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. 2023 May 11;10(8):5560–5570. doi: 10.1002/nop2.1796

The impact of institutionalizing the nursing process based on TPSN model on the quality and quantity of nursing diagnoses

Maryam Namadi‐Vosoughi 1, Vahid Zamanzadeh 2, Leila Valizadeh 3,✉, Mojgan Lotfi 1, Akram Ghahramanian 1, Afsaneh Pourmollamirza 2, Fariba Taleghani 4, Farzaneh Bagheriyeh 1, Marzieh Avazeh 5
PMCID: PMC10333878  PMID: 37170427

Abstract

Aim

Nursing diagnosis is the basis of applying nursing process and evidence‐based care in nursing. This issue has been affected by the gap between theory‐practice in nursing. The attending nursing teachers Project aims to create an organizational link between health care centres and nursing schools, reducing the gap between theory‐practice and empowering nurses to apply nursing diagnosis.

Design

The present study was part of the second cycle of an action research study conducted in the cardiology ward in 2019–2020.

Methods

Interventions were performed in the form of Teacher, Patient, Student, Nurse Model to empower nurses in quantity and quality of nursing diagnosis.

Results

The results indicated a significant increase in the number of nursing diagnoses recorded. Moreover, the qualitative criteria based on PES components were found to have changed significantly after the interventions. Empowering nurses in the form of this Project could suggest that creating proper structures between nursing schools and health care centres, full‐time presence of faculty members in hospitals, and enhancing their roles in these institutes will lead to improvements in educational as well as health care systems.

Keywords: attending nurse teacher, nursing diagnosis, nursing process, TPSN model

1. INTRODUCTION

Evidence‐based care is an effective and innovative method for improving the quality of care in the health care system (Soll & McGuire, 2019), leading to improved health outcomes and patient safety (Ruzafa‐Martínez & Fernández‐Salazar, 2020). Therefore, it stresses the central role of nurses in proper decision‐making and providing care to individuals and families, taking into account their need for evidence‐based education and practice (Stannard, 2019). In this regard, academic education is the main tool for providing evidence‐based education and care (Li et al., 2019).

In nursing, the nursing process is the most practical tool for providing evidence‐based care (Song et al., 2019). It provides a basic framework for care provision based on a common scientific language among nurses (Olatubi et al., 2019). Using this strategy leads to independence, creativity, meritocracy and identity creation in nursing (Wu et al., 2019); on the other hand, its incomplete application leads to poor prognosis in patient treatment as well as lowering the effectiveness of care (Getie et al., 2021). The nursing process has five systematic dynamic steps: assessment, diagnosis, planning, implementation and evaluation. Proper assessment and correct diagnosis are the most fundamental steps in the nursing process (Bahrudin & Wulandari, 2019; Johnsen et al., 2016; Tan et al., 2021).

Despite the benefits of the nursing process, many nurses do not seem to fully understand it, and, as a result, do not seem to be using it much in practice. The theory‐practice gap is one of the main reasons for the nurses failing to apply the nursing process (Lotfi & Zamanzadeh, 2021; Osman et al., 2021). As a result, nurses face challenges in translating theory into practice (Akram et al., 2018; Gassas, 2021).

One of the main factors causing this gap is the lack of an organizational, structured and academic relationship between clinical personnel and nursing teachers and the poor performance of role models in educational and health care settings, which leads to a gap between teaching institutions (nursing schools) and health care institutions (teaching hospitals; Shoghi et al., 2019).

2. BACKGROUND

Literature review reveals that various strategies have been employed to reduce the theory‐practice gap in nursing and evidence‐based care in recent years. These strategies can be categorized into two patterns (Saifan et al., 2021). In the first pattern, called collaborative clinical teaching, specific clinical nurses are involved in nursing students' education. The results have shown that, clinically, this empowerment might not provide adequate, up‐to‐date science to students, with the clinical nurses and nursing students failing to gain much from the academic institution (Museene, 2018; Vitale, 2014). Some of the strategies for the first pattern include preceptorship, internship and clinical teaching associate (CTA) methods (De Voogd & Salbenblatt, 1989; Lee & Fitzgerald, 2008; Quek & Shorey, 2018).

The second pattern, which was designed and implemented to compensate for the drawbacks of the first pattern, is the academic‐practice partnership pattern (Gursoy, 2020). In this approach, there is a two‐way interaction between academic and health care institutions. It included methods such as joint appointments, the clinical scholarship model and dedicated education unit (Iseler et al., 2019; O'Connor, 2019). These approaches led to a relative improvement in reducing the theory‐practice gap. However, despite the improvements in some aspects, this gap still remains in nursing (Bvumbwe, 2016).

Studies in Iran also show the theory‐practice gap in nursing (Safazadeh et al., 2018a, 2018b) and there is evidence that the nursing process is not being practiced by professional nurses and nursing students in Iran (Delavari et al., 2020; Taghadosy & Hosieini, 2018). Nursing education in Iran is carried out in nursing schools under the supervision of the Ministry of Health and Medical Education. Nursing education programmes are planned and implemented by the Deputy of Education of this Ministry. Applicants must complete a 4‐year course in these schools in order to obtain the bachelor's degree in nursing. Nurses are allowed to work in clinical environments after obtaining a university degree. The Clinical Faculty Member Recruitment regulation was designed by the Ministry of Health and has been implemented as a response to the theory‐practice gap to create a link between academic institutions and health care centres. This regulation had some problems, such as the ambiguity of clinical faculty members' role in reducing the theory‐practice gap, obscurity of the process of interaction and participation of academic and health care setting, and the lack of clear, practical strategies. Due to these problems, the plan mentioned above did not significantly change nurses' medical and educational system (Tajabadi et al., 2018). Supreme Council of Nursing Policy in the Ministry of Health has called for improvements in this regard.

Many studies highlight the theory‐practice gap in nursing around the world (Salifu et al., 2019). Several international studies suggest that the reasons for the gap between theory and practice may have to do with a host of factors, including the different ways of preparing students in the university and clinical setting, lack of structured communication between nurses and faculty members, not applying the nursing process in hospitals, lack of communication between faculty and hospital and lack of active and direct involvement of nursing teachers in working with the patient (Safazadeh et al., 2018a, 2018b; Wyllie et al., 2020). The studies show that the main reason for the disconnection between theory and practice in nursing in Iran is due to the lack of interaction and effective participation of clinical settings with faculties, and not applying the nursing process in hospitals (Shoghi et al., 2019). In order to respond to these needs, the researchers during a study introduce and describe the innovative TPSN model with the aim to reduce the theory‐practice gap.

The results of this studies showed that the collaboration between academic institutions (nursing schools) and health care institutions (teaching hospitals) along with bilateral utilization of educational and skill capacities of Nursing faculty members and clinical nurses can be an influential supporting factors improving performance in both institutions (Fulmer et al., 2011; Tajabadi et al., 2018). The guidance provided by teachers and trained people can effectively integrate nursing theories and practices and improve the nursing process (Campbell, 1983). To develop the role of faculty members and in line with the promotion of evidence‐based education and performance, a practical model was designed and implemented within the framework of a participatory paradigm and an action research between nursing school and hospital.

The PARENT study was carried out, with the title of presenting the TPSN model to reduce the theory‐practice gap in nursing. In this study, the theory‐practice gap refers to the distance between what is taught in the classroom and what is provided in clinical area as nursing care. Clinical education integration component (TPS triangle) is one of the components of this model (Vosoughi et al., 2022). The nursing process was used as a strategy during this component to: 1.use a common language between education and clinical setting (attending nurse teachers, nursing students and nurses; Gonçalves & Sequeira, 2019; Mousavinasab et al., 2020), 2. provide a factor that creates continuous care among caregivers (Liu et al., 2021) and 3. achieve evidence‐based education and practice (Oreofe & Oyenike, 2018). The aim of this study was to investigate the effectiveness of institutionalizing the nursing process in the form of the TPSN model on the quantity and quality of nursing diagnoses.

3. THE STUDY

3.1. Aim

The aim of this study was to investigate the effectiveness of institutionalizing the nursing process in the form of the TPSN model on the quantity and quality of nursing diagnoses.

4. METHODS

4.1. Design

Parent study is the result of a national project with a participatory action research design. The research action cycle of this study has four phases, including problem identification, planning, action and reflection. A number of action research questions were raised in the second phase for a better implementation of the model (TPSN). These questions were as follows: (1) what is the common language in the process of teaching and providing nursing care between attending nurse teachers, nurses and nursing students? (2) What factor(s) will maintain continuity of care over time between caregivers and others? What is the key factor in evidence‐based education and practice in nursing?

Following this, the nursing process was entered into this model in the second cycle for answer these questions.

The present study was a part of that project. The research question in this study is: ‘Is institutionalizing the nursing process based on the TPSN model effective on the quality and quantity of nursing diagnoses’?

In order to investigate the effect of the interventions made in this regard (after entering the nursing process into TPSN model), a pretest–posttest comparison was conducted on the quality and quality of nursing diagnoses in the women's cardiology ward of Shahid Madani Hospital in Tabriz from 2019 to 2020.

4.2. Population and sample

The Cardiology ward had 30 beds and 15 nurses. Patients hospitalized in this ward were diagnosed with cardiovascular disorders such as angina pectoris, myocardial infarction and different types of cardiomyopathy. All 15 nurses working in the ward were included in the study.

The cardiology ward's archived patient files that met the inclusion criteria were used to access information. The inclusion criteria were as follows: 1. inclusion of informed consent permitting the use of the information in the file, 2. belonging to discharged or deceased patients and 3. hospitalization of more than 48 h. The following patient files were excluded from the study: 1. Patient files related to patients with non‐cardiac problems hospitalized in the ward, 2. Patient files of patients transferred from other wards and 3. Patient files filled by nurses other than the 15 nurses participating in the study.

Our setting was a general teaching hospital and informed consent to use the information from the patient files was obtained from all the patients when they were admitted to the hospital.

4.3. Sample size

Twenty patient files completed by the nurses were selected, and the number of recorded diagnoses was measured to determine the sample size. A total of 34 nursing diagnoses were extracted from 20 patient files. Since the researchers expected a 30% increase after the interventions, the estimated sample size of 100 patient files before the intervention and 100 patient files after it was calculated considering α = 0.05, power = 0.8 and effect size:0.5. The patient files used in the pilot study were not used in the main study.

4.4. The theoretical framework used in the field research

To develop the role of faculty members resident in health care settings and enhance the collaboration between academic and health care institutions, it was decided in the main action research that the studied ward would function based on a specific theoretical framework, and the role of faculty members would be developed in this structure. Therefore, a conceptual framework was designed and finalized based on literature review, qualitative interviews with educational managers, nursing professors, nurses, students (BSN to Ph.D.), nursing managers and discussions in focus groups; this framework provided the philosophical and theoretical basis of the present study.

The academic‐practice integration model of TPSN, which was developed within the Attending Nursing teacher Project framework, is a dynamic and interactive model for accountability in nursing and similar Disciplines. Unlike the medical model that includes patients, students and physicians as the three points of the triangle, this model is formed out of a large triangle in its initial view, where Teaching nursing system was attempting to direct the focus of the model on the receiver of the health services through prioritizing the person needing care and treatment (the patient, family and society) by positioning it in the centre of the triangle. It has to be added that this triangle is formed out of three smaller triangles (components), none of which is capable of realizing the ultimate goal of bridging the theory‐practice gap on its own.

The mentoring component (TPN triangle) is formed by the interaction between patients and nursing teachers (clinical faculty members) and aims to show the effect of faculty members on health and nurses. This can be achieved through specific strategies introduced in this triangle, such as changing nursing record forms, educating nurses, implementing nursing grand rounds, nursing morning rounds, journal clubs, patient visits by nursing attendants and educational rounds, which are the responsibility of resident nursing teachers. They are also responsible for making the required changes in the ward regarding promoting evidence‐based care and the nursing system, empowering nurses to provide nursing care based on the nursing process. These activities are done with the participation of nurses and, in some cases, nursing students.

The preceptorship component (PSN triangle) is formed through the interaction between nurses and even other health care service providers with students and patients and is based on the adjusted preceptorship model. Nurses can play an effective role in nursing students' teaching as role models after being empowered by attending nursing teachers in the mentoring triangle. In this model, due to the full‐time presence of faculty members in the clinical setting, nurse preceptors become empowered by their mentoring, which simultaneously affects educational and clinical performance of students.

The component of clinical education integration (TPS triangle) includes the interaction between teachers, patients and students. In this component, specific strategies such as cascade education, nursing grand rounds and teaching based on the nursing process lead to the training and empowerment of students (BSN to Ph.D.) in a well‐defined dynamic and interactive system with specific job descriptions for students, head nurses and trained clinical nurses. Moreover, each strategy introduced in each triangle is defined and implemented based on scientific texts and experts' opinions (Figure 1; Vosoughi et al., 2020, 2022; Zamanzadeh et al., 2019).

FIGURE 1.

FIGURE 1

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Academic‐Practice Integration Model of TPSN: A dynamic & interactive model.

4.5. Intervention

This research plan was designed in joint sessions between the nursing school and Shahid Madani teaching hospital of Tabriz, Iran and was approved by the deputy health minister for the nursing department. Moreover, the necessary offices for clinical faculty members and Ph.D students' accommodation were provided and equipped.

The schedule of medical‐surgical nursing students at different levels (BS to Ph.D) was prepared for conducting the study with the help of the research team in 2019. After that the department chair, deputy for education, nursing faculty members, the dean of the faculty, the head of Shahid Madani teaching hospital, the deputy for education in the centre, the head of nursing services, the head nurse of the ward and students were informed. Monitoring the nurses was done by the head of nursing services, the nursing educational supervisor and the head nurse. Oral feedback was obtained from the students, which was later discussed and analysed after being summarized by the research team.

In the model mentioned above, the clinical faculty members were present in the cardiology ward full time, and the nursing students of different levels also attended the ward periodically to receive training. The training was provided by the faculty members both for the students and the nurses in the cardiology ward. Education and practice were conducted within the framework of the nursing process. An appropriate instrument for health assessment was designed and taught to the nurses so that they would apply the nursing process and accurately implement the assessment stage. The assessment tool in the cardiology ward was a general tool for assessing all patients and did not exclusively assess patients with cardiac diseases. Due to the importance of assessment in the nursing process, the research team first prepared a suitable tool for assessing cardiac patients. Gordon's functional health patterns were used to prepare this tool. The tool exclusively assessed cardiac patients at arrival. After being designed, the tool was analysed by an expert panel including 10 educational and clinical nursing experts. Afterwards, it was analysed in a pilot study in a cardiology ward in the present study for 6 months. The required changes were applied, and the expert panel approved the tool again.

The theoretical and practical workshop for teaching of the nursing process was held in 3 two‐hour sessions. Education was provided in the form of lectures and practice. The topics included: Session 1, teaching the nursing process and its stages, Session 2, the nursing process in cardiac patients and Session 3, teaching the method of recording nursing diagnoses (the PES model). After the theoretical teaching, practical training of the nursing process was provided for some patients in each session.

After the workshop, an exam was given to the nurses to test their ability to implement the nursing process, and all the nurses demonstrated the required ability. Moreover, to consolidate the training clinically and authentically in the clinical setting and with the supervision of the resident nursing professor, one of the nursing Ph.D. students trained the nurses with this tool individually for 6 months. In order to improve the utilization of the nursing process and assess the nursing process implemented by the nurses, daily rounds were implemented by the resident nursing teacher in the ward and were analysed and discussed by the nurses in different shifts. Ph.D. and master's students were present in different shifts to train and consult the nurses. NANDA (2018–2020) nursing diagnoses were provided to the nurses for easy access. The nurses attended the morning shift on a rotating schedule and received the necessary education to optimize their education and theoretical and practical knowledge. The role and interventions are shown in Table 1.

TABLE 1.

Role and interventions.

Role Intervention
Attending nurse teacher Nurses Teaching the nursing process, preparing appropriate tool for the initial assessment of the patient, visiting patients, performing the morning round of patients focusing on the activities performed in line with the nursing process, educational round above the patient's bedside, conducting the Journal Club with the presence of nurses, Grand Round presentation with the presence of nurses
Students Teaching the nursing process, preparing appropriate tool for the initial assessment of the patient, visiting patients, performing the morning round of patients focusing on the activities performed in line with the nursing process, educational round above the patient's bedside, conducting the Journal Club with the presence of students, Grand Round presentation with the presence of students
Nurse Nurses Role model of implementing the nursing process, providing continuous care based on the nursing process, recording and transferring the nursing process
Students Role model of implementing the nursing process, teaching practical procedures, bedside educational round
Student PhD → MSN Setting Up And Running a Journal Club for nursing process implementation and practical procedures, Grand Round presentation
PhD → BSN Setting Up And Running a Journal Club for practical procedures and practical procedures, Grand Round presentation
MSN → BSN Role model of implementing the nursing process, teaching practical procedures, teaching practical procedures
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4.6. Data collection instrument

4.6.1. Exam to test nurse ability to implement the nursing process

The exam questions consisted of two theoretical and practical parts. The theoretical part consisted of 20 test questions related to 1. The nursing process in general (10 questions) and 2. The nursing process in patients with cardiovascular diseases (10 questions). Two members of the research team and the attending nurse teacher of the cardiology department designed the questions, drawing on NCLEX‐RN Examination questions (Silvestri, 2016). The designed test was reviewed and approved by 10 nursing professors and two medical education professors. In order to pass the exam, it was necessary for the examinees to answer 14 questions correctly. The practical part of the exam was the application of the nursing process for a patient with cardiovascular disease hospitalized in the cardiology department. The practical test was implemented and reviewed by one of the professors of this research, the Attending nurse teacher of the heart department and the supervisor of the heart department.

4.6.2. Nursing diagnosis quantity

The frequency of recorded nursing diagnoses was used to assess the quantity of recorded nursing diagnoses. The recorded diagnoses were extracted, grouped into 13 domains based on the NANADA (2018–2020) taxonomy and analysed (Herdman & Kamitsuru, 2017).

4.6.3. D‐Catch instrument

The third item of the D‐Catch instrument was employed to assess the quality of nursing records. This instrument was designed and standardized by W. Paans et al. between 2007 and 2008 (Paans et al., 2010). The D‐Catch questionnaire includes six items: nursing documentation structure, evaluation of admission, nursing diagnoses, nursing interventions, patient outcomes and legibility of nursing documentation; this instrument assesses the quantitative and qualitative status of nursing documentation. Relevancy, unambiguity and linguistic accuracy are evaluated as the qualitative aspects, and the scores include very good (4), good (3), moderate (2) and poor (1); the quantitative criterion of this item represents the completeness of records in terms of following the PES[1] model to prepare the nursing diagnosis statements and is scored from 1 to 4 (D'Agostino et al., 2017; Paans et al., 2010). Since this instrument is not used in Iran, the forward translation method was used. The original version was translated into Persian by an English translator; afterwards, the final Persian questionnaire was prepared by three nursing professors proficient in Persian and English by comparing the two versions. Then, to check the validity, necessary corrections were made using the opinions of 10 faculty members, and deficiencies and differences were reviewed and corrected by the research team. Finally, the Persian questionnaire was prepared. Next, to check the reliability of the questionnaire, 10 patient files were independently scored in the pilot study based on the D‐Catch instrument, and the correlation between the scores given by two raters was measured. The intra‐class correlation coefficient (ICC) was 0.98, showing acceptable reliability.

4.7. Data analysis

The data were analysed, using SPSS 16; the significance level was set at p < 0.05. To assess the quantity of nursing diagnoses before and after the intervention in different domains, the diagnoses were counted and the percentage was used. Also, to assess the quantity and quality of nursing diagnoses in the D‐Catch scale before and after the intervention in different domains, mean rank, and Mann–Whitney U test were used.

4.8. Ethical considerations

This study was approved by the Ethics Committee of Tabriz University of Medical Sciences (ethics code: IR.TBZMED.REC.1397.643), and the permission to conduct the study was acquired from the head of Shahid Madani Hospital based on a contract. Moreover, the researcher obtained informed consent from the nurses working in the cardiology ward and a consent letter signed by the patients when they were hospitalized, allowing the use of the information in their patient files.

5. RESULTS

None of the 15 nurses who were included in the study and received the required training left the study. In addition, 100 patient files before and 100 patient files after the intervention were randomly selected and analysed.

The recorded diagnoses before and after the intervention were extracted and classified in the related domains to investigate the effect of the intervention (Table 2). The diagnoses were made in eight domains. Before the intervention, 21 nursing diagnosis labels were recorded with a frequency of 174; most of these diagnoses (46.6%) with a frequency of 88 were related to the safety/protection domain, coping/stress tolerance domain (30.1%) with a frequency of 52 diagnoses, and the comfort domain (13.8%) with a frequency of 24 diagnoses. After the intervention, 41 diagnosis labels with a frequency of 848 were recorded by the nurses; the most frequent diagnosis was related to the activity/rest domain (43.1%) with a frequency of 365 diagnoses, followed by the safety/protection domain (19.6%) with a frequency of 166 diagnoses, and the nutrition domain (13%) with a frequency of 110 diagnoses. In sum, the results indicated that the quantity of diagnoses had increased after the intervention. Moreover, the activity/rest, nutrition and safety/protection domains showed the highest increase. No change was observed in the five domains of self‐perception, role relationship, sexuality, life principles and growth/development. The number of nursing diagnoses had decreased in coping/stress tolerance and comfort domains after the intervention; however, this decrease was negligible due to the low number of diagnoses.

TABLE 2.

NANDA diagnoses recorded by nurses on domains before and after the intervention.

Domain NANDA diagnosis Pre, N (%) Post, N (%) Totally, N (%)
Health promotion Ineffective health management 1 (0.6) 19 (2.2) 20 (1.9)
Domain 1 Risk‐prone health behaviour – 8 (1.0) 8 (0.8)

Nutrition

Domain 2

 Risk for unstable blood glucose level 1 (0.6) 20 (2.4) 21 (2.1)
Obesity – 41 (4.9) 41 (4.1)
Imbalanced nutrition: less than body requirements – 12 (1.4) 12 (1.2)
Excess fluid volume – 7 (0.8) 7 (0.7)
Risk for electrolyte imbalance – 12 (1.4) 12 (1.2)
Risk for metabolic imbalance syndrome – 11 (1.3) 11 (1.1)
Overweight – 6 (0.7) 6 (0.6)
Risk for imbalanced fluid volume – 1 (0.1) 1 (0.1)

Elimination and exchange

Domain 3

 Risk for constipation 4 (2.3) – 4 (0.4)
Impaired gas exchange – 13 (1.5) 13 (1.3)
Impaired urinary elimination – 5 (0.5) 5 (0.5)
Constipation – 29 (3.5) 29 (2.9)

Activity rest

Domain 4

Risk for decreased cardiac output

Activity intolerance

Impaired physical mobility

Risk for activity intolerance

Distributed sleep pattern

Risk for unstable blood pressure

Ineffective breathing pattern

Decreased cardiac output

Fatigue

Risk for decreased cardiac tissue perfusion

Risk for ineffective cerebral tissue perfusion

Ineffective peripheral tissue perfusion

Risk for ineffective peripheral tissue perfusion

Self‐care deficit

2 (1.1)

2 (1.1)

1 (0.6)

1 (0.6)

–

–

–

–

–

–

–

–

–

4 (2.3)

–

–

36 (4.2)

60 (7.1)

–

14 (1.7)

40 (4.7)

33 (3.8)

18 (2.1)

25 (3.0)

35 (4.2)

56 (6.6)

19 (2.2)

6 (0.7)

9 (1.1)

14 (1.7)

–

–

38 (3.8)

62 (6.1)

1 (0.1)

15 (1.5)

40 (4.0)

33 (3.3)

18 (1.8)

25 (2.5)

35 (3.5)

56 (5.6)

19 (1.9)

6 (0.6)

9 (0.9)

18 (1.8)

Perception/cognition

Domain 5

 Deficient knowledge 1 (0.6) 72 (8.5) 73 (7.3)

Coping/stress tolerance

Domain 9

 Anxiety 25 (14.5) 41 (4.8) 66 (6.6)
Relocation stress syndrome 9 (5.2) – 9 (0.9)
Risk for relocation stress syndrome 16 (9.2) – 16 (1.6)
Ineffective coping 1 (0.6) – 1 (0.1)
Risk for post‐trauma syndrome 1 (0.6) – 1 (0.1)

Safety/protection

Domain 11

 Risk for falls 74 (42.8) 40 (4.7) 114 (11.2)
Impaired skin integrity 1 (0.6) 4 (0.5) 5 (0.5)
Risk for infection 4 (2.3) 14 (1.7) 18 (1.8)
Risk for bleeding 1 (0.6) 67 (7.9) 68 (6.8)
Risk for allergic reaction 1 (0.6) 1 (0.1) 2 (0.2)
Risk for venous thromboembolism – 17 (2.1) 17 (1.7)
Risk for aspiration – 1 (0.1) 1 (0.1)
Risk for shock – 1 (0.1) 1 (0.1)
Risk for peripheral neurovascular dysfunction – 2 (0.2) 2 (0.2)
Ineffective airway clearance – 5 (0.6) 5 (0.5)
Risk for pressure ulcer – 13 (1.5) 13 (1.3)
Risk for vascular trauma – 1 (0.1) 1 (0.1)

Comfort

Domain 12

Acute pain

Impaired comfort

22 (12.7)

2 (1.1)

17 (2.1)

–

39 (3.9)

2 (0.2)
Totally 174 (100%) 846 (100%) 1020 (100%)
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Since there were 100 patient files (records) in each stage, the frequencies mentioned above in each diagnosis or domain were the same as the percentage.

The recorded nursing diagnoses were assessed using the third item of the D‐Catch instrument in terms of quality and quantity (Table 3). The qualitative criteria included relevancy, unambiguity and linguistic correctness, and the quantitative criterion assessed the completeness of the records in terms of following the PES model to prepare the nursing diagnosis statement. The results revealed that in terms of quantity and quality of the third item, the scores of all eight domains had significantly higher ranks after the intervention.

TABLE 3.

Changes in the D‐Catch scores of nursing diagnoses recorded by nurses on domains before and after the intervention.

Domains Domain 1: Health promotion Domain 2: Nutrition Domain 3: Elimination and exchange Domain 4: Activity rest Domain 5: Perception/Cognition Domain 9: Coping/stress tolerance Domain 11: Safety/Protection Domain 12: Comfort
Qualitative
Mean Rank (pretest) 0.00 1 2.50 5.56 1 27.46 39.86 13.02
Mean Rank (posttest) 14 36.5 24.50 58.45 37 71.78 119.47 32.26
Mann–Whitney, U 0.000 0.000 0.000 5.000 0.000 50.00 139.50 12.500
p Value <0.005 <0.005 <0.005 <0.005 <0.005 <0.005 <0.005 <0.005
Quantitative
Mean Rank (pretest) 0.00 3.50 2.50 6.33 2.00 27.80 40.76 13.75
Mean Rank (posttest) 14.00 36.46 24.50 58.38 37.49 71.35 118.73 31.24
Mann–Whitney, U 0.000 2.500 0.000 12.000 1.000 67.500 207.000 30.000
p Value <0.005 <0.005 <0.005 <0.005 <0.005 <0.005 <0.005 <0.005
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6. DISCUSSION

This study aimed to improve the ability of nurses working in the women's cardiology ward to use the nursing diagnoses and reduce the theory‐practice gap in nursing. The results indicated that institutionalizing the nursing process within the framework of the Attending nursing teacher project affected the quality and quantity of the application of the nursing process. After the implementation of interventions, the quantity of nursing diagnoses increased and their quality improved.

Proper application of the nursing process by the nurses leads to efficient outcomes in nursing and patient care (Leoni‐Scheiber et al., 2020). Various factors prevent nurses from using the nursing process; in this regard, the theory‐practice gap is an important factor (Lotfi & Zamanzadeh, 2021; Osman et al., 2021). Effective collaboration between Educational and health care institutions through institutionalizing the use of evidence‐based care may serve to significantly bridge this gap (Ülker & Korkmaz, 2017). The study conducted by Fulmer et al. reported that the existing capacity in nursing teachers' project in clinical settings could provide adequate scientific and practical support to nurses working in clinical settings, improving their assessment and treatment abilities (Fulmer et al., 2011). The results of the present study were also consistent with this study suggesting that empowering nurses within a participatory systematic structure of the institute of education and health care services may improve the nurses' evaluation of patients, leading to an increase in the number of effective diagnoses.

In a qualitative study, Matbouei et al. (2014) evaluated the barriers to recording nursing diagnoses from nurses' viewpoints; they reported five principal barriers, including 1. Nurses' heavy workload in terms of writing tasks, 2. Assignment of unrelated tasks to nurses, 3. Lack of bonuses and rewards for nurses recording nursing diagnoses, 4. Lack of a separate protective system for each patient and 5. Lack of in‐service educational courses coupled with a lack of awareness of new scientific discoveries according to continuous need assessment. Providing the possibility of care provision for the patients through performing initial assessments and follow‐up interventions through the Nursing Teachers Project. The present study is hoped to contribute a suitable basis for evidence‐based education and practice in the application of the nursing process. Therefore, this study has, in a way, has played a notable role in the use of the nursing process by nurses and increased the number of nursing diagnoses (Matbouei et al., 2014).

The study results conducted by Nøst et al. (2017) demonstrated that theoretical and practical educational interventions improve nurses' clinical reasoning and their documentation in relation to the nursing process. Assessing nurses' diagnoses using the D‐Catch instrument in the present study revealed that nursing diagnosis improved both in terms of quality and the criteria of relevancy, unambiguity and linguistic correctness, as well as in terms of quantity and the criterion of completeness based on PES components (Nøst et al., 2017).

Studies show that performing accurate and proper assessment in the first stage of the nursing process affects the quality and quantity of nursing diagnosis (Anim‐Boamah et al., 2022; Mahama & Ninnoni, 2019). Therefore, it can be concluded that designing a proper tool for assessing cardiac patients and training the nurses to use it positively may have affected nurses' diagnoses in the present study.

Assessing and meeting the cardiac patients' needs such as activity, nutrition and stress management have always been of great importance (Zaghlol, 2018), with nursing diagnoses mainly focusing on physiological needs (Galdeano et al., 2010); the results also indicated that nursing diagnoses were most frequent in the activity/rest, nutrition and safety/protection domains. Moreover, attending to these domains in cardiac patients is crucial considering the nature of the disease (Premkumar et al., 2022). Studies have indicated that despite nurses' awareness of patients' sexual problems, these problems are not addressed adequately. This can result from feelings of fear, shame, indecency and cultural differences (El‐Monshed, 2020; Lu et al., 2021). The present study did not assess nurses' attention to sexual issues. It seems that nursing diagnosis of anxiety in the coping/stress tolerance domain and diagnosis of risk of falls in the safety/protection domain were routinely performed before the intervention. However, after providing nurses with the proper training, they were selected only in suitable cases, and their number decreased.

Our findings revealed that a suitable educational environment could provide a suitable context for nurses to use up‐to‐date evidence, such as the nursing process.

6.1. Limitations

The present study had some limitations. One of the limitations was that the nurses and patients in the study were all female. It is recommended that this type of study be conducted in wards with male nurses and patients to increase the generalizability of the results. The resident nursing faculty member implemented the rounds in the morning shift, but we tried to compensate for this limitation by using Ph.D. and master's students in the afternoon and night shifts. The present study had a time limit since it was a part of a Ph.D. dissertation. Longer interventions might have more significant and longer lasting effects. It is recommended that further studies be conducted with longer interventions and follow‐ups.

7. CONCLUSION

This study was part of an action research study aiming to improve the quality and quantity of nursing diagnoses by implementing the Attending Nursing teacher Project within the framework of a practical model, a collaborative paradigm between the school and hospital.

Improvement of the quantity and quality of nursing diagnosis records by empowering them within the framework of the Attending Nursing teacher project indicates that providing a proper structure between nursing schools and clinical institutions, residency of faculty members in hospitals, and developing their roles in these centres may lead to the promotion of the health care and educational system, which can lead to the improvement of patients' status as well as an increase in their satisfaction.

The nursing process is considered a standard in nursing practice. Today, in most cases, the nursing process is implemented with defects. This project shows that the existence of a suitable platform for nurses improves the use of the nursing process and nursing diagnoses. Collaborative paradigm between the school and hospital and efficient organizational planning provides this platform.

The present study's findings can be utilized in different domains of health policy‐making, educational and clinical settings and in promoting the role of nurses and nursing faculty members. This study can provide a practical model of the infrastructures, processes, series of actions and necessary plans for practical actions, to the decision makers and policy makers of nursing.

AUTHOR CONTRIBUTIONS

Conceptualization: LV, VZ, MN, AGH. Data curation: MN. Formal analysis, VZ, AP, MA. Methodology: VZ, LV, MN, ML, FT. Project administration: VZ, LV, MN. Software: APM, MA, FB. Supervision: VZ, LV, ML. Validation and Visualization: VZ, LV, ML, FT. Writing—original draft: MN, AP, FB, MA. Writing—review and editing: VZ, LV, AGH. All authors have read and agreed to the published version of the manuscript.

FUNDING INFORMATION

The Research Administration of Tabriz University of Medical Sciences, Tabriz, Iran, financially supported this study.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interests.

ETHICS STATEMENT

The study approved by the Ethics Committee of Tabriz University of Medical Sciences (ethics code: IR.TBZMED.REC.1397.643).

ACKNOWLEDGEMENTS

The authors express their gratitude to the Deputy for Research of Tabriz University of Medical Sciences and the nursing staff of Shahid Madani Hospital for their cooperation in this study.

Namadi‐Vosoughi, M. , Zamanzadeh, V. , Valizadeh, L. , Lotfi, M. , Ghahramanian, A. , Pourmollamirza, A. , Taleghani, F. , Bagheriyeh, F. , & Avazeh, M. (2023). The impact of institutionalizing the nursing process based on TPSN model on the quality and quantity of nursing diagnoses. Nursing Open, 10, 5560–5570. 10.1002/nop2.1796

The author(s) agrees to take responsibility for ensuring that the choice of statistical approach is appropriate and is conducted and interpreted correctly as a condition to submit to the Journal.

DATA AVAILABILITY STATEMENT

The datasets generated during and/or analyzed during the current study will be available from the corresponding author on reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The datasets generated during and/or analyzed during the current study will be available from the corresponding author on reasonable request.

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