice as the availability of adequate staffing allowed nurses time to implement nursing intervention on the clients. Enough staffing will be able to cut across all the shifts so as to reduce the too much workload on an individual with increased number of patients.
When enough trained hands, with skill and knowledge are employed, auxiliary and quack are removed for easy implementation of nursing process.
Arnold and Boggs (2003), observed that interpersonal relationship among staff allowed for open discussion and exploration of feelings. This provides a cordial working relationship among the staff, which in turn ensures good communication, easy delegation of duty and unity thereby ensuring implementation and sustainability of the nursing process.
Umunna (2006) on the part of the clients concluded that they need more enlightment by the health team on the new approach and the clients should be fully integrated in their care to gain their full co-operation about the new technique of care.
Since nursing process is scientific, it is based on findings of studies in the different aspects of human beings. These findings have been built into theories and models, which describe the function of the human body and the ways in which human beings behave in different situations. Some of these theories/models guide assessment, planning, implementation and evaluation. Some nursing theories and models applicable to the nursing process include:
a) Roy’s Adaptation Theory-which views the client as an adaptive system.
b) Virginia Henderson’s Framework of Nursing which sees the Nurses as legally and independent practitioner with authority for basic Nursing care, that is assisting the client to gain independence in meeting the fundamental human needs.
c) Gordon Majory’s Functional Health Pattern Models, which stated that functional health patterns evolve from client-environment interactions.
d) Maslow’s hierarchy of needs model, view human needs as being in hierarchical order with the most basic needs at the base of the pyramid and the higher ones at the apex. The lower or basic needs are the life- threatening needs and they need to be gratified first before the higher ones can emerge/met.
Summary of related Literature Review
The study was aimed at factors hindering the implementation of N.P at Mater Misericordae Hospital, Afikpo, Ebonyi State. Based on the objectives of the study, pertinent literature were reviewed on:
• The concept of nursing process (N.P)
• Historical perspective of nursing process
• Characteristics of nursing process
• Importance of nursing process
• Nurses’ factors for non-implementation of nursing process.
• Patients’ factor against nursing process
• Strategies to ensure full implementation and sustenance of nursing process.
• Theoretical framework of the study.
This chapter focused on brief history and current developments of nursing process and the relevance of its implementation. Nurses’ factors responsible for the non- implementation of the nursing process which was viewed from the knowledge and skill and nurses’ attitude towards nursing process. It was obvious that nurses have negative attitude and shallow knowledge about nursing process, poor critical thinking and intellectual skill, poor orientation, lack of competence in using the nursing process.
The chapter further deals on the administrative factors that hinder the implementation of nursing process, factors like-lack of funds by the authorities of the hospital, shortage of staff, lack of motivation, poor salaries, too many patients and inadequate material and equipment to work.
The empirical studies on strategies to ensure nursing process implementation and sustenance were rightly reviewed, however, although, some work have been conducted in Nigeria, these researches did not involve Abakaliki or other institutions in Ebonyi State. Hence, the need for this study to fill the gap in the literature.
Finally, Roy’s adaptation theory, Virginia Henderson’s framework of nursing, Gordon Majory’s functional health pattern and Maslow’s hierarchy of basic human needs were modified and used for the study.
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