Knowledge, attitude and practice of nurses towards documentation of nursing care plan

Abstract

The quality of nursing documentation is an important issue for nurses both nationally and internationally. 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. Accurate nursing documentation leads to the evolution of knowledge and enhance professional autonomy.The aim of this study was to assess knowledge, attitude and practice of nurses towards nursing documentation of nursing care plan. This is a descriptive cross section study which was carried out to examine knowledge, attitude and practice of nurses towards nursing documentation. Both quantitative and qualitative methods were used. The study was carried out at three different hospitals namely; Choma General Hospital, Southern province, Kitwe Central Hospital, Copper belt province and Senanga District Hospital in Western province.50 respondents were selected from each Hospital with a total of 150 respondents, a simple random sampling method was used. The research instrument which was used for data collection was a self administered questionnaire it consisted of five parts, namely section A had questions concerning demographic data, section B the nursing care performed, section C documentation performed in the wards, section D knowledge and section E staffing levels. The questionnaire was completed by nurses and analysed using the SPSS V.I7 of the computer software. Findings showed that majorityl41 (94%) of nurses documented nursing care plan although it was found that most of the nursing care documented was incorrect and many did not know what to document. Majority of respondents who have been practicing for more than 16 years 40 (26.7%) showed an overwhelming positive attitude towards nursing documentation. This proves the saying which says experience is the best teacher.87 (58%) of respondents reported that they like nursing documentation. The constraints cited leading to poor documentation of nursing care plan were among others (table 20) shortage of staff, lack of incentives and not knowing what to document. The study revealed that lack of in - service training in nursing documentation has contributed to inadequate knowledge on nursing documentation. 133 (88.7%) of respondents did not undergo in - service training. If in - service training was an ongoing exercise for the nurses it would certainly increase their knowledge on nursing documentation.The recommendations made are as follows; The following recommendations were made in the light of findings of the study as follows: Ministry of Health The Ministry of Health should ensure that the following are done: 1. Improving on the supply of materials such as stationary 2. Employ more staff nurses of all categories in order to improve on the staff shortage. 3. The electronic computers should be provided in Hospitals in order to minimize use of paper for nursing documentation. General Nursing Council 1. There is need to reorient and Introduce training courses on nursing documentation especially for the trainees trained from the private nursing schools in order for nurses to keep abreast. Choma General Hospital, Senanga District Hospital and Kitwe Central Hospital 1. Improve nurses' attitude through motivating them and provision of necessary information with regards to nursing documentation. 2. The nurse managers that is the Nursing Officers and the Nursing Sisters to be monitoring the documentation on the wards. 3. The leaves such as occasional leave, vacation leave should be well planned by managers to avoid staff shortages. 4. The managers should put a deliberate policy of motivating those staff who are doing a commendable job. 5. Exchange visits with other hospitals should be encouraged to learn on how other hospitals are managing.