Open Journal of Nursing, 2013, 3, 395-399 OJN
http://dx.doi.org/10.4236/ojn.2013.35053 Published Online September 2013 (http://www.scirp.org/journal/ojn/)
Compliance of state registered nurses to nursing
standards during practice in tertiary facilities in Malawi
Edoly Shirley Lengu1, Rodwell Gundo1, Alfred Maluwa2*, Noel Mbirimtengerenji1
1Department of M edical-Surgical Nursing, Kamuzu College of Nursing, University of Malawi, Lilongwe, Malawi
2Research Directorate, Kamuzu College of Nursing, University of Malawi, Lilongwe, Malawi
Received 10 May 2013; revised 12 June 2013; accepted 15 July 2013
Copyright © 2013 Edoly Shirley Lengu et al. This is an open access article distributed under the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
The aim of this study was to describe the quality of
practice offered by nurses to patients who underwent
surgical incision into the abdomen (post-laparotomy)
at tertiary hospitals (Kamuzu, Mzuzu, Queen Eliza-
beth and Zomba) in Malawi. The study design was
descriptively cross sectional and utilized a quantitative
data collection and analysis method. All available 48
registered nurses in the surgical ward of four central
hospitals and 100 patients that were admitted in the
ward during the time of study were recruited. A
3-point scale rating consisting of compliance (C = 1),
partial compliance (C < 1.0 - 0.5) and non compliance
(C < 0.5 - 0.0) was used to describe the nurse mid-
wives compliance with the process standards of care.
Results show that nurses in all the 4 central hospitals
partially complied with assessment and planning
standards. During assessment, the nurses assessed the
physical aspects of care but did not assess the psy-
chological, spiritual and cultural aspects of care. At
planning the nurses assigned and delegated tasks
based on the knowledge and skills of the provider
selected but did not comply with factors related to
safety, effectiveness and cost of care. All the facilities
fully complied with implementation standard because
they implemented care in a safe and appropriate
manner and communicated with patients/ significant
others and other health care providers. However, re-
garding systematic and ongoing evaluation of pa-
tients’ condition only Mzuzu Central hospital par-
tially complied while the rest of the facilities were not
compliant. All the facilities did not comply with
documentation standard of care because the patient
records were not legible and did not precisely depict
comprehensiveness of care nor bore signatures of the
implementers of the care. Results are discussed by
relating the level of compliance to standards and the
quality of patient care.
Keywords: Nursing Standards; Implementation
Practices; Documentation Practices; Surgical Incision;
Critical Patient Care
1. INTRODUCTION
“Nursing” or “practice of nursing” means caring, com-
mitment and dedication to meeting the health needs of all
people [1]. Nurses direct care to promote, maintain and
restore health in various settings to individuals, families
and communities. They are prepared to identify and
assist with the health care of all populations [1]. Nursing
practice is composed of a wide variety of roles and
responsibilities necessary to meet the health care needs
of society [2]. The State Registered Nurse Midwives
(SRNMs) are expected to offer skilled care to those
recuperating from illness or injury, advocate for patients’
rights, teach patients so that they make informed
decisions, suppor t patients at critical times and help them
navigate the increasingly complex health care system.
Society views the quality of nursing practice based on
the scope of practice. The unique focus of nursing is on
the response of an individual or group to an actual or
potential health prob lem or life pro cess.
Every state registered nurse midwife, when entering
the nursing profession, assumes the responsibility of
public trust and its correspo nding obligation to adhere to
set standards of nursing practice. Nursing uses scientific
knowledge and combines critical thinking skills with
caring behaviour. The State Registered Nurse Midwife
(SRNM) is responsible and accountable fo r the quality of
nursing care given to clients. It is therefore expected of
them to comply with the standard s in the clinical nursing
practice settings throughout the country. The standards
set by the Nurses and Midwives Council of Malawi [3]
*Corresponding a uthor.

E. S. Lengu et al. / Open Journal of Nursing 3 (2013) 395-399 396
cannot be separated from practice. The NMCM has
structure, process, and outcome standards set for state
registered nurse midwives in Malawi.
The Ministry of Health in Malawi started reforming
the health sector in December, 1999, with emphasis on
quality assurance, which is being addressed within the
new health policy [4]. The overall obj ective of the policy
is to improve the quality of care through serv ice delivery,
integration, capacity building and training of health care
personnel to provide quality care. Malawi’s Nurse
Practice Act [5] under the NMCM protects the public by
legally defining and describing the scope of nursing
practice. Furthermore, the Act also legally controls
nursing practice through licensing requirements to ensure
compliance with standards of care. Nurses who know
and follow their Nurse Practice Act and standards of care
provide safe and competent nursing care [6]. In Malawi,
literature on the compliance of registered nurse midwives
to nursing standards is scanty, therefore the aim of this
study was to describe the practice of SRNM’s on post-
laporatomy patients in public central hospitals in Malawi
and compare them to the set process standards by the
Nurses and Midwives Council of Malawi. Specifically,
the study assessed the quality of professional practice
and identified the extent of the care SRNM provided for
patients and if they were in line with the set standard of
care.
2. METHODS
2.1. Design and Setting
The study design was descriptive cross sectional and
utilized quantitative data collection and analysis method
to describe the quality of professional practice as
reflected in clinical nursing care of patients. Four tertiary
facilities (Central hospitals) which provide post-
laparotomy services to patients in the country were
selected. The facilities were, Kamuzu, Mzuzu, Queen
Elizabeth and Zomba Central hospitals. The study was
conducted for 6 days at each facility. Consenting adult
male and female patients that were admitted in the
surgical wards of the facilities after undergoing surgery
due to laparotomy were recruited. A total of 100 patients
were admitted during the time of the study and all
consented to participate in the study. The patients’
records from the day of arrival at the unit from theatre to
day three in the ward were reviewed. The state registered
nurse midwives that provided clinical nursing care to
post-laparotomy patients were observed for compliance
with set process standards in the care of the patients. A
total of 48 SRNMs were available in the surgical wards
during the time of the study and all consented to
participate in the study. A checklist was used to collect
the data. The checklist had five NMCM set standards on
assessment, planning, implementation, evaluation and
documentation of care. The marks against each nurse
were categorized into a three-point rating scale; Non-
compliance (C) < 0.5 - 0.0; Partial compliance (C) < 1.0
- 0.5; and Compliance C = (1.0).
2.2. Data Collection
Nurses were observed as they rendered care to post-
laparotomy patients by a registered nurse midwife. She
was assisted by 2 research assistants who had experience
in caring for laparotomy patients. The research team
worked with the nurses for a number of days so that they
got used to them and to prevent Hawthorne effect during
data collection. Observations on practice were initially
done before the midwives were interviewed. Hawthorne
effect refers to psychological response in which par-
ticipants of research change their behavior because they
know that they are being observed [7]. The observations
were done when the nurses were taking reports, during
doctor’s rounds and during actual practice, such as
patient assessment and briefing sessions when staff
members were coming from the off days. Reactivity and
observer biases were thus eliminated [8]. The research
team reviewed the patient record according to the five
NMCM set process standards of assessment, planning,
implementation, evaluation and documentation. The pa-
tient records were collected after report taking and each
data collector analyzed a separate patient record of
post-laparotomy for day three in order to get a full pic-
ture of the care given.
2.3. Ethical Consideration
The study was approved by internal ethical review
boards in Malawi (College of Medicine Research and
Ethics Committee) and in South Africa (University of
South Africa, Health Studies Research and Ethics
Committee). Permission to collect data in the four
facilities was obtained from the heads of the facilities.
Informed consent was obtained from all the participants
who were informed of the objectives of the study and
were told that they were free to withdraw at anytime if
they wished and that their decision to withdraw would
not affect their treatment and care at the hospital. The
study used codes to refer to patients to ensure par-
ticipants’ confidentiality and anonymity.
2.4. Inclusion and Exclusion Criteria
The study targeted SRNMs that were working in the
surgical wards of public central hospitals in Malawi
where clinical care to post laparotomy patients was
provided. Th e study also targeted th e records of all adult
post laparotomy patients from the day of arriving in the

E. S. Lengu et al. / Open Journal of Nursing 3 (2013) 395-399 397
ward after operation in the theatre, to the third day of
stay in the ward. All other cadre of staff other than
SRNMs or all other surgical patients other than post
laparotomy were exclud ed from the study.
2.5. Data Analysis
Data was analyzed using SPSS version 16.0. Descriptive
statistics were computed for the data. The results are
presented as mean scores across the nurses on each of the
5 process standards; assessment, planning, implemen-
tation, documentation and evaluation. Means of 1.0
across a standard at a given facility signified compliance
(C = 1) while those of less than 1.0 to 0.5 signified
partial compliance and means of less than 0.5 to 0.0
represented non compliance.
3. RESULTS
3.1. Demographic Data
The mean participants’ ages were; 43 (range 33 - 67)
years at Kamuzu Central hospital, 49 (range 42 - 66)
years at Queen Elizabeth Central Hospital, 41 (range 28 -
73) years at Zomba Central Hospital and 45 (range 37 -
67) years. The demographic characteristics of the
patients by facility are shown in Figure 1. Most of the
patients (over 90%) at each facility were employed.
Across facilities, there were equal proportions of the
males and females, the employed and unemployed
(Figure 1).
The SRNM’s that were working in the tertiary
institutions were all females with the majority of them
(92% at Kamuzu, 94% at Mzuzu, 95% Queen Elizabeth
and 98% at Zomba Central hospitals) being married.
Their ages ranged from 23 to 56 years at Kamuzu, 35 to
67 years at Mzuzu, 24 to 55 years at Queen Elizabeth
and 24 to 59 at Zomba Central hospitals. The nurses had
varying working experience ranging from 5 to 15 years
in the surgical wards.
Figure 1. Demographic characteristics of laparotomy patients
at Kamuzu Central Hospital, Mzuzu Central Hospital, Queen
Elizabeth Central Hospital, and Zomba Central Hospital.
3.2. Evidence of Compliance to NMCM Set
Process Standards
Scores for each facility across the 5 standards are shown
in Table 1.
All the 4 central hospitals partially complied with
assessment and planning standards (Table 1). Regarding
the assessment standard, the nurses assessed the physical
aspects of care but they did not assess the psychological,
spiritual and cultu ral aspects of care. During plann ing, all
the nurses assigned and delegated tasks based on the
knowledge and skills of the provider selected. They
however, did not comply with factors related to safety,
effectiveness and cost of care, hence partial compliance.
Results show that all the facilities fully complied with
implementation standard. The facilities implemented
care in a safe and appropriate manner with evident
communication with patients/significant others and other
health care providers. Regarding systematic and ongoing
evaluation of patients’ condition only Mzuzu Central
hospital partially complied with the evaluation standard
while the rest of the facilities were not complian t (Table
1). At Mzuzu, the nurses evaluated effectiveness of care
in relation to outcome. In all the facilities, the nurses did
not make diagnosis based on assessment data and did not
assess personal data for complete patient history.
All the facilities did not comply with documentation
standard of care. Results from patient record analysis
show that the nurses did not make sure that the records
were legible and that they precisely depicted compre-
hensiveness. The records in addition did not bear
signatures of the implementers of the care.
4. DISCUSSION
The SRNMs partially complied with the assessment
standard. According to the Nurses and Midwives Council
Standards [3], the nurses were supposed to assess the
patients in terms of their physical, spiritual, psycho-
Table 1. Scores of State Registered Nurse Midwives across the
five Nurses and Midwives’ Council of Malawi Standards
during their practice at 4 tertiary facilities in Malawi.
Scores for Each Tertiary Health Facility
Standards of CareKamuzu
Central
Hospital
Mzuzu
Central
Hospital
Queen
Elizabeth
Central
Hospital
Zomba
Central
Hospital
Assessment 0.9 - 0.50.9 - 0.5 0.9 - 0.5 0.9 - 0.5
Planning 0.9 - 0.50.9 - 0.5 0.9 - 0.5 0.9 - 0.5
Implementation1.0 1.0 1.0 1.0
Evaluation 0.4 - 0.30.9 - 0.5 0.4 - 0.3 0.4 - 0.3
Documentation0.4 - 0 .30.4 - 0.3 0.4 - 0.3 0.4 - 0.3

E. S. Lengu et al. / Open Journal of Nursing 3 (2013) 395-399 398
logical, cultural and economic status in order to have a
complete history of the patients. The complete history
would in turn assist in the provision of comprehensive
care to the patients. The nurses instead partially co mplied
with the assessment standard because they concentrated
only on the physical assessment of the patients. Results
suggest that nurses in this study were following
recommendations by Lewis et al. [2], that physical needs
of patients should be addressed before the other needs.
However, after assessing the physical needs, the nurses
were supposed to assess the other needs so that they
provide complete and holistic care to the patients. The
imbalance between assessment of the physical needs and
other aspects including the psychological needs of
patients may have compromised the quality of post-
laparotomy care in this study. For example some patients
may have presented with mental problems which needed
intervention or be liefs which would make them to refuse
certain treatment such as blood transfusion. Patient as-
sessment according to the standard could have revealed
these other needs of the patients and appropriate in-
tervention or care rendered.
Work overload of the nurses in the surgical wards of
the facilities in this study could have contributed to the
fact that the nurses concentrated on the physical assess-
ment only. The wards had on av erage 70 patients against
one SRNM (Nurse: patient ratio of 1:70). This ratio is
seven times higher than the recommended ratio of 1:10
[3]. Despite the high nurse patient ratio, the n urses could
still have complied with the patient assessment standard
by prioritizing the patients according to their state of
condition. It is therefore recommended that patients are
fully assessed so that comprehensive care is provided.
Results show partial compliance with planning
standard in all facilities because the nurses did not
comply with factors related to safety, effectiveness and
cost of care. Compliance with the planning standard
would ensure proper utilization of the available resources
and that clients’ and or significant others are properly
assisted. Compliance with planning standard could also
assist in identifying and utilizing appropriate services
that are available to address health related issues. Similar
results of partial compliance with planning standard are
reported by a number of authors [9,10]. These authors
have attributed shortage of staff as a contributing factor
for partial compliance with the planning standard.
However, in this study both the material and human
resources were inadequate and therefore contributed to
partial compliance with the planning standard. The
partial compliance with planning standard adversely
affected quality of care. For example, some patients’
wounds were infected and some patients did not receive
their medication at the prescribed time. Some patients
that needed pain killers were not given immediately the
drugs were ordered. It is therefore recommended that
nurses comply with planning standard so that compre-
hensive care is rendered to post-laparotomy patients.
The nurses fully complied with implementation
process. Results show that the nurses implemented care
in a safe and appropriate manner and they maintained
communication with patients, significant others and other
health care providers. Resu lts show that the SRNM were
competent in carrying out implementation procedures
required in the nursing practice. This may be related to
the way that they are trained and their experience in
working with patients in the wards as most of them had
cared for post-laparotomy patients for more than 5 years.
Similar results are reported by Karkkainen and Eriksson
[11].
The nurses in this study did not fully comply with
evaluation standard. They partly complied with evaluation
standard because they concentrated on other aspect of
care. The results are similar with a study conducted by
Karkainen and Eriksson [11] which show recommended
improvements in patient teaching and recording of pa-
tients’ own opinion. The partial compliance with evalua-
tion standard had negative implications on the quality of
care. The nurses were supposed to evaluate their process
of care with full involvement of the client, family
members and other health members. The evaluation would
assist them to determine the effectiveness of interven-
tions in relation to outcomes and to revise diagnosis,
outcomes and plan of care as needed. Evaluation could
also have assisted the nurses to check if any treatment
implemented had an effect on the patient’s condition. It is
therefore recommended that evaluation standard be fully
complied with so that the effectiveness of post-laparotomy
care is determined.
The results for documentation show that all facilities
did not comply because the clients’ records were not
legible, did not depict comprehensiveness and did not
bear the signatures of the implementers of care. Instead,
the nurses concentrated on implementing the aspects of
care but without keeping any records. Similar results were
reported by Rodden and Bell [12] in their study in the
United Kingdom in which documentation was described
as a forgotten skill by practicing nurses. These resu lts are
reported despite the fact that documentation is a legal
requirement [13]. Documentation allows hospital staff to
share information about patients. Information sharing can
help reduce duplication thereby reducing the amount of
workload for the already few available nurses and time
spent on diagnosing illnesses that have already been
previously identified by other health workers. It also
protects hospital staff against unforeseeable legal claims.
This is more important now that documentation standard
is complied with in view of the increased number of
lawsuits in which patients su e health wo rkers. In add ition,

E. S. Lengu et al. / Open Journal of Nursing 3 (2013) 395-399 399
[2] Lewis, S.L., Heikemper, M.M., Dirksen, S.R., O’Brien,
P.G. and Bucher, L. (2007) Medical-surgical nursing:
Assessment and management of clinical problems. 7th
Edition. Mosby Elsevier, St Louis.
patient complaints have increased considerably over the
past few years thus making documentation vital for
future reference. The time spent by SRNM in answering
law suits and patient complaints is worth any time
savings that might have initially been made when the
SRNM properly follow the nursing process. In most
cases, hospital documents have to be kept for a specified
period before they are destroyed. It is therefore essential
that nurses comply with the documentation standard so
that comprehensive care to clients is well documented
for future refe r e nce.
[3] Nurses and Midwives Council of Malawi (2005) A regu-
latory body committed to the promotion and upholding of
professional standards and protection of public health.
Government Printers, Zomba.
[4] Ministry of Health and Population (1999-2004) National
health plan. Malawi Government Press, Lilongwe.
[5] Nurses and Midwives Council of Malawi (1995) Nurses
and midwives act (act 16 of 1995). Government Printers,
Zomba.
5. CONCLUSION [6] Kozier, B., Erb, G. and Blais, K. (2004) Professional
nursing practice: Concepts and perspectives. 7th Edition,
New Jersey, Pearson Education, 265p.
The nurses complied with implementation standard
because they perceived it to be the main thrust of their
profession. However, they partially complied with as-
sessment and planning standard and did not fully comply
with evaluation and documentation. Thus the quality of
care in the facilities was compromised. To raise the
quality of care according to stipulated standard, it is
recommended that the nursing standards be strictly
enforced in Malawi to ensure the quality of care. In
addition, the number of SRNMs should be increased
through increased student intake and retention of the
current workforce through incentives. There is also a
need to introduce in service training on nursing standards
and the current nursing curriculum needs to be reviewed
to incorporate issues of compliance to nursing standards.
[7] Rayner, A., McLachlan, H., Forster, D., Peters L. and
Yelland, J. (2010) A statewide review of postnatal care in
private hospitals in Victoria, Australia. BMC Pregnancy
and Childbirth, 10, 26. doi:10.1186/1471-2393-10-26
[8] Polit, D.F and Beck, C.T. (2008) Nursing research: Ap-
praising evidence for nursing practice. 7th Edition, Wolt-
ers Kluwer, Lippincott and Williams and Wilkins, Phila-
delphia, 566p.
[9] Kovner, C. and Gergen, J. (1998) Nurse staffing levels
and adverse events following surgery in US hospitals.
Image: The Journal of Nursing Scholarship, 30, 315-321.
doi:10.1111/j.1547-5069.1998.tb01326.x
[10] Hall, L., Doran, D. and Pink, G. (2004) The relationship
between nurse staffing models and patient outcomes.
http://www.ncbi.nlm.nih.gov/guide/literature/
6. LIMITATION [11] Tzeng, H. and Ketefian, S. (2003) Demands for nursing
competencies: An exploratory study in Taiwan’s hospital
system. Journal of Clinical Nursing, 12, 509-518.
doi:10.1046/j.1365-2702.2003.00738.x
The study was limited to post-laparotomy patients in
public central hospitals in Malawi. Therefore, the results
may not be generalized to other settings. However, the
results paint a general picture about Nurses compliance
with NMCM standards of care.
[12] Rodden, C. and Bell, M. (2002) Record keeping: Devel-
oping good practice. Nursing Standard, 17, 40-42.
www.ncbi.nlm.nih.gov/pubmed/12360739
[13] Trenoweth, M.C. (2007) Succeeding in nursing and mid-
wifery education. John Wiley & Sons, West Sussex.
7. ACKNOWLEDGEMENTS
The study was conducted as part of the senior author’s Master of Arts
degree in Health Studies at University of South Africa, with funding
from University of Malawi, Kamuzu College of Nursing.
REFERENCES
[1] Craven, R.F. and Hirnle, C.J. (2013) Fundamentals of
nursing, human health and function. 7th Edition, Wolters
Kluwer, Lippincott and Williams and Wilkins, Philadel-
phia.