1. Introduction

The way we perform at work and our attitude, values or behavior toward others is a sensitive issue for it reflects how we were been educated and learned in the field we are specialized. Performance can be an issue if over a prolonged period of time; a nurse makes continuous errors or demonstrates poor practice that involves insufficient skill or knowledge, poor judgment, inability to work as part of a team, or difficulty in communicating with colleagues or people in their care. Nurses are the largest group of health professionals in all countries. They are designed or educated and trained as partner of other health care professionals to cater the health needs of clients/patients directly most of the time through nursing process. According to current American and Canadian practice standards, nursing practice demands the efficient use of the nursing process and professional participation in activities that contribute to the permanent development of knowledge about this methodology [1]. “Nursing is caring. Nursing is an art. Nursing is a science. Nursing is client centered. Nursing is adaptive. Nursing is holistic. Nursing is concerned with health promotion, health maintenance, and health restoration. Nursing is a helping profession.” These are the things we need to adapt in our system in order for us to commit ourselves in the nursing profession and continue to discover the value of being a nurse. It is in the practice of nursing where a process is applied of giving nursing care is applied and it is called as nursing process. Nursing process is a step by step series of actions that produce something or that lead to a particular result related to health of a client or patient. It is a matter of fact that nursing process is the focus of nursing practice where professional nurses must be expert. This process has its steps that guide nurses in rendering holistic nursing care to be demonstrated excellently for this is the foundation of quality nursing care to clientele. Furthermore, interaction is important in between the patient and the nurse because it is the only means of gaining cooperation in time nursing care is being implemented. On Orlando's Deliberative Nursing Process Theory, the focus is on the interaction between the nurse and patient, perception validation, and the use of the nursing process to produce positive outcomes or patient improvement. Orlando's key focus was to define the function of nursing [2]. In this, personal working attribute of a nurse is involved. Libya is an African country but belongs to Arab culture. This country import nurses because of no qualified professional nurse to collaborate with physicians and other health professionals for the health needs of the clients. It is only those who are with certificate in a short term education course in nursing field which is either be a graduate from six months training course or the three years diploma in nursing offered by the higher institute of health. It was only in 2007 that baccalaureate degree in nursing was started and most of their educators are Filipinos. As nursing educators started to teach and supervise students during clinical or hospital exposure, it is a must to guide them with the standard of nursing practice based on nursing process but students questioned the matter based on what they observed from most of the Libyan nurses. This issue triggered the interest to come up with a research team to conduct a study on how effective do Libyan nurses in performing their job as a nurse base on the steps of nursing process; how do they express themselves as a professional nurse with their patients; and if there is relationship in between.

2. Methods

Descriptive normative design was utilized and purposive sampling was employed. The sources of data were sixty two (62) Libyan nurses observed by Libyan physicians with the assistance of the authors in different schedule and set up but same location for they are the only health professional who has capacity to monitor and evaluate how efficient the nurses in terms of their responsibilities since there were no qualified professional nurses to do for most of them are graduates of either be the three year program leading to diploma in nursing offered by higher institute or the six month training of the same agency and nurse technician is the rank that most of them are handling. Only foreign nurses are with baccalaureate degree and some of the first graduate within the country but still they are not capable since they are neophyte in their job. An evaluation checklist as the data gathering tool was developed where items are most on common responsibilities and considerations of the nursing process and the attitudes, values and/or behavior of a nurse that was subjected to content validation and reliability testing (rK – R = 0.909). Likert Scale was used as basis in rating how Libyan nurses apply the nursing process and their personal attributes at work during scheduled observations. Collected data were tallied and subsequently subjected to descriptive statistical treatment using the Statistical Package for Social Sciences Version 20.0 (SPSS) employing Pearson product-moment correlation coefficient (PPMCC) to test if there is significant relationship between the nursing process self-efficacy and personal attributes of Libyan nurses employed in hospitals of Misurata, Libya.

3. Results

Nursing process self-efficacy of Libyan nurses

Table 1 presents how effective do Libyan nurses in their function as a nurse in the hospital. The results reveal that nurses are good enough as they apply the core of their vocation with an over-all average weighted mean of 2.89. As to steps of the nursing process, Implementation stage where interventions were done and is the leading among all with an average weighted mean of 3.14 followed by the evaluation phase (3.03), then assessment (2.79) and lastly, the planning phase with average weighted mean of 2.60.

Table 1. Nursing process self-efficacy of Libyan Nurses

Furthermore, table 2 presents the personal attributes of Libyan nurses. Generally, Libyan nurses were observed as good with weighted mean of 3.22 which is near to be very good. Taking into consideration each item that describe Libyan nurses attributes, having smooth relationship with peers, superiors and co-workers is the leading among the four and was observed as very good with weighted mean of 3.69 followed by how they present themselves physically which is “ neat and well-groomed; and adheres to dress code” with weighted mean of 3.18 then by being courteous, tactful in dealing with client and relatives (3.16) and the last is on punctuality in reporting for duty and time management at work with weighted mean of 2.85.

Table 2. Personal Attributes of Libyan Nurses

Moreover, Table 3 proved if there is there is no significant relationship between the nursing process self-efficacy and personal attributes of Libyan nurses in Misurata, Libya.

Table 3. Relationship between nursing process self-efficacy and personal attributes of Libyan nurses

The statistical derived values that are essential in validation using the Pearson product-moment correlation coefficient are as follows: the Pearson’s r is 0.0641; n = 4; p = .359. The correlation between nursing process self-efficacy and personal attributes is significant at the 0.01 level (2-tailed).

This means that there is a strong relationship between the nursing process self-efficacy and the personal attributes of Libyan nurses in Misurata, Libya.

4. Discussion

It is a mere fact that nursing process is the core of nursing practice where its steps should be followed by the nurse in meeting the health needs of clients. Thus, this is the main reason why the researchers utilized the steps of nursing process in identifying how efficient do Libyan nurses’ render nursing care to their patients. But work values or personal working attributes sometimes affect how individual perform. Nursing process has four common steps as follows: assessment, planning, intervention/implementation and evaluation. Nursing diagnosis was not included because it is considered as a part of assessment and is not being practiced or applied in Libya. Assessment is the first thing that a nurse can do while on duty. It is the root and the source or reason of doing the other steps of nursing process. In this phase, the nurse need to stay with the patient to gather data health status and needs through therapeutic communication and observation as well as the conduct of diagnostic assessment like taking vital signs and alike. Planning comes next where nurse can plan nursing care to patient based on the result of assessment but need the priority health needs of the client or patient. Furthermore, the planned interventions or nursing care will be put into action on the implementation phase of the nursing process then lastly; the nurse will evaluate the outcome of the set of actions rendered.

In this study, taking into consideration the weighted mean of each step, nursing process was not practiced in a way it should be. The result of an assessment is the basis for planning of care to be implemented and evaluated. It was in the findings that the weakest step was on planning and assessment is the aspect where they were observed weaker. Intervention or the implementation phase was the leading step followed by evaluation. In this regard, nurses show the dependence to physicians. There are three (3) kinds or classifications of nursing intervention, the independent, dependent and interdependent. Dependent nursing care requires the order of a physician while independent interventions are planned autonomous actions by the nurse based on identified health related problems as the result of assessment, and the interdependent or collaborative nursing interventions are the result of multi-disciplinary teamwork or consultation. Among the seventeen (17) important responsibilities of nurses, the top five are in which taking vital signs leads among them all with weighted mean of 3.50. This is quite good to consider but Libyan nurses still need to be more efficient because vital signs are one of the most to be in priority concern for it reflects vital organ functions. As Watson said that, basic is a term that is frequently used to describe blood pressure, pulse, respiratory rate and body temperature. And respiratory rate was identified as one of the most important sign and yet one of the most frequently omitted clinical observations as it was also found this to be a problem in clinical practice. The objective of observation is to monitor patients’ progress, thus ensuring the prompt detection of adverse events or delays in recovery [3]. The practice of proper waste disposal comes next with weighted mean of 3.38. It’s nice to know that Libyan nurses’ are very good enough in terms to efficiency in the practice of standard/universal precautions that is necessary in handling patient. Pratt et al. enunciated that the primary role of personal protective equipment is to protect staff and reduce opportunities for transmission of microorganisms in hospitals that since the mid-1980s the use of gloves as an element of personal protective equipment has become an every-day part of clinical practice for healthcare workers [4]. Expert opinion agrees that the two main indications for the use of gloves are to protect hands from contamination with organic matter and microorganisms, and to reduce the risks of transmission of microorganisms to both patients and staff. On the other way around, Libyan nurses were observed as good in terms of self-efficiency in data collection during assessment phase regarding client’s health status through interview, history taking and from diagnostic results which is the most critical responsibility of a nurse during assessment with weighted mean of 2.35. This is similar to the work of Birgersson and Wahren & Wilhelmsson that the result of assessment, is seldom used in Swedish clinical care settings [5, 6] The collection of data is a professional nursing act forming the basis for all caregiving. Every element of nursing care flows from it. It is considered to be at the core of quality health care and serves initially to determine the required treatment. Subsequently, it serves to evaluate the course of the treatment in comparing the results with the initial data gathered. Gathering and recording data contributes to the visibility of the nurse’s role. Moreover, in systematically gathering the information describing the state of the patient upon arrival and during the evolution of the illness and the treatment, the nurse demonstrates the pertinence of the planned interventions and the type of results obtained. In this, and with the findings of this study, Libyan nurses need to be more efficient and it is a must as its significance was explained earlier.

Another thing that needs to be more efficient is on the analysis of gathered data as basis for planning of care with weighted mean of 2.50. Critical analysis is important in prioritizing health needs of patient/ client. It is essential in coming up with independent nursing care for nurses are the first to find immediate health care of patients as they are the one with frequent contacts every shift.

Since nurse always in contact with clients and other health care professionals most of the time while at work, personal attributes or work values is important aspect to maintain. Individuals bring a number of differences to work. They have a variety of personalities, values, and attitudes. When they enter into organizations, their stable or transient characteristics affect how they behave and perform. Moreover, companies hire people with the expectation that they have certain knowledge, skills, abilities, personalities, and values. In various studies, the values had been differently introduced and defined. Most of the reviewed articles had focused on common nursing ethical values [7]. Some has several values and the other has only one value that had been introduced and defined. Konishi (2009) had only studied the value of harmony in nursing and had suggested that as one of the most fundamental values in Japan [8]. Verpeet (2003) had defined values as nurses’ responsibility against their patients, profession, other health team members, and society [9]. Naden (2004) in his study to define components of human dignity indicated braveness, responsibility, respect, commitment, and ethical desires [10]. Moreover, Wros (2004) reported a significant difference in ethical value of decision making among the nurses in two countries [11]. Table 2 reflects the personal attributes of Libyan nurses at work. In this study, Libyan nurses were found good enough with an average weighted mean of 3.22. To be good is not enough but should be excellent in dealing with work, colleagues, patients and others. Anyhow, though Libyan nurses were good generally in terms of personal attributes, there is an aspect that they were been observed as very good. One in which is they have smooth relationship with peers, superiors and co- workers with weighted mean of 3.69. As Trailer (2004) claimed that respect to the patients has the highest priority among codes of ethics and acts as a basic value to design the nursing ethical codes which include three main elements of respect, reliability, and mutuality [12]. It was mentioned that nurses encountered people in the whole life-span, from birth until death, meeting patients and their families in various contexts require various aspects of competence [13]. This implies that nursing practice requires application of complex combinations of knowledge, skills, values, behavior and attitudes. Moreover, values are learned through observation and experience. Therefore, they are influenced greatly by cultural, ethnic, and religious groups and by family and peer groups [14]. In addition, work behavior that the nurse should possess and required in the nursing profession is being self-confident [15] Individuals who are self-confident typically speak up when wronged, challenge injustice, strive for positive change, work well with others instead of tearing them down and starting malicious conflict, and bring energy and enthusiasm to their work. Self-confidence is bolstered by quality, contributive performance. When people are performing well, they become more confident. Better performance is obviously better for patients, families, employers and the community.

Horton (2007) stated that personal and organizational values have effects on nursing and introduced values such as responsibility, honesty, patients’ participation, integrity and humanity protection, patients’ independency, deep humanistic relationship, dignity, hope, passion, teamwork, differentiation, versatility, altruism, nurturing, integrity and support, reciprocal trust, sound knowledge, clinical competence, communications, unity, homogeneity, coordination, self-sacrifice and devotion, self-protection, privacy preservation, creativity, aesthetics, management, economizing, braveness, commitment, ethical attitude, personal orientation, judgment, freedom, individualism, acknowledgment, and personal success [16]. Shih (2009) reported that 75% of the participants had indicated taking care of the patients and their related individuals and altruism as the most common nursing values. Other values in his study were provision of holistic professional and appropriate care, promotion of personal and professional competency, disease prevention, health promotion, promotion of interpersonal communication skills, and receiving fair reward [17].

Personal attributes influence how an individual perform that could identify what kind of output does it bring as if how an individual perceive self and environment. Attitude, behavior and values are attributes that are essential on how an individual work. Values are desirable qualities, standards or principles that serve as your guiding force, especially when making decisions and pursuing options that best meet your needs and lead to increased happiness.

Values influence both your actions and reactions.

Therefore identifying and focusing on your work and personal values helps you clarify what is most important to you, and helps you become more successful and satisfied in life. By clarifying and applying your values, you can achieve enhanced self-awareness and ultimately be guided towards a more satisfying career.

The finding of having positive significant relationship of personal attributes and self-efficacy is a condition that could inspire every individual to realize how they can deal their lives while they work as influenced by their personal attributes.

5. Conclusions

Through the statistical treatment that was carried and the findings made on nursing process self-efficacy and personal attributes of Libyan nurses’ in Misurata (Libya), the following conclusions were made:

1. Libyan nurses are generally good enough in terms of self-efficacy in the application of nursing process.

2. Libyan nurses are strong and observed as more efficient on the third steps of the nursing process (intervention) as well as on the last step (evaluation) but weak in the first and second steps (planning and assessment).

3. Libyan nurses’ commonly good on personal attributes but they have very good and smooth relationship with colleagues and other health care professionals.

4. There is a strong relationship between the nursing process self-efficacy and their personal attributes.

6. Recommendations

The nursing service department staffs who were been evaluated in this study on their performance in terms of nursing functions and personal attributes were graduates of the higher institute of health under the three years course leading to diploma in nursing and six months training program. In relation with the academic qualification together with the findings of this endeavor, the following recommendations were made:

1. Collaborative effort of the Ministry of Health; Ministry of Higher Education & Scientific research and the Ministry of Labor and Employment to improve the quality and standard of nursing education and practice in Libya.

2. Since there is an existing bridging program offered by the university leading to baccalaureate degree in nursing, students enrolled in this course must take it religiously. They should be challenged as well to attend conferences, workshops, training, seminars and other innovations to update and maintain competency of nursing as a vocation inside and outside Libya.

3. Continuous effective performance evaluation of nurses through interactive process where transparency exist regarding the performance of the nurse and for a chance to point out the strength and weaknesses as basis for professional development planning.

ACKNOWLEDGMENTS

This is to extend appreciation and special thanks to those shared and extended their insights and expertise. To our friends and colleagues at work who shared assistance and support, we are grateful of having you.