ABSTRACT
Background: Nursing documentation is an essential component of nursing practice that has a potential to improve patient care outcome. Poor documentation of nursing care activities among nurses has been shown to have negative impacts on the health care quality. However, little has been explored about nursing documentation practice in the study area.
Objective: The aim of this study was to assess the attitudes of nurses towards effective documentation in Imo State University Teaching Hospital Orlu.
Method: Institutional based cross sectional study design was employed. The study was conducted from March l3 to April 6/2023 among 391 nurses. Data was collected using a structured self- administered questionnaire. Simple random sampling was used to select the study participants. Pre-taste was done among 39 (10%) of sampled nurses working in shenen gibe Hospital and Cronbach’s alpha was calculated. Nursing care standard checklist was used to review documents from major wards. Data was entered into Epidata version 3.1 and then exported to SPSS version 21for analysis. Descriptive statistics, Binary logistic regression and multivariate logistic regression was used to describe, identify candidate variable for multivariate logistic regression and identify factors associated with documentation practice. P-value of less than0.05 was used to declare statistical significance in multivariate logistic regression.
Result: Among the participants good nursing documentation was practiced by 48.6%. Adequacy of documenting formats, motivation from supervisors, in-service training and familiarity with operational standard of nursing documentation were significantly associated with practice of nursing care documentation [AOR=0.357, AOR =4.237, AOR =0.462,AOR=2.165, respectively. Conclusion: Nursing documentation practice was poor among nurses under the study. Adequacy of documenting formats, availability of motivation, familiarity with operational standard of nursing documentation and in-service training were significantly associated with practice of nursing care documentation.
Recommendation: Nursing leaders should motivate the employees to enhance the practice of documentation, avail the necessary documenting materials besides adequate staffing which may be related to time shortage. Researchers also need to carry out large scale studies in order to address the problem.
Keywords: Documentation, Nursing care, nursing record of patient care, documentation practice.
CHAPTER ONE
INTRODUCTION
1.1 Background of study
Nursing documentation is defined as any written or electronically generated information about a client that describes the care or service provided to that client including what occurred and when it occurred (1). It is a vital component of safe, ethical and effective nursing practice whether done manually or electronically (2).
Accurate and complete nursing documentation has been accepted as a very important aspect of professional practice to nurses since the emergence of nursing as a profession. As written in nurses legal hand book, "Notes on nursing: What it is and what it is not”, stated the necessity of recording patients‟ progress in words for communication among nurses and the importance of reporting patient related observation accurately (2). Nursing documentation is an important component of nursing practice that occurs within the client health record and is not an optional extra to be fitted in if circumstances allow (3).
Nursing documentation should fulfill the legal requirements since its consequence may end with malpractice suits. The old saying, „If it wasn‟t charted, it wasn‟t done,‟ still holds today. According to Nigerian legislation, a written document is the only evidence if a health professional commits homicide due to negligence There are also evidences indicating that nursing documentation has relationship with patient mortality(4).
Why do nurses need to document their care? The first reason is: It allows nurses and other care providers to communicate about the care provided so as to facilitate continuity of care (5) and to improve their relationship with patients (2). Second, it serves as evidence in legal proceedings through demonstration of the applied nursing knowledge, skills and judgment (6).
Documentation also provides valuable data for research in Nursing, which have the potential to improve health outcomes. In addition to these, it may form the basis of teaching plans (7). On the other hand, the level of contributions nurses do in the health care system can be witnessed through proper documentation of their roles (8).
A nursing document, whether written or electronic, should be client focused, consists of relevant information, accurate without missing details, chronologically written, clear and concise, permanent, confidential and timely (8).
In Nigeria, nursing communication is mostly limited to hand written in most of health settings even though an electronic method called HMIS (health management information system) has been rolled out across different hospitals (9). Based on observation, there are there are limited critical reflections on the nature and outcomes of nursing care for the patients. Even though the quality and effectiveness of nursing practice is mostly demonstrated by documenting the application of the nursing process, nurses may record patient visit registry in the outpatient departments(10).
1.2 Statement of the Problem
Nursing documentation should, but often does not show the rational and critical thinking behind clinical decisions and interventions, while providing written evidence of the progress of the patient. Although keeping a patient record is part of their professional obligation, many studies identified deficiencies in practice of documentation among nurses globally. It has been reported that nursing records are often incomplete, lacked accuracy and had poor quality(5),(11).
One of the main problems facing in nursing is lack of standardization of the documents and forms nurses are required to use. It is not unusual for differently designed forms that have similar functions to exist even within the same facility. Lack of uniformity creates confusion and increases chance of documentation error(2),(12).
The challenges for documentation reported so far include shortage of staff, inadequate knowledge concerning the importance of documentation, patient load, lack of in-service training and lack of support from nursing leadership(13),(14). Despite the reasons for not documenting completely and accurately, nurses need to realize that rules and regulations by accrediting organizations expect complete and accurate documentation as indicated in their practice standards(15).
Poor documentation in nurses has been shown to have negative impacts on the health care of patients. The impact may lead to harmful consequences like exposing the care provider for medication administration error. Quality of patient care can also be hindered by an absence of sufficient documentation of data (16). On the other hand, a good documentation improves credibility of the institution, and makes the nursing profession visible. This means that, the situation may lead to the extent that can affect the status of the health care facilities because health care facilities are evaluated by the quality of documents they keep in most cases(17),(18). Good nursing documentation clearly and concisely communicates the observations, actions and outcomes of care, in a timely and accurate manner. However nurses constantly struggle to document in a way that is timely, accurate and legally practical. Poor nursing documentation can place patients, staff and organizations at considerable risk of physical and legal harm(19).
In sub Saharan Africa identified deficiencies in various aspects of nursing documentation, Specially South Africa and Uganda reported a problem in attitudes, knowledge and practice towards the practice of nursing documentation among nurses (20). Proper documentation allows real representation of what is happening on the ground (16).
The global trend of missed, inappropriate or incomplete documentation of nursing care is alarming and as with most developing countries such as Nigeria, struggling with inadequate nursing staff and yet burdened with an increasing workload, the tendency for documentation errors cannot be ignored(21).
It is unfortunate that nursing documentation continues to draw criticism from professionals, community and regulatory organization because of incomplete, substandard charting practice Nurses action are typically described as compassionate, committed and caring yet these attribute are often difficult to recognize in the nursing documentation. Most of nurses‟ actions are either not documented or not properly documented and thus crates a great problem when it comes to evaluation of client(22).
In Nigeria, inadequacy of data collection with lack of quality was found to be a problem (21). Imo State University Teaching Hospital, Orlu (IMSUTH) uses paper-based documentation, with the scientific nursing process as the documentation guiding framework. However, audits of patient records for quality assurance purposes and morbidity and mortality reviews revealed poor documentation of nursing assessments and other pertinent patient care information.
Despite the barely observable deficiencies, studies conducted on this issue of interest are very minimal. Therefore, this study is aimed to assess the practice of patient care documentation and its associated factors among nurses working in Imo State University Teaching Hospital Orlu Imo state.
• Objectives
General Objective
To assess the attitudes of nurses towards effective documentation in Imo State University Teaching Hospital Orlu, Nigeria,2023
Specific Objectives
• To determine level of nursing documentation practice among nurses working in IMSUTH
• To identify factors associated with nursing documentation practice among nurses working in IMSUTH
1.4 Significance of the Study
Nursing documentation serve as an integral part of safe and effective nursing practice that reflects knowledge, judgment, critical thinking and meaningful patient focused information. Also uses for meeting legislative requirements, quality improvement, purpose of communication, accountability and documentation is important as assessment (2). Additionally, the study will help concerned body for preparation of effective strategies on how to improve nursing documentation practice among nurses which will directly or indirectly improve nursing care quality, patient satisfaction and documentation skill, attitude and knowledge. Also the finding from this study will help nursing personnel to find means of uplifting standards of nursing documentation and make the nurses realize the benefits of documentation in their daily practice. Also it may increase patient safety and enhance the quality of nursing. The result of this study will be used by the Nurses Association, Imo State University Teaching Hospital Orlu Nursing Director Office and non-governmental organizations that seek to improve the quality of nursing care being provided. The aim of this study was to determine nursing documentation practice and associated factors.
1.5 Limitation of The Study
Limitation
• The responses might have been liable social desirability bias.
• Self- report may over/underestimation the level of documentation practice.
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