Use of the nursing process at public and private centers in a health area

Aim: to analyze whether the nursing process method is used at public and private centers in the health area Gipuzkoa (Basque Country) and, if yes, to analyze in the framework of which model and how it is used. Method: cross-sectional study, based on the analysis of the nursing records used at the 158 centers studied. Results: the nursing process is applied at 98% of the centers. It is applied at all public and 18 out of 21 private centers. Virginia Henderson’s model is the most used to apply it, and most centers use nursing diagnoses, the NIC-NOC terminology and standardized care plans. Conclusion: the use of the nursing process is widespread in Gipuzkoa, with greater use at public than at private centers.


Introduction
The nursing process is the work method nursing uses in care delivery (1) . It consists of five phases: assessment, diagnosis, planning, implementation and finally evaluation.
Its creation dates back to the 1950-1960, in the United States and Canada. At that time, the idea started to gain force that, beyond isolated actions, nursing activities are part of a process (2) .
During the initial years, it was mainly discussed and developed in the teaching area. In the 1970's, its use was extended to clinical practice (professional practice), and the laws regulating health professionals' practice in the United States and Canada started to acknowledge that the use of the nursing process is one of the responsibilities of the nursing profession (3) .
Today, according to different reviews (4)(5) , the nursing process method is used at health centers all over the world.
In Spain, studies show that the use of the nursing process starts to expand in the 1990's (6)(7)(8) and that, nowadays, it is widespread (9) . There are few studies, however, which present concrete numerical data on its 905 www.eerp.usp.br/rlae Huitzi-Egilegor JX, Elorza-Puyadena MI, Urkia-Etxabe JM, Zubero-Linaza J, Zupiria-Gorostidi X. application. Among studies that do, one Spanish study should be highlighted (10) , in which the establishment of the nursing process was analyzed at primary health care centers in Spain.
The aim in this research is to study whether this method is used at public and private health centers in Gipuzkoa (Basque Country). If yes, the intent is to analyze in the framework of which nursing model and how it is used. The results will provide knowledge on the way nursing works in Gipuzkoa.

Method
A cross-sectional study was developed (January- The criterion to determine whether the nursing process is applied or not at a given center is the existence of nursing records corresponding to the assessment phase of the nursing process, as subsequent phases are based on the first (1,11) . Therefore, if nursing assessment records are present, it is considered that the nursing process is applied; if not, it is not.
On the other hand, the criterion to determine that the nursing process is applied in the framework of a specific nursing model was to observe that, in the elaboration of the nursing assessment records, the guidelines of that model are followed.
Authorization from the management at the centers involved was obtained before getting access to the nursing records. The centers' anonymity was preserved in the publication of data.

The Research Ethics Committee at Universidad del
País Vasco -Euskal Herriko Unibertsitatea (UPV-EHU) started to function in 2010. As data for this study were collected in 2009, getting ethical clearance from that committee was not possible.
Data were subject to quantitative analysis, using descriptive statistics.

Results
In 155 out of 158 centers under analysis, the nursing process is applied. Hence, the nursing process is applied at 98% of the centers studied. It is applied at all public and 18 out of 21 private centers.
Nevertheless, at many of the centers where we considered that the nursing process is applied, its use has not been extended to all services. To give an example, at public specialized care centers, it is used at most services (traumatology, cardiology, nephrology, general surgery…), but not at the intensive care unit, operating rooms, recovery, emergency, radiology, delivery and neonatal services. In another example, at public primary care centers, it is used in nursing consultations, first aid and home care, but not in midwifery and pediatric consultations nor in the emergency service.
In Table 1, it is shown what centers were studied, the number of nursing professionals working at the centers and at the services where the nursing process is applied.  According to the figures in Table 1, the number of nursing professionals working at the services where the nursing process is applied represents 66% of nursing professionals working at the centers under analysis.
They represent 73% of professionals at public and 38% at private centers.
Concerning the nursing model used to apply the nursing process, out of 155 centers, Virginia Henderson's model (12) is applied at 133 (86%); Marjory Gordon's conceptual structure (13) at 17 (11%); and the RAI-NH 2.0 (Resident Assessment Instrument Nursing Home 2.0) (14) at one. At the remaining four centers, the nursing process is applied without the support of any model or conceptual structure, and records are elaborated at the criterion of nursing professionals working at each center.
As for the nursing diagnoses, these are used at 148 (95%) out of 155 centers applying the nursing process.
In quantitative terms, professionals working at services where nursing diagnoses are used represent 61% of nursing professionals working at the centers studied. In all cases, the NANDA-I (15) criteria are used to reach the diagnoses.

Discussion
The results related to the number of centers applying the nursing process are in accordance with the reviews found (4)(5) . These reviews state that the nursing process is widespread among centers all over the world.
Our study reveals that this is also the case at almost all centers in Gipuzkoa.
In comparison with related studies, the figures obtained in our research are higher than in another Spanish study, which indicates that 43% of health centers apply the nursing process in primary health care (10) .
On the other hand, it is noteworthy that the use of the nursing process is more widespread at public than at private centers. One reason can be that, in Spain, the public health system has received more human and material resources than the private system (18) . The more resources are available, the easier it becomes to put in practice new work methods.
When considering the data per activity area, in mental health and gerontology-geriatrics, the nursing process is applied at all centers and services (both public and private). In primary and specialized care, on the other hand, it is not always used. This can be related www.eerp.usp.br/rlae Huitzi-Egilegor JX, Elorza-Puyadena MI, Urkia-Etxabe JM, Zubero-Linaza J, Zupiria-Gorostidi X.
to the length of the patient's stay in each area. Mental health and gerontology-geriatrics patients are medium or long-term patients, which grants nurses a greater margin to act and apply the nursing process. In primary and specialized care, on the other hand, many patients are short-term, making it difficult for the nurse to apply the nursing process.
The results related to the nursing model used to apply the nursing process show that, in Gipuzkoa, Virginia Henderson's model (12) is the most used to apply the nursing process. In addition, considering that neither Marjory Gordon's (13) conceptual structure nor the RAI-NH 2.0 structure (Resident Assessment Instrument Nursing Home 2.0) (14) are nursing models, but assessment structure (13)(14) , we could say that Virginia Henderson's is the only nursing model used in Gipuzkoa.

This is in line with other studies developed in
Spain (10,19) , showing that Henderson's model is the most used. Also, this is in accordance with global practices, as different authors conclude that Henderson's model is one of the best known and used models globally (20)(21) .
Anyway, the figures obtained in our study are higher than findings in other similar studies. In a study developed in Canada, only 25.5% of the centers use a nursing model to apply the nursing process (22) . In a study developed in Spain, it is affirmed that, in primary care, 35% of the centers use a nursing model (10) . In the latter, Virginia Henderson's (12) is the most frequent model.
Except two, all centers using Marjory Gordon's conceptual structure (13) belong to the mental health sector. This can be due to the fact that the school in Basque Country that offers the specialization program in mental health nursing has elected this structured.
As for the results related to the use of the nursing diagnoses, in all cases, the NANDA-I criteria were used to elaborate these. That is in line with the international reality, as observed in a review (4) . On the other hand, these results on the use of diagnoses cannot be compared with others as, although some studies affirm that the use of nursing diagnoses is widespread in Spain (8,10) and around the world (3) , no numerical data are provided on their use.
Findings on the number of centers that have computerized the nursing process is positive as, according to one study (23) , computerization enhances information quality, interprofessional communication and nursing activity measures.
Besides analyzing in the framework of what nursing model and how it is used, future studies could look at the coherence in the completion of nursing process records, which has already been done in other places (4,(24)(25)(26) .

Conclusions
These study results offer concrete numerical data on the application of the nursing process and show that, like in the rest of the world, the use of the nursing process is widespread in Gipuzkoa, with higher levels at public than at private centers.
As for the nursing model used, this study reveals that, in Gipuzkoa, Virginia Henderson's model is the most used nursing model to apply the nursing process.
Finally, this research reveals that the nursing diagnoses, the NOC-NIC terminology and standardized care plans are a reality at most centers.