Documentation practice and associated factors among nurses working in public hospitals in Wolaita Zone, Southern Ethiopia

Abstract

Background Nursing documentation documents the everyday activities of nursing care that are planned and implemented on individual patients by nurses of different educational statuses. Documentation of nursing activities is the key source of clinical information to meet professional and legal requirements. Although nursing documentation is an important part of nursing practice, it is commonly undone by nurses working with patients for different reasons. Objective To assess the documentation practice and their associated factors among nurses working in public hospitals in the Wolaita Zone, Southern Ethiopia. Methods An institutional-based cross-sectional study was conducted among 402 nurses and a simple random sampling technique was used to select participants. Data were collected using a pretested structured self-administered questionnaire adapted from previous studies. Statistical Package for the Social Science version 26 was used for data entry and analysis. Independent variables with p-value < 0.25 from bivariable logistic regression were entered into the multivariable logistic regression method and significant associations were obtained at an adjusted odds ratio with a 95% confidence interval and p-value < 0.05. Results In this study, the good documentation practice among nurses was 42% [95% confidence interval (CI), 37.2–46.8]. There was a statistically significant relationship between documentation practice and age [adjusted odds ratio (AOR): 2.590 (95% CI: 1.4–4.79)], educational status [AOR: 2.248 (95% CI: 1.13–4.48)], hospital level [AOR: 4.185 (95% CI: 2.63–6.72)], work experience (2–5 years and > 5 years) [AOR: 4.066 (95% CI: 1.55–10.64)] and [AOR: 5.395 (95% CI: 1.97–14.81)] respectively and in-service training [AOR: 0.582 (95% CI: 0.366–0.923)]. Conclusion and recommendations This study demonstrated that the good practice of documentation among nurses was found to be low. Age, educational status, working in comprehensive specialized hospitals, work experience, and having in-service training had significant associations with documentation practice. It is very important to plan and intervene with different strategies, such as providing training for young nurses, nurses with low educational status, nurses working in primary hospitals, and nurses with less than two years of work experience on documentation standards, to create positive attitudes and enhance their knowledge.

Nursing patient record practice and associated factors among nurses working in North Shewa Zone public hospitals, Ethiopia

“…A value of 3, 2, 1, and 0 were scored for the options “Always,” “Sometimes,” “Rarely,” and “Never,” respectively. The participant's performance was categorized into Good Practice when scored above or equal to the mean score of the practice questions, and Poor Practice when scored below the mean value ( 1 , 2 , 15 ).…”

“…It accurately reflects nurse evaluations, changes in clinical status, treatment given, and pertinent patient information. Documentation is the primary clinical information source to fulfill legal and professional standards ( 2 ). It is a crucial part of the nursing process as it is a vital form of communication within the healthcare team regarding patient care.…”

“…Similarly, in Ghana, 46% of the patient care was not documented in nursing care records, 63% of the patients did not get progress notes from the nurses after the first day of admission, and 57% of the documentation was not signed by the nurses ( 5 ). Nursing care documentation was also inadequate in the Southern (42%) ( 2 ) and Northwestern Ethiopia (37.4%) ( 6 ).…”

“…Several researches recommended utilizing a multidisciplinary approach to solve documentation issues. These include developing rules and regulations ( 1 , 7 ) and providing continuing opportunities for nurses to receive training on the effectiveness of documentation ( 2 , 6 , 15 ). It is also expected of nursing leaders to encourage, support, and hire more personnel ( 6 , 15 ).…”

“…Several factors determine how closely nurses are adhering to the nursing care documentation procedure. This includes age, educational status, operational standard of nursing documentation, hospital level, in-service training on standard nursing processes, work experience (>5 years), and availability of documenting sheets ( 1 , 2 ). Demotivation, workload, shortage of time, and inadequate administrative assistance are also factors that contribute to poor patient record-keeping quality ( 16 ).…”