The implementation of the nursing process in lower‐income countries: An integrative review

Abstract Aims This review study aimed to investigate the strategies for implementing the nursing process in the clinical practice and the assessment of the implementation rate of this process in clinical settings of lower‐income countries. Design An integrative review. Method The search was conducted of EMBASE, MEDLINE, CINAHL, Scopus and ISI databases from 1975–July 2018. Following the formation of the research team, two researchers independently selected the eligible studies; finally, 39 articles were approved by the research team for this study. Results The researchers identified three themes: Effects of implementing the NP in clinical settings, Development and application of electronic software in the NP and Factors affecting the implementation of the NP. This review revealed that nurses and nursing managers in hospitals are interested in implementing the nursing process in the form of widely and continuously. But the necessary infrastructure, such as manpower, electronically or manually tools, has not yet been provided, and the implementation of the nursing process is done either imperfectly or not done.

, Phaneuf, López, & Ruíz (1993) or Alvarez (1987), considered the nursing diagnosis, which was traditionally seen as part of the nursing assessment as a separate phase and described the process as containing five phases (Potter & Perry, 2017). Nowadays, the NP is a systematic problem-solving with five steps: assessment, diagnosis, planning, implementation and evaluation to identify, prevent and treat actual or potential health problems and promote wellness (Potter & Perry, 2017). For the emphasis of the American Nursing Association (ANA) on passing the course of nursing process after formal education to upgrade their qualifications, approval of a law on the validation of nursing care based on patient care plans by the Joint Commission on the Accreditation of Hospitals (JCAH) in the 1970s and increased nurses' concern for their development as a profession due to the developments in nursing education leading to the nursing process was seen as an important means for that development (Yura & Walsh, 1978).
In a decade, it was used as a teaching tool in educational settings, and when this process was used in hospitals, it appeared useful and effective for most countries (de la Cuesta, 1983).
The acceptance and emergence of the nursing process in England were related to the professional dimension. In this period, dissatisfaction wave from the nursing care provided in the United Kingdom.
Major factors of dissatisfaction include denial of a task-orientated approach to nursing, the lack of individualized care, the low level of nurses' job satisfaction and the superficial nature of the nursepatient communication. The nursing process, as an antidote for the treatment of toxins, destroyed most nursing dissatisfactions in the country (de la Cuesta, 1983;Walton, 1986).
In lower-income countries (IPNA, & Residents/Nationals of These Countries Qualify for Low-Income Country Rates, 2018) due to the dissatisfaction of care provided by nurses, poor quality of care and nurses' dissatisfaction from their profession have led use the nursing process; since 1980, studies have begun on the implementation of the NP in the clinical settings (de la Cuesta, 1983;Vanaki & Zamanzadeh, 1994;Zamanzadeh, Valizadeh, Jabbarzadeh-Tabrizi, Behshid, & Lotfi, 2015). In several studies, the usefulness of this process has been confirmed in accordance with the context of different countries (Semachew, 2018;Zamanzadeh et al., 2015).
However, the acceptance and application of the nursing process are clear in the high-income countries (Di Mauro, Vanalli, Alberio, & Ausili, 2018), but in low-income countries after about 40 years of the development of and usefulness of this process in these countries, it is not yet known how much the nursing process is implemented, the acceptability of the nursing process and the importance of this process in the clinic settings (Fernández-Sola et al., 2011;Wagoro & Rakuom, 2015;Zamanzadeh et al., 2015).

| AIM
To evaluate the strategies for implementing the NP in the clinical practice and the assessment of the implementation rate of this process in clinical settings of lower-income countries.

Research question:
Is the nursing process implemented with specific strategies in lower-income countries in the form of widely and continuously?

| Design
The integrative review (Whittemore & Knafl, 2005) was applied in this study. Considering that scientific information is increasing in all fields and professions nowadays, practitioners do not have enough time to review all the information on their interested background to get the most valuable information; the integrative review (IR) method What does this paper contribute to the wider global clinical community?
The nursing process is not implemented nursing in Iran, Ethiopia, Kenya, Taiwan and generally in lower-income countries, for the following three reasons: • Inadequate knowledge of nursing faculty members from the nursing process.
• Lack of necessary infrastructures in hospitals.
• Lack of support from nursing institutions (Nursing Organization and The Nursing Board).
is an approach that by combining different methods and examining all the findings of particular issues or subjects, and provides useful and valuable information to the researcher or practitioners on that subject (Whittemore & Knafl, 2005). Mixed studies review (MSR) can be more appropriate for decision-makers and practitioners by providing a rich and practical understanding of complex health interventions and programmes (Pace et al., 2012). In this research, we used the Whittemore and Knafl's (2005) integrative review framework stages, which included Problem identification, Literature search, Data evaluation, Data analysis and Presentation.

| Stage 1: Problem Identification
The first step in the review method is the clear identification of the problem; then, variables of interest are defined theoretically and practically. The NP has five consecutive steps, and nurses can improve the quality of their care by implementing this process. The NP as a systematic and dynamic way to deliver nursing care included five interrelated steps: assessment, diagnosis, planning, implementation and evaluation. This process is a cycle that never ends, the guideline that ensures good nursing care and improves patient outcomes (Fernández-Sola et al., 2011;Potter & Perry, 2017). There are many effective factors in the implementation of the nursing process including knowledge of faculty members, nursing managers and nurses about the NP, the interest and attitude of nurses towards the implementation of the process, manager's support in the implementation of the NP and implementing the NP in clinical settings (Potter & Perry, 2017;Shoorideh & Ashktorab, 2011;Zamanzadeh et al., 2015).

| Stage 2: Literature Search
The research question was designed based on the SPICE (setting, perspective, intervention, comparison and evaluation) framework that is more valuable than PICO (population, intervention, comparison and outcomes) framework with two statistically significant changes (Cooke, Smith, & Booth, 2012). These changes included dividing the population component into both "setting" and "perspective" and "evaluation" instead of outcomes (Andrew, 2006;Crumley & Koufogiannakis, 2002). These new concepts of the SPICE framework authenticate that data practice is a social science, not a hard science, and incorporates other concepts such as "outputs" and "impact" together with less tangible effects of a library or instructional intervention (Andrew, 2006). SPICE framework is a more appropriate framework for health and social sciences (Andrew, 2006;Eldredge, 2001) and helps practitioners to identify their practice-based questions (Andrew, 2006). This framework was also used for matching the research design to the question, inclusion and exclusion criteria and guide the database search strategy (Andrew, 2006 To determine the type of extracted studies, the method of searching, and determining the inclusion and exclusion criteria, the research group was formed on 5 May 2018. In the first, two researchers (MK and ME (health librarian)) independently searched for articles in EMBASE, MEDLINE, CINAHL, Scopus and ISI databases from 1975-July 2018 without any language restrictions. Grey literature searching was conducted using professional databases and dissertations (Masters and Ph.D.). Then, the final papers were extracted according to the inclusion and exclusion criteria of the study (Table 1).
The reasons for choosing low-income countries including Iran, Brazil, Bolivia, Taiwan, Ethiopia, Mexico and Egypt in this study were that the challenges of nursing care in their clinical settings were similar (Fernández-Sola et al., 2011;Ledesma-Delgado & Mendes, 2009;Rajabpoor et al., 2018;Semachew, 2018;Yeh et al., 2009).
The initial search resulted in 4,350 records from databases and 327 records from grey literature and reference by reference based on the search terms. Subsequently, 887 papers were duplicates and excluded from the study and the total records identified were 3,790.
Finally, 39 articles were identified consistent with the inclusion and exclusion criteria. The process of identifying, evaluating and selecting articles is presented based on preferred reporting items for systematic reviews and meta-analyses (PRISMA) (Moher, Liberati, Tetzlaff, & Altman, 2009)

| Stage 3: Data Evaluation
Critical appraisal of methodological features is complex to evaluate the quality of studies in integrative reviews (Whittemore & Knafl, 2005). Due to lack of guidelines for evaluating research quality in integrative reviews, the Mixed Methods Appraisal Tool (MMAT) was adopted as it helps overcome challenges associated with evaluating the methodological quality of varied studies Pace et al., 2012;Whittemore & Knafl, 2005). We used this method to evaluate the quality of selected studies and also to increase the validity of the study.
The Mixed Methods Appraisal Tool (MMAT) seems to be a useful and unique tool for evaluating MSR (qualitative, quantitative and mixed methods) with scores varying between 25% (meeting one criterion)-100% (meeting all four criteria) (Crowe & Sheppard, 2011).
The MMAT is designed for the appraisal stage of systematic mixed studies reviews and permits to appraise the methodological quality of five categories to studies of qualitative research, randomized controlled trials, non-randomized studies, quantitative descriptive studies and mixed methods studies (Crowe & Sheppard, 2011;. This tool is recommended by the National Institute of Excellence in Health Services in Quebec (INESS) and increasingly popular because of their potential for addressing complex interventions and phenomena, specifically for assessing and improving clinical practice (Hong, Gonzalez-Reyes, & Pluye, 2018).
The eligibility of articles was discussed in the research team. To appraise the papers selected in this study, at first, two reviewers independently evaluated the quality of the papers with the MMAT method, and then, it was discussed in the research team, and in cases where there were disagreements, the articles and scores of the two reviewers were examined to until consensus was reached. Articles with a score of less than 50 percent were excluded from the review.
None of the studies was excluded during the quality appraisal of the articles by the research team.
According to the evaluation of studies based on MMAT, it was found that the quality of studies was moderate. The quality scores for the studies are included in Tables 2, 3 and 4. Data collection was performed in most quantitative studies using researcher-made questionnaires; therefore, the necessity of designing and psychometrics of a functional tool seems essential for evaluating the implementation of the NP. Center of Tehran The quality of nursing care after the training of the case group was improved from moderate to good rather than before training and the control group.
50% (Vanaki & Zamanzadeh, 1994) Iran In order to investigate the effect of nursing process implementation using problem-based recording in quantity and quality of nurses documentation

| Data analysis
The data analysis stage is one of the most difficult aspects and potentially fraught with error. Similar data are categorized and grouped, after compared data. Then, these coded categories are compared which improves the analysis and synthesis process (Whittemore & Knafl, 2005). The first, to manage data for a better understanding and enhance the visualization of patterns, shows the relationships between primary data sources, and the following characteristics are considered as the initial subgroups: author, country, year, study design, data collection and results. Then, data synthesis from the selected studies was coded by highlighting relevant parts of the text and assigning code words to these areas.

| Ethic
Given that this review article was part of a Ph.D. thesis, a code of ethics was obtained from the Ethics Committee with number: IR.TBZMED.REC.1397.170.

| RE SULTS
Of the 39 studies identified in this review, 18 (46%) focused on the effects of implementing the nursing process in the clinical setting, nine focused (23%) addressed the development and application of software to support the NP, and 12 (31%) discussed factors that affected the implementation of the NP. The papers studied were mainly quantitative papers, and fourteen articles were conducted using descriptive, exploratory and cross-sectional design.
Twelve articles were conducted using the quasi-experimental or RCT research design, five articles were conducted using technological products and methodological studies, five articles were conducted using qualitative research design, and three articles were conducted using the review articles. Most quantitative studies used researcher-made questionnaires to collect the required information.
After data are compared with each other to identify the specific patterns of studies and the precise and important themes in them, three themes were identified that the description of each is given below:

| EFFEC TS OF IMPLEMENTING THE NP IN CLINI C AL S E T TING S
Of the 39 studies reviewed, 18 studies were studied in this scope (Table 2). The implementation of the NP in the clinical practice improves the quality of nursing care, increases the quantity and quality of the curriculum, improves nurses "knowledge, improves the quality and quantity of nurses" documentation and increases job satisfaction and self-efficacy.

| DE VELOPMENT AND APPLI C ATI ON OF ELEC TRONI C SOF T WARE IN THE NP
Nine studies were examined on designing NP software and its application ( Table 3). The NP electronically documentation is a reliable tool for measuring the quality of diagnostic documents, interventions and nursing outcomes and more efficient than a manual documentation system. The development of this tool and its application can help in decision-making and quality of care. It also reduces errors and increases the care of nurses in inpatient care.

| FAC TOR S AFFEC TING THE IMPLEMENTATI ON OF THE NP
Out of 12 studies on the factors influencing the implementation of the NP, 6 papers examined the barriers to the implementation of the NP, 6 studied on the factors affecting the implementation of the process, and its barriers have been discussed (Table 4). In general, the factors affecting the implementation of the NP can be divided into two categories, individual factors and management factors.
The following factors were considered as individual factors: inadequate knowledge of faculty members from the concept of NP and consequently poor learning by students and nurses and nurses' lack of desire to implement NP in the clinical practice due to low knowledge.

Management factors include shortage or lack of infrastructure
for the implementation of NP, incomplete documentation system in nursing reports, nurses' high workload, nursing staff shortages in hospitals, weak in in-service training, lack of supervision of managers on implementation of NP, lack of punishment and encouragement for the implementation of the process and lack of support nursing institutions for the implementation of the NP.

| Stage 4: Presentation
In the final stage of the framework, more precise details of the primary sources and evidence as a logical chain to provide a result consistent with the findings provide for the reader of the review (Whittemore & Knafl, 2005).
Studies of Mazlom and Rajabpoor (2014) and Sayadi and Rokhafroz (2013) was done on the software design of the NP, and the software testing was limited to one ward of a hospital and was not used in other wards or other hospitals in Iran. And their software became for the lack of implementation of this software in hospitals, the lack of necessary infrastructures and the lack of supporting by responsible institutions. Virtually, the NP in Iran is not executed either manually or electronically. Moreover, except for the study of Dal Sasso et al. (2013) and Saba and Feeg (2005), information on the use of others designed the NP software in other countries is not available.

| D ISCUSS I ON
Based on the findings of this study, it was found that the nursing process can be used continuously and extensively in lower-income countries. The findings of the study indicate that the nursing process is consistent with the context of clinical settings in these countries (Manal & Bayoumy, 2014;Semachew, 2018;Zamanzadeh et al., 2015).
The NP is accepted as a care standard with the stages of assessment, nursing diagnosis, planning, implementation and evaluation in the world. The NP has been of great help for nurses in the development of the nursing profession, nursing research and facilitating management activities in nursing (Potter & Perry, 2017).
The implementation of this process increases patients' satisfaction due to an increase in patient-nurse communication, improves the quality of nursing care and documentation. If the nursing process is implemented electronically, it saves time and nursing errors are reduced (Ghafouri Fard et al., 2012;Rajabpoor et al., 2018;Semachew, 2018;Takahashi, Barros, Michel, & Souza, 2008). But, in lower-income countries for three reasons, the NP is not conducted extensively and continuously at the hospitals or performed very poorly: low proficiency of faculty members from the concept of the NP, lack of necessary infrastructure and lack of supporting nursing institutions and managers (Rahmani et al., 2016;Rajabpoor et al., 2018;Semachew, 2018).
Faculty members do not provide the necessary conditions for transferring student learning from the knowledge stage to the application stage and higher levels of Bloom's taxonomy (Anderson & Sosniak, 1994;Johnsen, Fossum, Vivekananda-Schmidt, Fruhling, & Slettebo, 2016).
The lack of infrastructures such as lack of appropriate nursing documentation system manually, lack of software NP, poor HIS in hospitals, lack of standard tools for assessing nursing care based on NP and lack of tools supervising the implementation of the NP is the second reason that the nursing process is not implemented in these countries (Rahmani et al., 2016;Rajabpoor et al., 2018;Semachew, 2018 (Rahmani et al., 2016).
The existence of the NP by electronic means provides a valuable opportunity for nurses and nursing students to improve their clinical performance (Frigstad et al., 2015). Due to legal issues, nurses spend a lot of time writing their reports; if the NP is implemented electronically, this writing time will be reduced and nurses will have more time to evaluate the patient and pay attention to them (Semachew, 2018).
Its implementation requires a lot of effort by nursing institutions and administrators because most nurses have little knowledge about the NP (Aein & Frouzandeh, 2012;Semachew, 2018).
The institutionalization of the NP in hospitals and its continuous implementation by nurses will depend on countries' economic, educational and access to care services. In the United States of America and Europe, this process despite numerous challenges runs manually or electronically (Di Mauro et al., 2018;Zamanzadeh et al., 2015).
The acceptance and emerge of this process in the clinical settings in the United States can be examined through two dimensions: sociological dimension and professional dimension (de la Cuesta, 1979).
These two dimensions led to the massive movement to lead the nursing towards professional. The NP was a professional strategy for nurses in accordance with contemporary American society (de la Cuesta, 1983).
The acceptance and emergence of the NP in the high-income countries including England, Italy, Switzerland, South Korea and China were related to the professional dimension. Dissatisfaction wave from the nursing care provided in these countries. Major factors of dissatisfaction include dissatisfaction of care provided by nurses, poor quality of care and nurses' dissatisfaction from their profession and denial of a task-orientated approach to nursing.
But with the implementation of the nursing process in these countries, many problems and dissatisfaction have solved (de la Cuesta, 1983;Semachew, 2018).

| CON CLUS ION
The NP as a scientific standard improves the quality and quantity of nursing care and documentation, and save time and cost with its implementation as electronically; improves nurse-patient communication and with evidence-based nursing care; and promotes critical thinking in nurses. Therefore, lower-income countries must provide the necessary background for the implementation of this process.

| RELE VAN CE TO CLINI C AL PR AC TI CE
Top managers and institutions of nursing should provide infrastructures such as e-NP (electronically of NP) in the clinical settings; then, they will support the implementation of the NP, increase their supervision over the implementation of NP and increase nurses' motivation to nursing care based on the NP and designing a checklist for NP monitoring and attached them to patients' records. Therefore, appropriate policies must be adopted to implement the nursing process in the clinical settings of the lower-income countries in the form of widely and continuously.
Considering the inadequate knowledge of nurses and faculty members about the NP, nursing diagnosis textbooks in accordance with the context of the country must be translated and used in clinical practice and nursing process training courses are also mandatory for graduate nurses.
An appropriate tool for assessing the quality of nursing care based on the NP is not psychometric, native software tailored to each country and in accordance with international standards in lower-income countries has not been widely used, and the NP is still not implemented in these countries. Therefore, studies with instrumental research, software development and action research are necessary to institutionalize the NP.

ACK N OWLED G EM ENTS
This review article is part of PhD thesis in Tabriz University of Medical Sciences and was supported by the research deputy of Tabriz University of Medical Sciences, and we would like to thank Naser Khalilzad and Tabriz University of Medical Sciences for the guidance and resources provided for this review.

CO N FLI C T S O F I NTE R E S T
No conflicts of interest declared.

E TH I C A L A PPROVA L
Approval code of ethics with number: IR.TBZMED.REC.1397.170.