The study found that lack of policy/guidelines for nursing care documentation from MOH/UNMC and Hospital was the most limiting factor for documentation of nursing care. This concurs with the study by Pullen & Loudon (2006) which revealed that there was lack of policies and standard model across the National Health Services (NHS) for documenting & communicating in formation in patients’ files. This greatly affects nursing care documentation since there are no proper guidelines to follow.
Many participants reported that they lacked CNE/CME about documentation (79.3%).This is in line with Ehrenberg (cited in Bjorvell 2002) who reported that nursing care documentation was hindered by lack of knowledge and difficulty in writing. Also Tapp (1990) found that nurses lack professional identity and language in nursing. This implies that nurses lack knowledge and skills about nursing care documentation since they don’t get on job training about documentation
The study findings also revealed that there were no specific forms for documenting nursing care and those forms which were there were inadequate. This is in agreement with the a study by Tornkvist et al(1997) who reported that lack of a consistent record system & routines was one of the significant barriers of nursing care documentation. This denotes that sometimes nurses don’t document because they lack forms to use.
Also among the most significant findings about barriers to nursing care documentation was lack of time (70%).This is in line with a study by Gugerty et al (2007) who found that among the barriers of nursing care documentation; lack of time ranked number one. Ehnfors (1993), Tapp (1990) also reported lack of time among other barriers to nursing care documentation. This most likely is attributed to work overload.
The research findings indicate that documentation reduces the time for patients care as reported by many respondents (63.3%).These findings are in agreement with Gugerty et al (2007) who noted that 81% of participants believed requirements for patient care
documentation reduced time spent with patients; and 63% felt this happens often or very often. These findings indicate that documentation consumes time for patient care and most nurses take “hands on care” a priority over documentation (Tapp 1990). This significantly affects nursing care documentation and has a negative impact since care not documented is care not done in courts of law (Roskerr &Sirotnik 1997).
There is also low nurse-patient ratio (63.3%).This is in line with Mwizerwa (2000) who found that understaffing in Mulago affected the delivery of health care to patients. Beebwa (2004) also reported that 87% are over worked and 63.3% don’t finish assigned work on time. Since there are many patients compared to the nurses; there is work overload and hence nurses lack time to do documentation of nursing care. This implies that nurses get burnout and easily forget to document the care they have rendered to patients hence a negative impact on documentation.
Many participants reported they do documentation as a routine activity other than a means of recording and communicating important information (56.7%).This concurs with Gugerty et al (2007) who reported that 55% do routine documentation for reasons other than communicating pertinent information. This can be argued that they don’t mind whatever they record since they don’t know the importance of documenting. Thus their documentation will be insufficient hence a barrier to nursing care documentation.
Among barriers of nursing care documentation reported was lack of materials and equipment for assessment and documentation. This supports Draiko (2004) who found that lack of supplies greatly affects nursing care and its documentation. Lack of logistical support is a major setback in nursing care documentation since nurses fail to access what to use in documentation like forms. It is evident that lack of policies, education, inadequate forms and low nurse-patient ratio compromises nursing care documentation in MRRH.
5.4 Strategies that can be employed to improve nursing care documentation.
The hospital should organize workshops/CNE/CME about nursing documentation. This was reported by majority of participants (83.3%) and is in line with Williams (2000) who observed that all health practitioners in public health facilities who have knowledge of
documentation should use it in medical/nursing education and emphasized that in service training is mandatory for those who don’t meet identified documentation standards in order to be on the same level with the rest. This would equip the nurses with knowledge of what to document and when to document and also realize its significance.
A big number of participants also suggested that more nurses be employed (56.7%).This is supported by Beebwa (2004) who reported that 84% of respondents suggested recruitment of more nurses could improve shortage of nurses. It would reduce on patient- nurse ratio and consequently work load hence the nurses will enjoy their job and documentation is also anticipated to improve
Supplying enough documentration forms and other supplies was also suggested to be a way of improving nursing care documentation. Since inadequate forms was reflected as a barrier of nursing care documentation; if more forms would be availed then nurses would be free to record and documentation would improve.
Motivating nurses through increasing salaries, offer rewards like gifts, promotions and prepare tea for staffs on duty was also raised to be among the ways that can be employed to improve documentation of nursing care. These concurs with Kingman (2003) who noted that giving incentives in form of monetary and non monetary values to community nurses would motivate them and make them more focused on their work; This would improve documentation of nursing care as well.
The participants also suggested that developing policies/guidelines for nursing documentation would enhance their documentation. This is supported by Thoroddsen & Ehnfors (2007) who suggested that nurses need to use standardized language to document patient care data in the health records and to demonstrate contributions of nursing care. WHO (2003) also stressed that hospital management must develop policies and procedures so that when nurses identify documentation deficiencies then steps can be clearly defined through guidelines.
Other suggested ways of improving nursing care documentation include; instituting internal & external supervision team, encourage team work and emphasis documentation in schools.