Perceived barriers and facilitators to nursing process usage: a narrative review

The nursing process (NP) is a systematic, patient-centred framework fundamental to professional nursing practice, yet its implementation remains suboptimal, particularly in low- and middle-income countries (LMICs). This narrative review examines the global implementation of the NP, with a focused case analysis of evidence from Pakistan (n = 2 studies) and other LMICs, and identifies barriers, facilitators, and research gaps. Pakistan was selected for focused analysis due to the authors' direct knowledge of its healthcare system and the absence of any previous synthesis of NP implementation evidence in this context.

This narrative review employed a literature search across PubMed, CINAHL, and Google Scholar using Boolean operators with keywords including "Nurses' Perceptions," "Nursing Process," "Barriers," and "Facilitators." Inclusion criteria captured original research and reviews published between January 2017 and September 2023, with seminal older studies included for theoretical context.

editorials, commentaries, non-English publications, and studies without original data on NP barriers or facilitators. The search prioritized evidence from LMICs, with additional Pakistan-specific database searching. Twenty-six studies were included in the final synthesis.

The synthesis reveals a stark disparity in NP implementation. While high-income countries report adoption rates exceeding 80%, implementation in LMICs including Ethiopia, Ghana, and Nigeria is inconsistent (approximately 50-60%). Key facilitators identified included supportive supervision (reported in 4 studies), availability of documentation tools (6 studies), and continuing education (5 studies). Thematic analysis identified critical barriers across four domains: (1) systemic and resource-related factors, (2) educational and knowledge-based factors, (3) administrative and socio-cultural factors, and (4) nurse-related individual factors. In Pakistan, two studies suggest good theoretical knowledge among nurses (86.7-89.5%), but practical application is hindered by similar systemic barriers.

The nursing process remains a cornerstone of high-quality care, yet its potential is unrealized in many resource-constrained settings. To address the implementation gap, strategic investments in administrative support, continuous professional development, and resource allocation are needed. This review identifies an urgent need for qualitative inquiry in Pakistan to explore nurses' lived experiences regarding NP implementation in clinical settings-specifically, how contextual factors (workload, supervision, resource availability) shape daily practice decisions.

Not applicable.