Documentation of Nursing Care: Current Practices and Perceptions of Nurses in the Government Hospital’s of Wollega Zones, Oromia Region, Western Ethiopia

Abstract

Basic and fundamental source of information in health care is the patient record, of which nursing documentation is a part. Despite continuous and consistent advice from quality- improvement programs and professional bodies over several years, achieving and maintaining good, quality standards of clinical documentation is still a problem in the health profession. The aim of the study was to assess the perceptions of nurses regarding the current documentation practices and implementation of hospital policy and problem experienced on documentation of nursing care in government hospital of Wollega Zone, Oromia region, Western Ethiopia. A Cross-sectional institutional based study was conducted on 219 nurses working at different government hospitals of Wollega Zones, Oromia region, Western Ethiopia from August 1-20, 2016. Hospitals were selected by purposive sampling, while simple random sampling method was employed to select study participants. A structured self-administrated questionnaire was used to collect the data and trained BSc nursing staffs facilitated the data collection. The data was analyzed by using SPSS for windows version 20 and descriptive, Bi-variate and Multivariable logistic regression analyses were performed to summarize data. The P<0.05 was taken as statistically significance. More than half (56.2%) of the participants were females and majority (51.6%) were in the age group of 20 to 29 years. All most near to half (48.9%) of the participants had 6 to 10 years of work experience and 45.2% had diploma in nursing. Around 55.3% of nurses know the availability and implementation of policies pertaining to documentation of nursing care. As the work experience of the nurse’s increases, the act of documentation increases by 0.002% with P value of 0.003. In addition, perception and feelings of nurses includes nobody reads what I have written on documents and why should I bother? were significantly associated with a P value of 0.002. The main reasons for not to document were, lack of awareness regarding hospitals documentation policies, supportive supervision from near managers and friends on what they document, using more pages as well as using traditional documentation system were included. Therefore, hospitals and healthcare settings should focus on increasing awareness of their staff on policies and procedures about documentation.