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Revista da Escola de Enfermagem da USP

Print version ISSN 0080-6234

Rev. esc. enferm. USP vol.46 no.4 São Paulo Aug. 2012 



Nursing process: what does it mean to nurses from Santa Cruz (Bolivia)?



José Granero-MolinaI; Cayetano Fernández-SolaII; Maria Hilda Peredo de GonzalesIII; Gabriel Aguilera-ManriqueIV; Judith Mollinedo-MalleaV; Adelaida María Castro-SánchezVI

IPh.D. Graduated in Nursing and Humanities. Professor, Department of Nursing and Physiotherapy, Universidad de Almería. Almería, Spain.
IIPh.D. Graduated in Nursing and Humanities. Professor, Department of Nursing and Physiotherapy, Universidad de Almería. Almería, Spain.
IIIGraduated in Nursing and Law. Professor, School of Human Health Sciences, Universidad Gabriel René Moreno. Santa Cruz de la Sierra, Bolivia.
IVPh.D. Graduated in Nursing and Psychology. Professor, Department of Nursing and Physiotherapy, Universidad de Almería, Almería, Spain.
VGraduate in Nursing. Professor, School of Human Health Sciences, Universidad Gabriel René Moreno. Santa Cruz de la Sierra, Bolivia.
VIGraduated in Nursing and Anthropology. Ph.D., Universidad de Granada. Professor, Department of Nursing and Physiotherapy, Universidad de Almería. Almería, Spain.





Bolivian nurses have not yet incorporated the scientific method and taxonomies into nursing care. This qualitative study aims at understanding the meaning that faculty and nursing professionals from the Department of Santa Cruz de la Sierra (Bolivia) attribute to the nursing process. Data collection was performed through interviews and participant observation. The analysis was performed using the theoretical and methodological framework of Symbolic Interactionism and Grounded Theory, utilizing ATLAS.ti.6.0. The following topics emerged from the data: difficulties in implementing the nursing process due to a lack of preparation and training in leadership, dominance by physicians, lack of records, and poor support from the institution. Advantages were that it combines criteria and language and facilitates the autonomous role of nursing. In conclusion, nurses should establish their professional expectations regarding the implementation of the nursing process and care plans, which is a cultural change that involves faculty, management and clinical nurses.

Descriptors: Nursing process; Nursing diagnosis; Nursing records




Although the nursing care process is a global practice, the International Council of Nurses (ICN) recommends the enhanced implementation of standardized international diagnoses and classifications(1) in developing areas, a cultural change that included, among other issues, exchanges between academics and professionals(2-3). In countries like Bolivia, nursing remains closely connected with religious conditions, consideration of women and socioeconomic development; and, as the country has not taken part in this generalized flow, nursing practice still needs to be documented, assessed and further developed through research. In the attempt to mitigate these situations, nurses from different countries have joined in international health projects(4), including training projects focused on communication and professional development tools, through standardized languages that link up diagnoses, interventions and outcomes. Bolivian nursing history already includes participation in projects focused on specific teacher education or training programs(5) but, in most cases, the goals were shared with the medical area and not specifically focused on care development and the enhancement of a nursing methodology, without attending to nurses' own expectations and needs. Based on these, and in view of the gaps detected at universities and health centers in the Province of Santa Cruz de la Sierra (Bolivia); the Undergraduate Nursing Program at Universidad Autónoma Gabriel René Moreno (UAGRM), together with nurses from Hospital Hernández Vera de la Villa 1º de Mayo, Hospital Boliviano-Japonés, Hospital San Juan de Dios and Centro de Salud María Cecilia, developed an Inter-University and Scientific Research Cooperation Project (PCI) to train nursing faculty and clinical nurses regarding the application of the Nursing Process. This project took place between 2007-09, with help and funding from the Spanish Agency for International Cooperation and Development (AECID), within its priority action area in Latin America Human resource education and training in health.

The nursing process is considered a proper method that permits developing the essence of nursing in a scientific manner and, at the same time, permits solving problems in professional practice. This gives rise to the demand to put it in practice in health care administration at hospital institutions as well as in the community(6). Hence, this is an action loaded with meaning nurses can use as a care delivery method. Despite internal strategies for its development in Bolivia, however, activities are still procedures, without any reference to theoretical foundations or a systematic method. Therefore, the lack of advances in its implementation point towards the need to put in practice training strategies for faculty and clinical nurses, considering the meaning they attribute to the nursing care process and to other contextual elements that can influence its operation.

The aim of this study is to understand the meaning nursing faculty (UAGRM) and clinical nurses (four hospital and health centers) attributed to the nursing care process in Santa Cruz de la Sierra (Bolivia).



This research fits into the theoretical framework of Symbolic Interactionism, whose basic premises are that the human being acts on things based on their meaning for him/her and that this meaning derives from the social interaction established with other people. It can change through interpretative processes the person uses when treating the things that surround him/her(7). Symbolic interactionism is frequently used as a focus in social sciences. It produces knowledge focused on the meanings of events for human beings(8). Grounded Theory (GT) was adopted as the methodological framework. Based on symbolic interactionism, the intent is to generate a theory based on the data obtained through the exploration of the phenomenon in the reality it is inserted in. The collected data will be submitted to systematic and comparative analysis and organized in conceptual categories to explain the phenomenon of interest. All of this will comply with requirements for constant data comparison, the researcher's theoretical sensitivity and theoretical sampling, a coding and integration process that contributes to produce the theory(9).

This qualitative study was developed between 2007 and 2008. Semistructured group interviews and participant observation were the strategies used for data collection in three phases. Theoretical sampling techniques were used to guarantee adequate exploration of the concepts, as well as intentional sampling techniques to guarantee that nurses working at all institutions that cooperate with the development of the PCI would participate in the study. First Phase: a semistructured interview was held with six nurses (4 B.Sc. and faculty members at UAGRM, one Hospital Nurse Supervisor and one Hospital Head Nurse), who visited UAL in April 2007. The interview included open questions focused on the object of interest. Answers were recorded with the participants' previous consent, transcribed and submitted to content validation by the interviewees themselves(10). Interviews took place at the Nursing and Physiotherapy Department of Escuela Universitaria de Ciencias de la Salud (EUCS) at UAL, where three research team members acted as moderator, reporter and observer, respectively. Open questions were asked based on a preliminary bibliographic review, focused on exploring terms like: nursing process, care plan, teaching about the nursing process at UAGRM, characteristic nursing role at clinical centers, use of specific documentation and expectations of health professionals and users about nursing care. After initial data analysis, some categories were not sufficiently explored and, as the number of subjects had not been predetermined (based on GT), they had to be made concrete in a second interview. Second Phase: developed in identical conditions, six other nurses were identified (four faculty members and two clinical nurses), who visited UAL in September 2007. Further data analysis confirmed theoretical saturation.

In a Third Phase, developed in July 2008, and for the sake of triangulation, Spanish project members contrasted the results obtained from these interviews through participant observation, developed during two-day visits to each of the four hospital centers that participated in the PCI (two observers per work shift, during the morning/afternoon shifts), and also to UAGRM. At the hospitals, they talked with the professionals, reviewed documents and identified actions, interactions and work procedures, collecting information in a field diary. University facilities were visited, the project members watched classes, the study plan was reviewed and meetings were held with the students. The final results join interviews transcripts with the reporter and observer's notes, elements that, in turn, were supported by participant observation. Open, axial and selective coding were performed, in line with the constant comparison method, based on which categories could be extracted(11). To facilitate the inductive data categorization and analysis process, ATLAS.ti 6.2® software was used, representing a Hermeneutic Unit that joined the transcripts, interpretations and related codes, resulting in a final report that took the form of two conceptual (Network) maps, based on which the final research reports was elaborated.

All interviewees were informed about the study aims, the voluntary nature of their participation, received guarantees of confidentiality and anonymity and gave their informed consent. Approval for the study (Protocol No. 25) was obtained from the Research Ethics Committee at Facultad de Ciencias de la Salud Humana of UAGRM, issued on February 16th 2007.



Study participants were 12 nurses, all female, with a mean age of 45.6 years and average professional experience of 15.4 years. The analysis permitted the construction of two central categories, representing the meaning the interviewed nurses attributed to the research phenomenon (Figure 1) and the interactions its implementation requires (Figure 2).

According to the participants, the nursing process means expectations that their profession will be strengthened, internationalized, that the prestige of their career will be recovered and that patient care criteria will be unified (see figure 1).

The implementation of the nursing process demands a change in interactions among the nurses, with other professionals and the environment. In the world where nurses interact with others, the nursing process supposes a range of advantages or stimuli, like the empowerment of their own role, enhanced visibility and even better user care. On the opposite, they perceive interactions that hamper the implementation of the nursing process, like opposition from physicians and nurses' little involvement in management (Figure 2).

We present the interpretation of the data, accompanied by representative discourse fragments, anonymously (En= Nurse 1, Nurse 2, etc.), textually and between inverted commas.

In their opinion, the theoretical notions are correct and comprise a clear concept of the nursing process as well as the nursing method:

The Care Plan is an instrument that permits the prioritized individualization of care according to the patient's assessment, a list of activities to accomplish related to the patient's needs, with a specific format that permits systemization.(E1);

but they mainly miss its connection with practice, an issue that coincides with spontaneous interventions and a rich debate:

It is a care protocol that helps with systemization, individualization and execution; it allows all of us to speak the same language and would avoid the current problem that what is taught at university is one thing and what is put in practice is quite different (E3).

About the use of the nursing process and the NANDA, NIC, NOC or ICNP® taxonomies in the UAGRM course plan, the interviewees manifest a clear disconnection between theoretical teaching and its actual application to patients. It is essentially studied in the Nursing Fundamentals subject, and reaffirmed in further subjects through its exclusively theoretical application, focused on specific diseases:

Each teacher delivers the process in his own way, without a uniform method. A final theoretical paper on the process is required from the student, with a single patient (E2).

Each teacher is accountable in function of the subject, teaches according to his/her personal understanding and students do not apply it in practices, as this is not demanded either:

The own role is addressed since the first course, but not applied actually, it's an academic activity in which the student does not deal with the NANDA diagnoses, nor with the NIC and NOC taxonomies, there's a lack of practice, know-how (E8).

These multiple answers make us explore the teachers' educational background, which is very heterogeneous, as the nursing process was not studied in the course and each sought his/her education means:

Ongoing efforts are individual, reading Internet references, with a lot of difficulty, that's how all of us teachers have studied it, we just saw it and at great effort (E6).

Nevertheless, they have agreed on evaluations based on the use of Marjory Gordon's functional health standards, but at theoretical level, not as a nursing work method:

The university has provided more education on curricular design than on the Nursing Process, and that's what we expect from the PCI, to organize workshops about the Nursing Process, focused on teachers and hospital professionals(E12).

That is why they demand practical training, an issue they relate with the recovery of the nursing profession's prestige, envisaging the project as a great opportunity:

We want to recover the previous status, do courses in Europe, that would grant the Nursing career prestige, to work with a European model (E4).

Together with the implementation of the medical program at UAGRM, this lack has taken the nursing program to a situation of historical minima, generating a whole range of conflicts and reproaches between both classes:

The implementation of the medical program 5 years ago relegated the nursing program. Students from both programs compete in their practices, medical students misappropriate themselves of nursing students' techniques and procedures and, moreover, by validating subjects, use the nursing program as an access route into medicine" (E5).

The nursing process is not studied as a proper work method that pervades all activities, but:

The clinical nurses know the method, but it is neither applied nor registered because there aren't any forms either. The nursing process is very important for the teacher, but not for the professional (E11).

Clinical nurses work without their own planning or records, something students end up assuming, repeating and adopting as the care form during practicums:

Students do not value it because there's no application, sees at it at the academic level but not at the practical level and ends up doing what the nurse has done her whole life (E6).

The polarization between teachers and clinical nurses reorients the interview to value the weight of theory and practice in course plans at UAGRM: finding a balance between the hours dedicated to clinical and community subjects, all subjects are compulsory, but their structure does not follow a nursing care process application model:

It would be desirable if this structure were based on nursing care and not so much on a physiopathological organization (E7).

The nurses' self-esteem is undermined by the lack of a scientific care method and proper documentation to reinforce their professional role:

At clinical centers, generally, a biologic and biomedical paradigm dominates, but it gradually changes. Nurses are aware that they play an independent role, claim their work, are professional who do not solely depend on the physician (E11).

And the issue is that nurses do not decide on care processes, organization and management in clinical practice. Moreover, in the organizational management chart, even the Nursing head is not at the level of the rest:

Directors and sub-directors are usually physicians, the Nursing Head seems in an aside to the sub-directors. The head nurse is an advisory entity, functions as a sub-director but does not appear as such in the organizational chart (E4).

Thus, they assert that they face multiple obstacles for their professional development at social level, in management and in interdisciplinary work, producing a severe self-esteem deficit:

At the community level, nurses take up roles that are not theirs, everything goes through their hands but it's the physician who signs. The same society gives all of the status and acknowledgement to the physicians, but the recovery of our self-esteem also has to depart from the nurses (E9).

The lack of nursing documentation to give expression to care is another fundamental key:

The nursing documentation that exists is a treatment sheet that mentions diet, medication, vital signs, diagnostic tests, ...and an attached supplement with nursing care. It collects what is done, not the action plan, and it is not kept in the clinical history, there is no specific nursing care document (E1).

Nevertheless, they mention being saturated with documentation that has nothing to do with care, but which they are responsible for.

We are weak in care management, we've got loads of reports, we're snowed under to make statistics that actually are not exhaustive studies (E4).

In a health system with scarce means and resources, with mass hospitals and health centers, the nurses attend to users who do not distinguish between the distinct categories of the profession. The nursing figure is hardly distinguished, there is an overload of administrative work and little management of people, knowledge and research, fields dominated by physicians in view of nurses' immobility:

We nurses want to start managing knowledge, research and education, but we know that it also depends on budgets and that's our main problem (E8).

The expressions indicate lack of response, dejection and resignation, as they assume that an important part of the problem is also rooted in their conformism and lack of drive in the fight to defend their interests. Nurses are expected to attend to patients' basic needs, provide support and understanding-compassion, but not professional care based on scientific knowledge and autonomous activity. And that is what is being claimed through the development of the PCI:

People do not know the nursing levels, they acknowledge your sacrificed work but continue thinking that you're the physician's assistant and doubt whether you're a prepared person. The nursing method will exert positive influence, as each person recognizes that the nurse is a potential, recognizes but does not shout it out (E7).



Nursing makes increasing efforts to enhance educational and research development in developing countries(12), but work habit transformation experiences have manifested the slowness of changes, the need to set reachable targets, to support the stakeholders and to use and make the most of resources(13). Our project tries to attend to the challenges the Pan American Health Organization has posed in health education and human resource management for Latin America, furthering interaction between universities and health services, which in Bolivia takes the form of technical support to strengthen local capacities and exchange experiences(14).

Many countries have incorporated the nursing process into their practice in a progressive and generalized way, turning nurses into knowledge and research producers, educational leaders and care managers, to which language standardization and taxonomy use have essentially contributed. But the development of this process is not uniform. While some countries computerize nursing documentation in the clinical history(15), in others like Bolivia, it is limited to sketching out scarce theoretical notions without any practical development. Various studies have demonstrated that nursing education not only improves patient care, but is a critical need for the profession(16). In this sense, Bolivian nursing's concern with adhering to an international method is understandable, for which it is key to determine its expectations and the meaning attributed to the nursing care process(17).

The nurses appoint the distancing between the academy and health practices as the base of the problem to set up the nursing process(18), attributable to its scarce curricular weight, lack of uniformity in teaching methods and teachers and graduate nurses' lack of education on this theme, resulting in students' deficient education. In line with other experiences(19), learning difficulties, lack of budget for education and the limited teacher-clinical practice relation are perceived as difficulties for its implementation. The gaps these nurses express agree with other studies on the need for education and training, as well as on the need for institutions' commitment to put in practice the nursing process(20); in addition to specific contextual elements(7), that is, and for the case of Bolivia, the chronic shortage of human and material resources, including the basic bibliographic for its study, practice and implementation.

The nurses express a lack of time and resources to dedicate to their own education, which are used in theoretical and administrative activities distanced from patient care, mainly in medical documentation management. That is why, in line with other studies(21), they show concern with the time the implementation of the nursing process would demand. They do acknowledge, nevertheless, that this would suppose producing records to allow them to publish results, which would enhance the visibility of Bolivian nurses(22) and would start their adherence to a global movement in the profession like the use of a scientific care method.

Limitations: the study results can be applied in the context where data were collected, but cannot be generalized to other contexts.



For the participating nurses who were interviewed, the nursing process means providing them with a scientific method for the application of care, a perception that is more frequent among faculty members than among professionals. They mostly perceive the relation between the nursing process and practical work, whose implementation would grant meaning and relevance to their professional know-how, raising Bolivian nursing to the same level as the profession in the international sphere.

The nurses detect severe constraints for the development of the nursing process, but have no doubt that these can be solved by international cooperation through the PCI. It would need a "cultural change" that transforms nursing from a mere executor of medical orders into a professional who plans care by following the scientific method, a question other professionals should not perceive as a threat.

In their opinion, strategies are needed to enhance its implementation in teaching and care in the Province of Santa Cruz de la Sierra, with students as the axis of transmission between both activity areas. The analysis of the interviews reveals a consensus on the need to make the most of the students' potential as drivers of change.

Bolivian nursing's scarce tradition in managing its own resources and knowledge is considered an impediment, not only for the implementation of the nursing process, but also for its further development. This reveals the need to create an operational nursing unit to safeguard and encourage the expansion program, within the province and in the rest of the country. The interviewees also perceive the lack of specific documentary and bibliographic support as severe constraints for the development of the goals set.

As a result of the research conclusions, a series of specific punctual actions were put in practice, including:

Development of theoretical-practical seminars on the nursing process, which UAL faculty presented in 2008, including the participation of all UAGRM faculty and nurses from the four hospital centers involved in the project.

Various meetings took place with nursing student associations at UAGRM to inform them and involve them in the project development.

A Care Plan Unit (CPU) was created, including representatives from nursing faculty, clinical nurses, the community and the Nursing Council, currently in charge of safeguarding and encouraging the expansion of the nursing process to other centers through professional education.

An Initial Nursing Evaluation document was designed, contextualized and validated by the CPU, in the pilot phase, and its incorporation into the patient's clinical history. Also, a pilot study on a Standardized Perioperative Care Plan is in process at the hospitals involved, validated and contextualized by the CPU since June 2008.

An interview program with education, health and social authorities was designed to explain about the project's potential and request their cooperation.



To the participating nurses, faculty and authorities from UAGRM and to the Spanish Agency for International Cooperation and Development for funding the PCI (A/6907/06, and A/8374/07).



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José Granero-Molina.
Departamento de Enfermería y Fisioterapia Escuela Universitaria de Ciencias de la Salud de la Universidad de Almería
Carretera Sacramento, S/Nº - 04120 - Almería, España

Received: 08/15/2010
Approved: 02/16/2011

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