A study to determine factors influencing documentation in nursing at monze hospital.

Abstract

The main purpose of this study was to determine factors influencing documentation in nursing practice. The ultimate goal was to help nursing leaders find means of uplifting nursing standards and make the nurses realize the benefits of documenting nursing practice. A descriptive cross-section study was carried out to explore the factors influencing nursing documentation. Both quantitative and qualitative methods were used. The study was carried out at Monze Mission Hospital in Monze District. Monze District is situated about 200 km south of Lusaka. Fifty respondents were selected using simple random sample method. Data was collected from the respondents through the use of seif-administered questionnaire. Data collected was analysed manually using a data master sheet and a scientific calculator. The study revealed that almost all (82%, 41) of the nurses documented nursing practice although it was found that most of the nursing care documented was inadequate and incomplete. (60%, 30) documented procedures, medication and inventory, (10%, 5) documented nursing care plan, (42%, 21) documented vital signs, blood pressure, fluid balancing, partogram, (18%, 9) documented admissions, history taking, (16%, 8) documented reports on critical clients and post-op clients, Glasgow coma scale. Majority of the nurses had an overwhelming positive attitude towards nursing documentation if constraints in the environment were removed. (56%, 28) reported that they like nursing documentation. Among the constraints cited leading to none documentation of nursing practice were: inadequate and poor staffing patterns on the wards. (92%, 46) respondents reported that staffing pattern was poor on the ward. The study further revealed that lack of in-service training on nursing documentation has contributed to inadequate knowledge on nursing documentation.