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Abstract

Introduction

The Nursing Process is a structured framework consisting of five interrelated steps – assessment, diagnosis, planning, implementation, and evaluation. The application of the Nursing Process helps nurses to provide patient-centered care, ensure patient safety, and quality control in the clinical setting. Despite its importance, the Nursing Process is partially used in many clinical nursing care services. This study assessed nurses’ knowledge and perception of the utilisation of the Nursing Process in patient care.

Methods

This was a qualitative, exploratory, and descriptive study. Fourteen Registered Nurses and Midwives were recruited from a district hospital in northern Ghana. Data were collected through semi-structured interviews, transcribed, and analysed using thematic analysis.

Results

The study revealed two major themes: nurses’ knowledge of nursing care and the nursing process, and their perception of its use. Findings showed that nurses understood nursing care to be holistic and patient-centered, with admission processes largely guided by patient assessment. While nurses demonstrated awareness of the nursing process, its application was often partial and unconscious.

Conclusion

Although participants viewed the Nursing Process as a good concept with a positive impact on patient care, it was largely perceived as an ideal framework for complex cases rather than as a mandatory tool for routine daily practice. The study emphasised the need for ongoing professional development, institutional support, and better resource allocation to promote consistent and effective use of the Nursing Process in clinical practice.

Keywords

knowledge nurses nursing process perception utilisation

1. Introduction

The Nursing Process is said to be an organised sequence of problem-solving steps employed by professional nurses to identify and manage patients’ health problems (Haapoja, 2014; Osman et al., 2021). In recent years, there has been growing global recognition of the importance of nurses consistently applying the Nursing Process with professional autonomy, as it has become widely accepted as a benchmark for nursing practice (Bulson & Bulson, 2011; Burns et al., 2010; Varkey, 2021). The Nursing Process equips nurses with critical thinking skills to address diverse healthcare challenges, improves the quality of care, ensures patient safety, promotes cost-effectiveness, and supports the achievement of healthcare goals (Amaral & Norcini, 2023; Haapoja, 2014; Neville-Norton & Cantwell, 2019; Wang et al., 2017). It serves as a unifying framework for holistic care (Julie et al., 2017; Stonehouse, 2020), enabling nurses and midwives to address patients’ physical, psychological, social, and spiritual needs in a systematic and organised manner (Batstone et al., 2020; Haapoja, 2014; O’Brien et al., 2019). Recognised by the International Council of Nurses, global nursing associations, and aligned with the code of ethics for nursing practice, the Nursing Process is regarded as a vital tool for enhancing nursing professionalism and advancing the standards of care delivery worldwide (Amaral & Norcini, 2023; International Council of Nurses, 2021).

Many elements, including training, experience, and institutional norms, shape nurses’ viewpoints on the Nursing Process (Gazari et al., 2020; Tadzong-Awasum et al., 2022). However, although the Nursing Process is globally regarded by nurses, it is not widely used due to the perceived lack of competence and confidence in its application by most nurses (Baraki et al., 2017; Camargo-Figuera et al., 2021; Koy et al., 2023). When applied, the utilisation of the Nursing Process can assure nurses of meeting their responsibilities to the care of their patients, which will, in the long run, benefit the patient, family, the nurse, and the facility as a whole (Shiferaw et al., 2020). Nevertheless, in the context of Ghana, nurses’ knowledge and perceptions of utilising the Nursing Process in a resource-constrained district hospital are not known. Exploring the nurses’ perspectives qualitatively in this context was to inform policy and practice in the utilisation of the Nursing Process.

2. Review of Literature

Notwithstanding the benefits of the utilisation of the nursing process, there are multiple and complex rooted factors, such as educational gap, ethical dilemmas, cognitive bias, diversity in patient population, among other things, that can thwart the utilisation of the Nursing Process (Baraki et al., 2017; De Oliveira Vargas Bitencourt et al., 2022; Shiferaw et al., 2020). Educational gaps among nursing staff may result in inconsistencies in understanding and applying the nursing process, leading to suboptimal patient care (Lotfi et al., 2021). Nurses with further training on the Nursing Process and a higher level of education in nursing might approach patient assessment, diagnosis, planning, implementation, and evaluation differently, which could result in fragmented care and compromised patient outcomes (Seidu et al., 2021). Moreover, without adequate education and training, nurses may struggle to recognise and address ethical dilemmas that arise in patient care, further complicating the utilisation of the nursing process.

Ethical considerations are integral to nursing practice, and unresolved ethical dilemmas can hinder effective decision-making, even with the use of the Nursing Process (Ethicist, 2016; Gray, 2019). Cognitive biases can also hinder the utilisation of the Nursing Process by influencing nurses’ judgment and decision-making. Preconceived notions or stereotypes about certain patient populations may lead to biased assessments and treatments, potentially causing disparities in care delivery. Additionally, diversity in the patient population introduces unique challenges to the use of the nursing process, as cultural, linguistic, and socioeconomic differences may impact communication, understanding, and adherence to care plans (Lai et al., 2013). Failure to accommodate these diversities can result in misunderstandings, mistrust, and ultimately, ineffective utilisation of the nursing process. Therefore, addressing educational gaps, ethical dilemmas, and cognitive biases, and promoting cultural competence among nursing staff are crucial steps in enhancing the utilisation of the Nursing Process and improving patient care outcomes.

In Africa, the healthcare systems are striving to adopt the Nursing Process as an evidence-based practice tool and to integrate it into routine care (Baraki et al., 2017; Tadzong-Awasum & Dufashwenayesu, 2021) because it is a vehicle that encourages nurses to use the best available evidence in their decision-making processes. The continent faces a dual burden of widespread infectious diseases such as HIV/AIDS, malaria, and tuberculosis, alongside an increasing prevalence of chronic conditions including hypertension, diabetes, cancer, and organ-related diseases (Adebisi et al., 2022; Agbonjinmi et al., 2022; Kamvura et al., 2022). These health challenges strain the already limited nursing workforce, which often operates under resource constraints and within poorly structured health systems. Despite its proven ability to promote coordinated, high-quality care that reduces complications, hospital stays, and treatment costs, the Nursing Process continues to be underutilised in many low- and middle-income countries (Agbonjinmi et al., 2022; Julie et al., 2017; Wagoro & Rakuom, 2015). Understanding the factors that influence its implementation is therefore critical to enhancing nursing care and improving patient outcomes.

Ghana provides a useful case for examining the factors influencing the utilisation of the nursing process, as its adoption enhances professional autonomy and strengthens nursing practice, research, and training (Korsah et al., 2017; N&MC, 2021). While the Nursing and Midwifery Council (N&MC) of Ghana promotes the Nursing Process as a framework for improving quality care, its consistent use is hindered by limited knowledge, and other factors (Agyeman-yeboah & Korsah, 2016; Gazari et al., 2021; Osman et al., 2021). Given the country’s cultural and religious diversity, nurses well-versed in the Nursing Process can provide holistic, culturally sensitive care that aligns with patients’ values, beliefs, and norms, thereby elevating standards of clinical practice (Gazari et al., 2020, 2021; Korsah et al., 2017). Conversely, reliance on routine care, medical orders, or personal experience without applying the Nursing Process undermines the delivery of independent, dependent, and interdependent nursing functions (Agyeman-Yeboah & Korsah, 2018; Osman et al., 2021) and this increases the risk of avoidable medical errors.

Although several studies in Ghana and sub-Saharan Africa have examined implementation of the Nursing Process, most of these works remain problem-descriptive in nature, focusing on staffing, documentation, and training constraints. The research offered limited insight into how nurses themselves experience, interpret, and negotiate the Nursing Process within their daily practice. This gap is particularly pronounced at the district hospital level, where professional ideals frequently collide with operational realities such as resource constraints and high patient volumes. Consequently, the intrinsic perceptions and lived experiences that shape nurses’ engagement with the Nursing Process remain insufficiently understood. To address this experiential gap, this study investigated nurses’ lived experiences and perceptions influencing the utilisation of the Nursing Process in patient care at a district hospital in Ghana.

3. Methods

3.1. Design

This study employed a qualitative research approach that utilised an exploratory and descriptive design. The exploratory design is suitable when research on a topic is understudied or complex, permitting open-ended investigation (Adu, 2019; Gazari et al., 2021). The descriptive phase captured the full range of experiences of actual use of the Nursing Process in daily nursing practice.

3.2. Setting and Population

The study was conducted in a district-level hospital along the Eastern Corridor belt in the northern region of Ghana. Registered general nurses (RGNs) and registered midwives (RM) working in any of the in-patient wards, with over six months work experience, and permanent staff were involved in the study.

3.3. Sampling and Sample Size Determination

The researchers employed a purposive sampling approach, which involved leveraging or deliberate selection of participants based on their expertise in the usage of the Nursing Process. This sampling method is commonly applied in qualitative research, mainly when aiming to understand a particular phenomenon, and is suitable for smaller population sizes (Ampomah et al., 2022; Hossan et al., 2023). The researchers initially selected 25 nurses, with the intention of ensuring gender balance, who met the inclusion criteria for this study. However, most of the female nurses withdrew their intention to participate in the study without reason, leaving more male nurses to be interviewed (see Table 1). This does not, however, invalidate the findings of this study, but should rather be interpreted in the context of nursing practice in relation to the concept of the Nursing Process in enhancing quality nursing care within a resource-constrained environment. A total of 14 interviews were conducted. By the time the 14^th person was interviewed, almost all the views, experiences, and thoughts of participants appeared not new or were similar, and nothing new was likely to be added. This demonstrates sufficient information power, ensuring the sample adequately captured the phenomenon under study (Younas et al., 2025). Data transcription, coding, and themes were simultaneously carried out after each interview.

Table 1.

Participants’ Demographic Data

S/N	Age	Gender	Professional category	Unit of work	Highest level of qualification	Work experience	Rank
P1	34	M	RGN	MW	BSc nursing	3yrs	NO
P2	29	M	RGN	PW	BSc nursing	3yrs	NO
P3	38	M	CCN	ICU	Membership	10yrs	PNO
P4	35	M	PN	PW	BSc Paediatric	10yrs	SNO
P5	29	M	RGN	ICU	Dip nursing	4yrs	SNO
P6	33	M	RGN	PW	BSc Nursing	5yrs	NO
P7	25	F	Midwife	Maternity	Dip midwifery	3yrs	SM
P8	23	M	RGN	MW	BSc nursing	3yrs	NO
P9	29	M	RGN	FW	Dip nursing	3yrs	SN
P10	38	M	Specialist	ICU	Membership	12yrs	Specialist
P11	27	F	Midwife	Maternity	BSc Midwifery	4yrs	MO
P12	29	M	RGN	ICU	Dip nursing	4yrs	SSN
P13	30	M	RGN	FW	Dip nursing	6yrs	SSN
P14	38	F	Midwife	Maternity	Dip midwifery	14yrs	PMO

ICU-Intensive Care Unit, CCN-Critical Care Nurse, MW-Male Ward, PW-Paediatric Ward, FW - Female Ward, PMO-Principal Midwifery Officer, PNO-Principal Nursing Officer, PN-Paediatric Nurse, RGN-Registered General Nurse, SSN-Senior Staff Nurse, MO-Midwifery Officer, NO-Nursing Officer, SN-Staff Nurse, SM-Staff Midwife, SNO-Senior Nursing Officer.

3.4. Data Collection

The data collection in this study was in the form of in-depth interviews, which were carried out in English (the official language of nursing education and professional communication, and communication in formal settings in Ghana). A pre-tested semi-structured interview guide, which was developed by the researchers based on the main objective of the study, was used as a tool for data collection. The interview guide was pre-tested among three staff nurses who met the inclusion criteria at another district hospital in the Northern part of Ghana. The researchers ensured that the necessary modifications to the interview guide were made after the pre-testing, ensuring that it captured adequate data to answer the main objective of the study. The semi-structured interview guide had two parts: A and B. Part A collected demographic information on participants such as age, gender, rank, work experience, and nursing qualifications. The B part of the interview guide had open-ended questions, e.g. “Kindly share with me the steps in the Nursing Process”, “Describe the nursing care you provide for patients from admission to discharge”, “Can you share your views on the concept of the Nursing Process”, “What are some of the challenges in using the Nursing Process?”, with follow-up probes used to obtain detailed responses (Creswell & Creswell, 2018; Stadtländer, 2009). These provided an opportunity for the researcher and the participants to delve deep into the subject area being discussed. The face-to-face interviews took place in a quiet and conducive office space in the hospital, as agreed upon with participants. Participants were reminded of the meeting beforehand and informed of the study details upon arrival. They were assured of confidentiality and the secure handling of audio recordings. Each interview lasted between 30 and 45 minutes, and the data collection exercise spanned from September to October 2024. This allowed for a flexible schedule with clinical participants and ensured adequate simultaneous data transcription and analysis to determine information power or saturation. All the interviews were conducted by the first author.

3.5. Data Analysis

In this study, the researchers analysed data as guided by Braun & Clarke’s reflexive thematic analysis approach (Braun & Clarke, 2021; Lochmiller, 2021). The process was carried out manually. The audio-recorded interviews were transcribed verbatim into Word document files. The participants were allowed to listen to the audio-recorded interviews before transcription, and they confirmed the recorded interviews as a reflection of their views before the data analysis. The steps involved familiarising with the data, generating initial codes, searching for related themes, reviewing themes, defining and naming themes, and finally producing a report. The 1^st author carried out the initial transcription of all the data, following which the 2^nd, 3^rd, and 8^th authors, who are experts in qualitative research, immersed themselves in the data through repeated reading and listening. Any inconsistencies were discussed and resolved through compromise. The researchers thoroughly reviewed and became familiar with the data to accurately identify similar or contrasting ideas. The process of reviewing audio recordings and transcripts numerous times also ensured that the researchers transcribed the recordings accurately. The data was systematically coded, with key statements and phrases appropriate to the research objectives highlighted and assigned descriptive codes. The researchers moved iteratively between transcripts, comparing codes and grouping similar codes into preliminary categories. Once the researchers determined the major themes, the themes and accompanying subthemes were further reviewed and defined to ensure clarity in the final reporting of the findings. Reflexive journaling and regular discussions were conducted among the research team throughout the analysis process to ensure rigor and credibility. This approach allowed for a deep engagement with the data, resulting in a rich, nuanced understanding of the participants’ perspectives on the Nursing Process.

3.6. Study Rigor

Methodological rigor is the meticulous, systematic, and disciplined application of research procedures to ensure findings are reliable, valid, credible, dependable, confirmable, and transferable (Creswell & Creswell, 2018; Gill & Gill, 2019; Muzari et al., 2022; Stadtländer, 2009). The researchers ensured credibility by verifying demographic data in audio recordings, conducting follow-ups with participants, and using a semi-structured interview guide to elicit rich responses. Interviews were scheduled at mutually convenient times to minimise distractions. The study followed Guba and Lincoln’s (1994) framework, maintaining strict adherence to research design, sampling, and procedures. To enhance trustworthiness, detailed descriptions of the study setting, participants, data collection procedures, and analytic processes were provided to support transferability to similar contexts. Confirmability was ensured through high-quality audio recording, verbatim transcription, independent researchers’ review, and systematic reflexivity, including maintenance of reflexive notes, team meetings on analysed data, and bracketing of pre-assumptions to minimise researcher bias (Peddle, 2022). In addition, member checking was conducted by playing back the audio recordings to participants after each interview meeting to validate the accuracy and credibility of the captured information. For dependability, the researchers maintained a comprehensive audit trail and documented all stages of the study, allowing for replication and comparison by other researchers.

3.7. Ethical Considerations

The researchers received ethical clearance from an Ethics Review Board (IRB). All information regarding the study was fully disclosed to all participants. They were informed that all the interviews would be audio recorded and assured that this information would be safely managed following a strict data management and protection policy. The anonymity of participants was strictly ensured. Biographic data of participants was taken and separated from the main data that was coded and analysed. Participants were assigned codes instead of names, and the codes were used to represent or identify each participant’s verbatim data. They were made to provide informed consent, and they were told that they were free to terminate or halt the interview process if they did not feel like continuing with the interview at any point in time. Minimal psychological risk was anticipated during data collection, as some questions might cause some discomfort due to fear of affecting their jobs. However, the participants were assured of anonymity that the information collected would not be made public or known to their immediate supervisors or managers.

4. Results

Findings of this study were centered on participants’ views on nursing care, nursing process, and nurses’ perceptions of the nursing process. Participants viewed nursing as a holistic care and the Nursing Process as not merely a theoretical concept but a tangible tool that facilitates structured nursing care, enhances decision-making, and promotes individualised care.

4.1. Participants’ Demographic Characteristics

The demographic characteristics of the 14 professional nurses and midwives interviewed at the hospital highlighted a diverse workforce engaged in utilising the nursing process, as shown in Table 1 below. The demographic profile revealed a workforce marked by both diversity and certain male-dominant trends. The study sample comprises 11 males and 3 females. The age range indicated a relatively youthful group of nurses, with many in their thirties (30s) and a smaller portion in their twenties (20s). This youthful composition may shape how the Nursing Process is viewed and practised, particularly with respect to experience and adaptability.

4.2. Organisation of Themes

The study generated 2 themes and 5 sub-themes, as seen in Table 2 below.

Table 2.

Theme and Sub-themes

Theme	SUB-THEMES
1. Nurses’ knowledge of nursing care and the nursing process	1. Understanding of nursing care
	2. Admission process is largely dependent on patient assessment
	3. Understanding of the nursing process
2. Nurses’ perception of Nursing Process use	1. Nursing Process: good concept with good impact
2. Nurses’ perception of Nursing Process use	2. Partial and unconscious use of the Nursing Process in patient care

4.3. Theme 1: Nurses’ Knowledge of Nursing Care and Nursing Process

The findings highlighted that nurses largely conceptualise the Nursing Process as a fundamental framework that guides clinical practice and enhances patient outcomes. The theme reflects participants’ recognition of the Nursing Process not merely as a theoretical construct, but as an essential tool for structuring care, promoting systematic decision-making, and ensuring individualised patient management. In essence, the theme underscores nurses’ understanding of the Nursing Process as central to the provision of quality care, thereby affirming its relevance to both professional practice and patient well-being.

4.3.1. Understanding of Nursing Care

Participants defined nursing care as a range of activities aimed at restoring patients to their normal state of health. It was described as holistic attention provided to unwell individuals. Nursing care was further reported to include admission procedures, ensuring patient safety, administering medications, and implementing doctors’ prescriptions.

“Nursing care, in my opinion, refers to all the activities that are carried out on the patient that will result in the patient recovering to their normal state. That is, all the nursing activities that will be carried out on the patient to enable them to recover to their normal states of health” (P 4).

“Nursing care is the holistic attention given to a patient. More especially, a patient who is not well.” (P. 1)

“… nursing care that is what is done when a patient is brought to the hospital on admission, the first attempt in caring or ensuring that the patient is safe, the medications that are given to the person, and then the orders that the nurse has taken from the doctor’s prescription” (P 14)

Participants described nursing care as the care provided to clients to ensure smooth recovery and restoration of health. Care was reported to be guided by patients’ specific diagnoses. Nursing care was viewed as encompassing all nursing activities aimed at helping patients return to their normal state of health. Participants also indicated that care extends beyond the patient to include family members involved in the recovery process.

“Nursing care is actually the care that we render or give to our clients for a smooth recovery. We care for patients based on their respective diagnoses.” (P 9).

“The care given to patients involves many things we, the nurses, do. This care usually covers everything about the patient and their family members involved in the patient's recovery process. (P.7)

4.3.2. Admission Process is Largely Dependent on Patient Assessment

Effective nursing care is guided by assessment throughout the admission process of patients. Participants stressed that assessment allows nurses to identify patient needs, establish a diagnosis, and plan for appropriate nursing interventions.

“In the ward, assessments form the basis of the care we provide. If you don't assess, then at the end of the day, you are not giving the right care because the outcome will not be the outcome you so wish or desire. From the assessment, we can identify problems that the patient has come with, hence from those problems, we can make, let's say, an intelligent guess of what the patient is suffering from” (P 5).

“The pediatric ward generally is very busy. Usually, we expect that when the patient comes, we do all our assessments head to toe, and then other assessment findings will be taken into consideration in nursing the patient (P.8)

“First of all, we do our assessment to see whether the patient meets the criteria for the intensive care unit or not. There are times we must go to the ward and assess patients before they are brought to the ICU. This ensures that the patient meets the criteria for admission into the ICU (P.14).

4.3.3. Understanding of Nursing Process

Participants consistently described the Nursing Process as a scientific and systematic method for delivering patient care. It was characterized as a step-by-step procedure used to assess patients, plan care, and ensure patient-centered interventions. Respondents also identified the Nursing Process as a guiding framework that structures nursing actions. Overall, findings indicate that participants perceive the Nursing Process as a formal, scientific tool that directs clinical practice. Some participants shared their views as follows:

“Nursing Process is a scientific method in nursing, which is a step-by-step procedure we use to assess our patients and provide care. So, the Nursing Process is just a scientific guideline that nurses use to plan their care and provide patient-centered care.” (P 2).

“I would say that the Nursing Process is the scientific way of nursing the patient” (P 5).

“To me, the Nursing Process is actually a tool or an instrument that we use to guide us in caring for our patients.” (P 7).

Participants emphasised that the Nursing Process is key to providing individualised care, as it allows nurses to assess and respond to each patient’s specific needs. They highlighted the importance of setting objective and nursing diagnoses to address the problems of the patient. Here are some of their views

In fact, the individualised and tailored care that is provided using the Nursing Process is the reason why we get good outcomes from our care” (P 12)

“We either set objectives, or we do what we call nursing diagnosis, and when we do that, we want to achieve good results. This ensures that at the end of the day, we carry out activities that are tailored towards either solving the problem or helping the patient out of the problem” (P 7).

4.4. Theme 2: Nurses’ Perception of Nursing Process Use

Participants expressed varied perceptions regarding the use of the Nursing Process in their clinical practice. Many viewed it as an essential framework that guides nurses to provide holistic and systematic care, emphasising its role in improving patient outcomes and ensuring consistency in nursing interventions.

4.4.1. Nursing Process: Good Concept With Good Impact

Participants consistently described the Nursing Process as beneficial and effective in guiding patient care. They reported that it promotes continuity of care, enabling other nurses to seamlessly continue management when shifts change. Respondents indicated that the Nursing Process enhances comprehensive assessment, particularly in pediatric care, leading to improved patient outcomes. It was also identified as a structured approach that supports clear documentation, informed decision-making, and organized care delivery.

“The Nursing Process is good. Since it is a process, when you are not able to finish the work and a colleague takes over, he or she can use the Nursing Process you have developed to continue the care. So, it's just a continuous process of care, yes, so, I think it's very good” (P 6).

“The Nursing Process has helped me, per se, to do a lot of things, especially caring for children and in assessment. If you can assess a child well, definitely, your findings will be better, and the outcomes will always be marvellous. You will get very good outcomes. So, I will say that the Nursing Process is a good one. It's a good thing; I will always recommend it.” (P 13)

“This approach provides a clear record of whether patient care is effective and allows nurses to make informed decisions about the next steps. Ultimately, it promotes better organisation and ensures that no aspect of patient care is overlooked.” (P10)

4.4.2. Partial and Unconscious Use of the Nursing Process in Patient Care

According to participants, the Nursing Process is often only partially and unconsciously applied in their practice. They inferred that while steps such as assessment and planning are regularly carried out, others, like diagnosis and evaluation, are less rigorously followed. Participants further noted that their nursing activities often align with the Nursing Process framework, but this occurs unintentionally, as many nurses apply the process unconsciously rather than deliberately following its steps during patient care. Here are some views expressed by some participants.

“To be frank, we don't usually use the Nursing Process in nursing all patients, but for critically ill patients, we use the nursing process. So, as much as possible for critically ill patients, we follow the Nursing Process in nursing them” (P 12).

“Hmmm, we use some aspects of the Nursing Process whilst deliberately ignoring others, for example, we do assessment and monitoring, but we don’t do nursing diagnosis” (P 2)

“So, everything that we do involves the nursing process, but sometimes we do it even without having it in mind that we are using the nursing process” (P 9)

“(...). Yes, I said, we often use the Nursing Process unconsciously because we learnt it and we practice always without following it systematically as spelt out in theory (P. 11).

Utilisation of the Nursing Process appeared selective and context-dependent according to the participants. Its application was emphasised mainly in the care of critically ill patients, while for other patients, it was not consistently followed in full. Certain components, particularly assessment and monitoring, were routinely practised, whereas elements such as nursing diagnosis were frequently omitted.

5. Discussions

This study examined nurses’ knowledge and perceptions regarding utilisation of the Nursing Process (NP) in patient care within the Ghanaian clinical context. An interesting finding emerged – nurses strongly value the NP as scientific, holistic, and essential to quality care, but the application of the Nursing Process in everyday practice is inconsistent, selective, and often unconscious. Rather than operating a deliberate, stepwise framework, the NP appears partially applied (internalised) in routine nursing care, and it is mostly activated explicitly for critically ill patients. This inconsistent use of the NP reflects the variation in knowledge, systemic constraints, and the theory-practice disconnect within Ghana’s resource-limited and high-demand health system.

Participants consistently described nursing as holistic and patient-centered, encompassing emotional support, education, and family involvement. These principles resonate with Ghanaian care settings where families play a visible role in bedside caregiving. While this aligns with family-centered care ideals (Ambushe et al., 2023), the findings also showed that organisational pressures subtly shift nursing practice toward task completion rather than being reflective and care driven by processes. In many public hospitals in Ghana, high patient-nurse ratios, limited logistics, and overcrowded wards compel nurses to prioritise physiological stabilisation and technical duties. Similar observations by Fagerström et al. (2018) and Kaldal (2023) indicate that systemic strain fragments holistic intentions into functional routines, explaining why nurses endorse the NP in principle but struggle to enact it consistently. This suggests that knowledge is inadequate for consistent implementation of the Nursing Process; however, relative factors and routine practice repetitions significantly influence attitudes on these processes even among knowledgeable healthcare practitioners.

Care delivery was further shaped by clinical urgency. Emergency and unstable patients received rapid interventions before comprehensive planning occurred. This reflects professional adaptability, yet it also reveals how urgency fosters a triage mindset in which formal diagnostic reasoning and evaluation are compressed or bypassed in some cases during nursing care. In a Ghanaian context, where nurses manage a large number of patients with limited monitoring equipment, the NP becomes selectively deployed. Adraro and Mengistu (2020) and Kwame and Petrucka (2021) similarly reported that protocol-driven environments restrict individualised application of theoretical frameworks. Consequently, the NP is often reserved for complex or critical cases rather than embedded across routine patient encounters. These routines in understanding may explain why care environments within healthcare settings should be structured to accommodate a more holistic approach to the implementation of the Nursing Process among care providers.

Assessment was the most consistently practiced NP component among nurses. Participants emphasised its role in identifying problems, prioritising care, and determining the appropriate nursing intervention. While this supports the foundational role of assessment (Li et al., 2024; NANDA International, 2021); it is suggested that in busy wards, assessment is performed primarily to trigger action rather than to support systematic diagnostic reasoning and evaluation. Nurses assess to intervene, not necessarily to reason formally. Potter et al. (2021) argue that environmental demands shape whether assessment leads to reflective planning or immediate task execution. In Ghana’s high-volume clinical settings, intuitive decision-making dominates, rendering parts of the NP implicit rather than explicit. Implementing the NP phases was uneven. Assessment and intervention dominated, whereas diagnosis and evaluation were less consistently applied. The NP was used among critically ill patients. Bukola et al. (2022), Zakaria (2014), and Akhu-Zaheya et al. (2017) link partial adherence to time pressure, staffing constraints, and resource scarcity. These challenges are amplified by limited documentation systems, heavy workloads, and minimal institutional monitoring of NP use. The struggle to consistently apply the nursing process mirrors wider documented challenges in integrating evidence-based practice into routine care, a hurdle noted among nursing students and professionals globally (Ejheisheh et al., 2025). This demonstrates how assessment quality and attention to detail are compromised by these limitations.

Participants viewed the Nursing Process as a scientific and structured framework essential for making nurses think deeply and critically to manage their patients’ health needs. This mirrors literature framing the NP as systematic, evidence-based and holistic (Owusu-Ansah & Agyeman-Yeboah, 2022; Tadzong-Awasum et al., 2022; Yilak et al., 2022) that enables nurses to deliver organised, efficient, and patient-centered care (Tadzong-Awasum & Dufashwenayesu, 2021; Tadzong-Awasum et al., 2022). On the contrary, critics argue that the Nursing Process can be very rigid, potentially limiting nurses’ ability to quickly adapt to patients’ dynamic situations. They note that in a rapid pace, such as emergency care, the structured phases of the Nursing Process are not always practical (Cristina Stefan, 2015; Fann et al., 2019; Zamanzadeh et al., 2015). The present findings suggest that Ghanaian nurses do not abandon the Nursing Process; rather, they adapt it by merging phases, limiting documentation, and prioritising interventions. This pragmatic adaptation sustains care delivery but weakens the visibility and completeness of Nursing Process implementation.

Overall, the findings indicate that inconsistent utilisation of the Nursing Process does not stem from a lack of knowledge or negative attitudes. Rather, nurses value the Nursing Process yet operate within environments that reshape how it is practiced. The Ghanaian clinical context demands speed, prioritisation, and adaptation, which compress reflective components of the Nursing Process into intuitive routines. As a result, the Nursing Process is practiced more as an implicit philosophy than as an explicit methodological guide. This supports literature reports of persistent theory-practice gaps.

Nevertheless, it is imperative to question if resource constraints can be fully attributed to the implementation challenges of the Nursing Process, as shown in this study, or rather aid as a suitable elucidation that conceals other conducive factors, such as disorganisation in the roadmap of care, failure to prioritise systems inadequately, or unsatisfactory manpower-training in resource-management approaches. Although healthcare resource limitations are incontestably factual and far-reaching, nursing care, in relation to the Nursing Process, in an equally limited-resource context, has proven enhanced practices, even without considerable resource improvements, but through improved team coordination, standardisation, and organisation (Curtis et al., 2024). This suggests that focusing on resource constraints only, though critical, may not be enough to optimise Nursing Process practices.

6. Implication of Study on Practice, Policy, Education and Research

These findings carry important implications for nursing education, management, and policy in Ghana.

6.1. Implication for Practice

1. Integrate the Nursing Process into hospital policies and standards – management and in-charges should ensure the use of the Nursing Process forms part of hospital protocols and is used as a standard requirement in the care of patients and performance evaluations (appraisal) to encourage accountability and consistency.

2. Appoint clinical preceptors/mentors to guide Nursing Process utilisation – Nurse managers should appoint preceptors who understand and can model conscious application of the Nursing Process during patient care, handing over and in nursing documentation.

3. Recognise and reward best practices – Develop a system that acknowledges nurses who consistently apply the Nursing Process effectively to motivate and reinforce its use in the clinical sector.

6.2. Implications for Policy/Management

1. Develop and Enforce a National Policy on Nursing Process Utilisation – The Ministry of Health should provide clear national guidelines that will mandate the implementation of the Nursing Process in all health facilities and integrate it into routine nursing practice.

2. Integrate the Nursing Process into Licensing and Accreditation Standards for Health Facilities – Make adherence to the Nursing Process part of hospital and training institution accreditation and link it with licensing requirements for professional nurses.

3. Facility-based allocation of protected time for Nursing Process-based planning in shift schedules or include structured assessment as a criterion in performance evaluations.

6.3. Implication for Education/Professional Development

1. Incorporate the Nursing Process in Pre-Service Education Curricula – Collaborate with nursing training institutions to ensure Nursing Process content is taught thoroughly with strong clinical practicums.

2. Integrating simulations into the curriculum that bridge Nursing Process theory to low-resource, high-volume scenarios and creating continuing education that helps nurses ‘make the implicit explicit’.

3. Ensure refresher training on Nursing Process application – organise regular refresher training on the practical use of the Nursing Process at the facility level

6.4. Implication for Research

1. Support Research and Monitoring on Nursing Process – Fund research into the barriers and enablers of Nursing Process utilisation and use findings to inform policy and quality improvement.

2. Promote participatory and action-oriented research to bridge the theory-practice gap – Implement follow-up studies, particularly participatory action research, that actively engage frontline nurses in co-designing and testing context-appropriate Nursing Process implementation strategies to enhance practical integration and sustainability.

7. Strengths and Limitations

The main strength of this research lies in the in-depth, rich data taken from professional nurses and midwives, providing constructive insights into the utilisation of the Nursing Process within a resource-constrained environment. The study also adds context-specific evidence that is appropriate to similar healthcare settings, specifically in the real-world district hospital context. The study explored the knowledge and perception of professional nurses and midwives on Nursing Process utilisation, but it did not include patients’ views. Incorporating patients’ views could give a better understanding of the Nursing Process in practice. The experiences of participants could be shaped by local hospital resources, policies, and management practices unique to district hospital status, which may not reflect conditions in better-equipped or differently managed hospitals. The study excluded some cadres of nurses, which may limit the broader view, knowledge, and perception of Nursing Process utilisation. This work was self-funded; hence, the study was limited to one study site instead of multiple study sites to make generalisation easier. Notwithstanding, the study is relevant to a broader extent in the context of comparable jurisdictions. Gender imbalance also placed some limitations on the study findings; however, the data gathered was rich enough to be applied across other contexts. Based on gender disparity, we recommend that future research investigate whether the application of the Nursing Process is affected by the gender distribution of nurses and midwives or not.

8. Conclusion

This study found that the nursing process is strongly valued by nurses, and it is seen as a scientific, holistic, and essential tool for the delivery of quality nursing care. But the application of the Nursing Process in everyday practice is inconsistent, selective, and often unconscious. The study emphasised the need for ongoing professional development, institutional support, and integrating the use of the Nursing Process at the policy level and at the practice facilities to promote consistency and effective use of the Nursing Process.

Footnotes

We are grateful to the management and nursing staff of the district hospital, particularly the Heads of Department and the Deputy Chief Nursing Officer, for their cooperation and participation in this study.

ORCID iD

Menford Owusu Ampomah

Ethical Considerations

The researchers received ethical clearance from the University of Ghana Institutional Review Board (IRB) at the Noguchi Memorial Institute for Medical Research (NMIMR) with reference number 115/23-24.

Consent to Participate

Informed written consent was obtained from all study participants. This study was conducted in accordance with the Declaration of Helsinki. All participants were also assured of the anonymity and privacy of their personal information.

Consent for Publication

Study participants were informed that research findings would be shared with the scientific community through a peer-reviewed journal publication.

Author Contributions

PK, MOA, and JAY - the conception of the study, management and analysis of data, and initial write-up of the manuscript. MOA and JYA - supervision of the study. AH, BA, ET, JGB, and LL reviewed the write-up by core data interpretation and analysis shaping. All the authors critically reviewed and edited the manuscript before submission. All authors consented to the manuscript’s content for submission.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request and in consultation with study participants due to concerns about the confidentiality and privacy of participants.*

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Nurses’ Knowledge and Perception in the Utilisation of the Nursing Process in Patient Care: A Qualitative Study

Abstract

Introduction

Methods

Results

Conclusion

Keywords

1. Introduction

2. Review of Literature

3. Methods

3.1. Design

3.2. Setting and Population

3.3. Sampling and Sample Size Determination

3.4. Data Collection

3.5. Data Analysis

3.6. Study Rigor

3.7. Ethical Considerations

4. Results

4.1. Participants’ Demographic Characteristics

4.2. Organisation of Themes

4.3. Theme 1: Nurses’ Knowledge of Nursing Care and Nursing Process

4.3.1. Understanding of Nursing Care

4.3.2. Admission Process is Largely Dependent on Patient Assessment

4.3.3. Understanding of Nursing Process

4.4. Theme 2: Nurses’ Perception of Nursing Process Use

4.4.1. Nursing Process: Good Concept With Good Impact

4.4.2. Partial and Unconscious Use of the Nursing Process in Patient Care

5. Discussions

6. Implication of Study on Practice, Policy, Education and Research

6.1. Implication for Practice

6.2. Implications for Policy/Management

6.3. Implication for Education/Professional Development

6.4. Implication for Research

7. Strengths and Limitations

8. Conclusion

Footnotes

ORCID iD

Ethical Considerations

Consent to Participate

Consent for Publication

Author Contributions

Funding

Declaration of Conflicting Interests

Data Availability Statement

References