FACTORS LIMITING DOCUMENTATION OF NURSING CARE IN PATIENTS FILES; A CASE STUDY OF MBARARA REGIONAL REFFERRAL HOSPITAL

MFITUMUKIZA VALENCE

2006/BNC/014/PS

A RESEARCH REPORT SUBMITTED TO THE DEPARTMENT OF NURSING IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF THE BACHELOR OF NURSING SCIENCE DEGREE OF MBARARA UNIVERSITY OF SCIENCE AND TECHNOLOGY

SUPERVISOR: MS MUWANGUZI PATIENCE

MAY 2008

Factors limiting documentation of nursing care

DECLARATION I, Mfitumukiza Valence, declare that the work presented in this research report is my original work and has never been presented to any other university/institution for any other award.

Signed

Mfitumukiza Valence Author

Date ...

Supervisors approval This research report has been produced under my supervision and submitted with my approval.

Signed . Date

Patience Muwanguzi BNSc, MNSc, PGD DS Cand, Ph D Cand. Supervisor

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DEDICATION To my dear and loving parents, Mr.Rwabutogo Benard and Mrs. Venancia Rwabutogo. To my brothers, Innocent, Denis, John Baptist, Didas and my sisters Evangelist& Winfred For the un measurable support, encouragement, love and tolerance, May God bless you abundantly

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ACKNOWLEDGEMENTS The almighty God be praised for granting me a gift of life, his endless love, knowledge and strength enabled me accomplish this dissertation. May his name be honored and glorified. I wish to extend my sincere thanks to my Parents who brought me up, nurtured and sent me to school and whose parental love, encouragement and support enabled me accomplish this study. My brothers and sisters for their financial, social, moral support and encouragement extended to me through all seemingly tough times. May the almighty God richly bless you. I am particularly grateful to my supervisors Ms Betty Kinkuhaire & Ms Muwanguzi Patience who despite their tight schedules used their precious time, efforts and knowledge to supervise this work from an idea till accomplishment. You showed me direction and I had to follow. May God bless you abundantly. To my cousin sister Jane for support and encouragement rendered to me throughout the course. To Mr.Kumakech Edward, who encouraged me to do the study and also helped me in analysis, Mr. Mwizerwa Joseph and Ms. Fortunate Atwine for their technical advice and proofreading my work and all the lecturers in the department who taught me. To my course mates (both directs and completion students) and more particularly Barebereho J.B (housemate), Kazungu & Nimwesiga for their kindness, cooperation and support in pursuit of a common goal. Last but not least, to my friends Davis, Tom, George, Enid,Nathan & John and others for their continuous support and encouragement helped me accomplish this study.

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TABLE OF CONTENTS DECLARATION.....................................................................................................................i DEDICATION.......................................................................................................................ii ACKNOWLEDGEMENTS..................................................................................................iii LIST OF TABLES.................................................................................................................vi LIST OF FIGURES...............................................................................................................vi LIST OF MAPS.....................................................................................................................vi LIST OF ABBREVIATIONS/ACRONYMS...................................................................vii DEFINITION OF CONCEPTUAL TERMS......................................................................viii ABSTRACT..........................................................................................................................ix CHAPTER ONE.....................................................................................................................1 1.0 INTRODUCTION............................................................................................................1 1.1 Background.......................................................................................................................2 1.2 Problem Statement............................................................................................................3 1.3 Objectives of the Study.....................................................................................................4 1.3.1 Broad objective............................................................................................................4 1.3.2 Specific objectives........................................................................................................4 1.3.3 Definition of variables.................................................................................................4 1.4 Significance of the Study..................................................................................................4 CHAPTER TWO....................................................................................................................5 2.0 LITERATURE REVIEW.................................................................................................5 2.1 Introduction.......................................................................................................................5 2.2 Barriers to nursing care documentation in patients files.................................................5 2.3 Strategies that can be employed to improve nursing care documentation........................7 2.4 Conceptual Framework.....................................................................................................9 2.5 DEFINITION OF OPERATIONAL TERMS................................................................11 CHAPTER THREE..............................................................................................................12 3.0 METHODOLOGY.........................................................................................................12 3.1 Area of study...................................................................................................................12 3.2 Research design..............................................................................................................12 3.3 Study population.............................................................................................................12 3.4 Inclusion criteria.............................................................................................................12 3.5 Exclusion criteria............................................................................................................12 3.6 Sampling .......................................................................................................................13 3.6.1 Sample size..................................................................................................................13 iv
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3.6.2 Sampling procedure.....................................................................................................13 3.7 Data collection tools......................................................................................................13 3.8 Data generation procedures............................................................................................14 3.9 Reliability & Validity.....................................................................................................14 3.10 Data analysis.................................................................................................................14 3.11 Ethical considerations...................................................................................................14 3.12 Dissemination of findings.............................................................................................15 4.0 RESULTS ......................................................................................................................16 4.1 Demographic characteristics of participants...................................................................16 4.2. Documentation practices among the participants..........................................................17 4.3. Perceptions and beliefs about data for documentation .................................................19 4.4. Factors limiting documentation of nursing care............................................................21 4.5. Strategies that can be employed to improve nursing care documentation.....................23 5.0 DISCUSSION OF RESULTS........................................................................................24 5.1 Demographic characteristics of respondents .................................................................24 5.2 Documentation practices among the participants...........................................................24 5.3 Factors limiting nursing care documentation.................................................................25 5.4 Strategies that can be employed to improve nursing care documentation......................26 5.5 Limitations......................................................................................................................28 6.1 Nursing implications.......................................................................................................29 6.2 Recommendations...........................................................................................................29 6.3 Areas for future research................................................................................................30 REFERENCES.....................................................................................................................31 APPENDIX A: INFORMED CONSENT FORM................................................................35 APPENDIX B: QUESTIONNAIRE.....................................................................................37 APPENDIX C: BUDGET ....................................................................................................44 APPENDIX D: INTRODUCTORY LETTER.....................................................................45 .......................................................................................................................................47

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LIST OF TABLES Table 1: Demographic characteristics of participants..........................................................16 Table 2: Factors limiting documentation of nursing care.....................................................21 Table 3: Strategies that can be used to improve documentation of nursing care.................23

LIST OF FIGURES

LIST OF MAPS MAP 1: MAP OF UGANDA SHOWING MBARARA DISTRICT...................................46 MAP 2: MAP OF MBARARA DISTRICT..........................................................................48

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LIST OF ABBREVIATIONS/ACRONYMS AIDS BNS CNE CME CRNBC FREC GONR HIV MOH MRRH NANDA NHS PI SPSS SU UEN UEM UECN URN URCN UNMC NMC Acquired Immune Deficiency Syndrome. Bachelor of Science Nursing Continuous Nursing Education Continuous Medical Education College of Registered Nurses of British Columbia. Faculty Research and Ethics Committee Goal Oriented Nursing Record Human Immune Virus Ministry of health Mbarara Regional Referral Hospital. North American Nursing Diagnosis Association National Health System Principal Investigator Statistical Package for Social Scientists Supervisor Uganda Enrolled Nurse Uganda Enrolled Midwives Uganda Enrolled Comprehensive Nurse Uganda Registered Nurse Uganda Registered Comprehensive Nurse Uganda Nurses and Midwives Council Nursing and Midwifery Council

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DEFINITION OF CONCEPTUAL TERMS Nurse A person who has undergone formal training and has skills and knowledge to care for the sick, disabled or of aiding in the maintenance of health (Rosskerr &Sirotnik, 1997).

Documentation

any written or electronically generated information about a client that

describes the care or service provided to that client (College of registered nurses of British Columbia 2005).

Limitations

Boundaries or terminal points considered as confining or restricting (Oxford

English dictionary).

Nursing care Activities done by a nurse to the patient aimed at improving and promoting health (CDC, 2006)

Patient Is an individual who is receiving needed professional services that are directed by licensed practitioner of the healing arts towards maintenance, improvement or protection of health or lessening of illness, disability or pain (CDC 2006).

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ABSTRACT Nursing requires documentation to ensure continuity of care, planning and accountability. This promotes evidence based practice. However, studies show that nursing documentation is still insufficient. Therefore, this study was aimed at identifying the factors limiting nursing care documentation in MRRH. The study employed a quantitative descriptive design, data was collected from a convenient sample of 30 nurses with varying levels of education, practicing in medical & surgical wards using self administered questionnaire. Data was analyzed with descriptive statistics using SPSS. The study findings revealed so many limiting factors to nursing documentation which include; lack of policy/guidelines from ministry of health, nursing council & hospital (88.9%), lack of training (CNE/CME) about nursing care documentation (86.2%), lack of specific forms for documentation of nursing care (79.3%) and lack of time for nursing care documentation (79.3%). Another reported barrier to nursing care documentation was low nurse-patent ratio (63.3%). It is evident from the study findings that lack of policies, training, low nurse-patient ratio and inadequate forms are the limiting factors to nursing care documentation in patients files. This implies that the practitioners should always try to document whatever they do to promote evidence based practice. In view of the above finding, it was recommended that the following strategies be employed to uplift nursing care documentation; the hospital managers should always organize CME/CNE about nursing care documentation to improve on knowledge and skills for nurses. Ministry of health /hospital should develop policy/guidelines about nursing care documentation.

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CHAPTER ONE 1.0 INTRODUCTION There is currently a considerable interest throughout the world within the health care sector to increase the quality of nursing documentation. This is being accomplished through creating new systems, re-evaluating old systems and analyzing limitations for nursing documentation (Bjorvell, 2002). Documentation is any written or electronically generated information about a client that describes the care or service provided to that client (College of registered nurses of British Columbia 2005). It is also defined as anything written or printed that is relied on as a record of proof for authorized person (Rosskerr &Sirotnik 1997). Nursing documentation has been one of most important functions of nurses since Florence Nightingales time because it serves multiple and diverse purposes. Health care systems require documentation to ensure continuity of care, serve as a tool for communication, research, audit, education, monitoring and evaluation of patients progress, planning and furnishes as evidence in courts of law. The patient record is a principal source of information in which the nursing documentation is an essential component. However, nursing documentation has not served such objectives because of its complexities (Cheevakasemsook, 2006). This study arose from the need to identify the limitations of nursing documentation in a hospital setting.

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1.1 Background In the past few decades the nursing profession has witnessed a change towards a more independent practice with explicit knowledge of nursing care. With this change, there has come an obligation to document not only the performed interventions medical and nursing but also the decision process, explaining why a specific nursing action has been prompted and outcomes (Bjrvell, 2002). Record keeping is a tool of professional practice and one that should help the care process. It is not separate from this process and it is not an extra option to be fitted in if circumstances allow. For quality documentation and reporting, factual basis, accuracy, completeness, currency, organization and confidentiality must be observed .This should done by someone having personal knowledge of the matter then being recorded (Rosskerr & Sirotnik ,1997). Health records may be paper or electronic documents such as electronic medical records, faxes, e-mails, audiotapes and images. These records include demographic data, admission nursing history, consent forms, reports of physical examination, reports of diagnostic studies, medical diagnosis, flow sheets, nursing care plans, records of care, treatment forms, and discharge plan (Roskerr& Sirotnik 1997). There are so many ways of documentation of nursing care interventions, but commonly used methods are; the problem-oriented medical record that is increasingly recognized as a method which provides a client centered problem solving approach to care. There is also traditional client record system, which is source-oriented record keeping. (College of registered nurses of British Columbia, 2005). Through documentation, nurses communicate their observations, decisions, actions and outcomes of these actions for clients. Documentation is an accurate account of what occurred and when. This helps nurses to monitor and evaluate patients progress. These records also serve as a data source for nursing research, clinical audit and educational tool. It may also be used as evidence in legal proceedings and disciplinary hearings through professional bodies (College of registered nurses of British Columbia, 2005).

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Documentation is one of the most functions a nurse performs, unless information about a patient/clients care is documented and communicated with careful thought, serious errors can occur (Porter and Perry, 1989). Nursing care must have been excellent, however care not documented is care not done in courts of law (Roskerr & Sirotnik, 1997). 1.2 Problem Statement Documentation is a vital aspect of nursing practice. Overtime, the format and quality of documentation have evolved, but the focus continues to be a positive impact on client care. Today the most challenging issues in nursing are how to document quality client care with constraints imposed by regulations, meager resources and finances (Bjorvell, 2002) The ideal documentation system should provide comprehensive client information, address client outcomes and standards, a facilitate re-imbursement from government and serves as a legal document (Rosskerr et al, 1997). According to studies done in Ontario; a review of charts suggested that documentation in the patients record did not accurately reflect the care that was given (Oldfield, 2007). There is no similar published study that was carried out in Uganda and MRRH in particular. However, according to my own observations while on clinical rotations on medical and surgical wards, documentation of nursing care interventions was not effectively done. If this continues, it will jeopardize quality of nursing care and gaps in records may be used as patients weapon to accuse nurses or institutions they serve of negligence of duty in courts of law. Hence a need to do a study to identify factors that limit documentation of nursing care interventions in medical and surgical wards of MRRH.

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1.3 Objectives of the Study 1.3.1 Broad objective To assess limiting factors and ways of improving documentation of nursing care in MRRH. 1.3.2 Specific objectives i. ii. To assess barriers to nursing care documentation in MRRH To identify ways of improving nursing care documentation in MRRH

1.3.3 Definition of variables Factors limiting nursing care documentation refers to personal, systematic and policy issues that hinder nurses from documenting nursing care activities in patients files. Ways of improving nursing care documentation refers to strategies that nurses think can be used to uplift documentation of nursing care in patients files. 1.4 Significance of the Study The study findings will help the policy makers and managers to set policies or develop tools that will help in documentation of nursing care interventions and improve on logistical design. It will help in identifying barriers to nursing documentation and stimulate the nurses to look for solutions to these barriers. This study will help in emphasizing the need for documentation while carrying out clinical teaching This study will act as a baseline for future research in nursing documentation.

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CHAPTER TWO 2.0 LITERATURE REVIEW 2.1 Introduction The purpose of the study was to identify factors limiting documentation of nursing care interventions in MRRH. The literature review to underpin this study was obtained from mainly studies done in western world, as there are no similar published studies done in Africa and Uganda in particular. Literature search was got from Internet, textbooks and Nursing Journals. 2.2 Barriers to nursing care documentation in patients files Clinical records are the most basic of clinical tools. Aggregated, they form a permanent account of individual considerations, reasons for decisions, essential for effective communication and good clinical care. However, they are often accorded low priority, are poorly maintained and not readily available. Independent inquiries, health reports and the courts have repeatedly criticized the quality of records and the resulting failings of care (Pullen and Loudon, 2006)

There is no standard guideline/model for nursing documentation. A relatively recent review of clinical record-keeping and communication in Scotland noted the lack of a standard model across the National Health Service (NHS) for documenting and communicating information in patients health records (Pullen and Loudon, 2006). This is non exceptional for Uganda.

Tapp (1990) in her study found that nurses lack distinct professional identity and language in nursing and a redundancy of forms result into inaccurate and devalued documentation of nursing care. She also reported other barriers such as lack of time, space and place, inadequate charting system, lack of value and use of record entries, environmental disruptions, inaccessibility of the record, a work group norm of a negative attitude to documentation and perceived difficulty in phrasing correctly. However, Haertfield (1996) attributed inhibitors to nursing documentation to the attitude of nurses itself. Nurses have a resistance to becoming visible with their knowledge.

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Hence, their documentation consists of passive descriptions of observations and responses unlike other professions who write about their judgments and examinations.

Allen (1988) revealed that nurses attitudes were contradictory in the sense that they valued the nursing process as a means of professionalism, but they found it difficult to bring it to terms with their work on the wards. Thus, nursing process is based on model of one-to -one nurse patient relationship, whereas nurses in most hospital realities have multiple patients assignments, this becomes difficult to document their nursing care.

Tornkvist, Gardulf, Strender (1997) cited in Bjorvell (2002) reported on the options held by 164 district nurses regarding their documentation and barriers they experienced. It was revealed that lack of a consistent record system and routines, lack of time, lack of knowledge about what should be documented, environmentally related condition such as inadequate computers, interruption and lack of support from supervisors and colleagues.

Ehrenberg, cited in Bjorvell (2002) found that nursing documentation is further hindered by lack of time, lack of knowledge, organizational obstacles, difficulty in writing and inappropriate forms. Difficulties are described on the individual level as well on the administrative organizational level. According to Bjorvell (2002), a study about nursing documentation in clinical practice revealed that 20% of the nurses thought that they did not have time to document nursing care and 71% stated that they did not have time to develop nursing documentation. It further showed that the greatest barrier was lack of time, which was ranked first. Other findings were increased paper work due to increased turnover, interruptions in thought, increased workload exemplified by sicker patients and less staffing. Sterling (1996) in her study about methods of wound assessment documentation concurs with the above.

Guttery (2007) affirms that 81% indicated that documentation reduces and directly affects time spent in providing direct care. 61% of respondents that they often or very often are kept from spending as much time with patients as needed. 54% indicated that the percentage of their shift /visit completing patients documentation was between 256
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50% while 29% reported that completing patient documentation for greater than 50% of the shift. 73% indicated that the demand for completing patient documentation caused them work beyond their work hours some times often, very often. Documentation shortcuts pose risk management issues, since the record must defend the professional judgment and standard of care for both the facility and the practitioner. 2.3 Strategies that can be employed to improve nursing care documentation Quality assurance monitoring can help improve nursing documentation. Audit can play a vital part in ensuring the quality of care being delivered to patients/clients. This applies equally to the process of record keeping. By auditing records, registrants are able to assess the standard of record keeping and identify areas for improvement and staff development. Audit tools should therefore be devised at local level to monitor the standard of record keeping and to form a basis both for discussion and measurement (NMC, 2003). Communication can improve nursing care documentation. Periodic meetings between hospital staff and nurses in each clinical specialty can help improve communication and provide targeted education. The participation of coding professionals boosts the value of these meetings, as they can provide insight into how terminology used by nurses translates into code assignments. Some hospitals present case studies at monthly meetings. Others post documentation tip sheets where nurses typically dictate or complete their records. (Rind, Kohane, Szolovits, et al.1997). Groves (1996) argues that another effective way to promote better documentation is to appoint a suitable liaison to assist with nursing communication, preferably a nursing advisor who would come to the department to review documentation problems. The liaison is responsible for contacting nurses when staffs have questions regarding documentation. Liaisons can also be charged with education and advising on nursing staff rules and regulations related to nursing record issues. . WHO (2003) stressed that Hospital Management must develop policies and procedures so that when nurses identify documentation deficiencies; the next steps are clearly defined. The process should determine how clarification from the nurses should be both 7
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requested and received. A statistically significant improvement was found in the use of Functional Health Patterns for documentation of nursing assessment, NANDA for nursing diagnoses and Nursing Interventions Classification for nursing interventions in documentation of daily nursing care for in patients. At all organizational levels intervention aimed at putting policy regarding documentation into clinical practice considerably improved daily use of standardized nursing languages. Nurses need to use standardized language to document patient care data in the health record and to demonstrate contributions to nursing care (Thoroddsen & Ehnfors, 2007). Groenman et al (1992) described attitude as an enduring cluster of beliefs, feeling and behavioral tendencies relating to any person, object or issue. People will have positive or negative feeling or emotions about a person, object or issue, these feelings and beliefs will influence the behavior directed at the person or object. Norms and values will also play an important role in the concept of attitude. In the light of these definitions a change in behavior as in this case nursing documentation behavior needs to involve a change in attitudes towards documentation. Thus, a positive attitude towards nursing care documentation is essential in ensuring a smooth follow of documentation in it self. Williams (2000) observed that all health practitioners in public health facilities who had access to knowledge of documentation should use it as continuing medical/nursing education as it is part of the professional requirement. In services training can be made mandatory for nurses who do not meet identified documentation standards in order to keep abreast with the rest. He however noted that lower level health centers are generally more likely to use gathering of information as second priority due to congestion and the high flow of cases to attend to. Even then, documentation should take center stage as a means of tracking medical cases mainly for two reasons; ongoing treatment and referral. Recent advances in electronic documentation are at the heart of social and economic transformation taking place in both the industrialized and many developing countries. As the cost of computers continues to fall and their capabilities increase, their applications are becoming vital in all sectors of the economy and the society including nursing documentation. According to Mansell and Wehn (2004), the increasing spread of 8
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information tracking through diverse media requires thorough documentation. The use of documents in the medical set up opens up new opportunities for developing countries to improve on service delivery to serve their development goals. It is the nurses themselves who have to change the nurses impact on the health care politics as well as the nursing role to improve the nursing care for patients (Bell 2004). 2.4 Conceptual Framework This is based on Imogene Kings general systems Framework; which focuses on the three interacting systems; personal, interpersonal and social system. This model employs theory of goal attainment that is met through the transaction between nurse and client. King describes her model as conceptual system and the goal of nursing as bringing a person closer to the health state (King 1981).King defines health as the way individual deals with stresses of growth and development while functioning within the cultural pattern. Nursing practice is directed towards helping individuals maintain their health so that they can perform their roles. Kings conceptual frame is a system of processes which include processes of perception, communication, purposeful interactions, information and decision-making .It helps nurses in hospital and community health agencies in delivery of nursing services to use goal oriented nursing record (GONR) to document nursing care related to goals for each client (Riehl-Sisca 1989). This makes it applicable to nursing documentation in nursing practice hence a necessary tool for guiding a study to identify limiting factors to nursing care documentation.

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Figure1: Conceptual framework for nursing care documentation using Kings theory.

Proper Documentation of Nursing care

Proper Communication among staff

Coordinated nursing care

Proper Accountability

Proper planning

Basis for research and education

Good Patients Management

Source: Adapted and modified from the theory of nursing; systems, concepts, process, by I.M King, (1981) Albany N Y: Delmar, p.145.

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2.5 DEFINITION OF OPERATIONAL TERMS Nurse Documentation A person educated and trained to care for the sick Written information about the patient that describes the care given and its outcomes Limitations Nursing care Factors that hinder documentation of nursing care. These are interventions done by a nurse to patient to prevent complications and improve his wellbeing.

Patient

A sick person who needs care.

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CHAPTER THREE 3.0 METHODOLOGY 3.1 Area of study

Perception Client

The study was carried out in Mbarara Regional Referral Hospital (MRRH) that is found along the Mbarara-Kabale high way, adjacent to Mbarara University of Science and Technology in Mbarara district. MRRH also acts as university teaching hospital, so students in the faculty of medicine in their clinical rotation also take part in provision of health services to the clients under supervision. The study was conducted on the medical and surgical wards. 3.2 Research design This study employed a quantitative descriptive design. Through descriptive studies, the researcher discovers new meaning, describe what exits, determine the frequency with which something occurs, and categorize information. (Burns & Grooves, 2003). This design helped to identify factors limiting documentation of nursing care in patients files. 3.3 Study population The participants were Nurses working in medical and surgical wards of MRRH. 3.4 Inclusion criteria The nurses included in the study are; Those who were qualified (enrolled nurses, registered nurses, BSN nurses). Those working in medical& surgical wards at MRRH Those who consented to participate in the study

3.5 Exclusion criteria Those excluded are; Other health workers who were not nurses. Nurses working on other wards Those who did not consent to participate in the study.

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3.6 Sampling 3.6.1 Sample size This was a subset of the population selected to participate in the research study and is a representative of the total population. In this study, sample size were calculated using Kish and Leslies formula (Kish 1965) No= Z
2 2 PQ/D

No= Sample size Z = Z-score (n a normal distribution curve corresponding to a 95% confidence interval) =1.96. P= Estimated proportion of population with characteristics under study 80% Q =1- P D= Absolute precision of 5% = .0.05 N0 =1.962 x 0.8(1-0.8) / 0.052 No = 3.8146 x 0.16 / 0.0025 No = 245 However, this sample size is for a large population and my study covered a small population, thus according to Israel (1995) to get a sample size for a small population the above sample size was substituted in this formula below n = No / 1 + (No -1) /N n = 245 / 1 + (245-1) / 35 n= 30.7 =31 People. n = Sample size N0 = Original sample size of a big population. N = total population under study. 3.6.2 Sampling procedure Convenience sampling was used; the researcher offered the questionnaires to only those who were on duty at the time of data collection. 3.7 Data collection tools Data was collected by use of self administered structured questionnaires.

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3.8 Data generation procedures A structured questionnaire was used to generate information. The respondents were asked to fill the questionnaire according to realities they experience on the ground. 3.9 Reliability & Validity The questionnaire was pre tested by giving it to 5 nurses not involved in the study to answer it and this enabled the researcher to identify problems encountered while answering the questionnaire then necessary corrections and adjustments were made. The questionnaire was given to research experts to review first before it was administered to ensure face validity To ensure quality control, the researcher administered the questionnaire himself; this didnt allow respondents to discuss questions with other people. This also offered the researcher an opportunity to probe further where necessary. During the interview, questions were explained thoroughly to make sure they were understood and hence provided answers which were relevant to questions. 3.10 Data analysis Data collected from the study was analyzed using Statistical package for Social Scientists (SPSS) version 10 to obtain descriptive statistical correlation and results were presented in form of tables and figures. 3.11 Ethical considerations Permission was sought from MUST Faculty Research & Ethics Committee (FREC) for approval and an introductory letter from Department of Nursing was obtained. Permission was also sought from the Medical superintendent, Principal nursing officer and In-charges of medical and surgical wards of MRRH. A written consent form by the researcher was given to the study participants and their consent sought prior to their involvement in the study. Participants were informed that participation was voluntary and that they were free to opt out at any time they wished and this would not affect their relationship with the researcher or their working relations with those who participated. 14
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Privacy and confidentiality were ensured, no names used; only codes and a private place were used for the interview. 3.12 Dissemination of findings Copies of the dissertation will be presented to the Department of Nursing, the MUST library, and MRRH. Findings will also be presented in conferences and published in nursing journals.

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CHAPTER FOUR 4.0 RESULTS This chapter presents the key findings from data analysis. The findings are arranged into three sections namely, demographic characteristics of participants, documentation practices, opinions and beliefs about documentation and factors limiting documentation of nursing care. 4.1 Demographic characteristics of participants The demographic profile of the participants is presented in table 1 below. The minimum age was 50 years and above (6.7%) and maximum age was 20-29 and 30-39 years (with the same percentage 36.7%).The majority of participants were married (63.3%). Table 1: Demographic characteristics of participants Demographic characteristics Age 20-29 30-39 40-49 50 and above Total Sex Male Female Total Marital status Single Married Widow/Widower Total Educational level Certificate Diploma Degree Total 11 19 30 10 19 1 30 17 10 3 30 36.7 63.3 100 33.3 63.3 3.3 100 56.7 33.3 10 100 Frequency (n) 11 11 6 2 30 Percentage (%) 36.7 36.7 20 6.6 100

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Qualification Uganda enrolled nurse Uganda registered nurse Uganda registered comprehensive nurse Uganda registered nurse & midwife Bachelor of nursing science nurse Total 30 Current position Staff nurse Nurse-in charge Intern nurse 25 3 2 100 83.3 10.0 6.7 100 40.0 23.3 23.3 13.3 100 23.3 76.7 100 7 15 3 2 3 23.3 50 10 6.7 10

Total 30 Years in service 1-5yrs 12 6-10yrs 7 11-15yrs 7 16yrs > 4 Total 30 Involved in planning at hospital level Involved 7 Not involved 23 Total 30

4.2. Documentation practices among the participants 4.2.1 Sufficiency of nursing care documentation The study findings indicate that the majority of the participants document the care given and the patients responses (90%) as shown in figure 2 below. Furthermore, the majority (70%) noted that nursing documentation is insufficient

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Figure 2: Documentation practices among nurses

Don't document, 10% Documentation practices among nurses

Document 90%

4.2.2 The frequency of documentation among the participants The majority (57.1%) of respondents reported that they do documentation occasionally or rarely as shown in figure3 as shown below. Figure 3: Frequency of documentation among nurses Frequency of documentation

Always, 49.2%

Occasionally 57.1%

4.2.3. Forms that are poorly documented The study findings indicate that the forms that are most poorly documented as shown in figure 4 include assessment forms (82.8%), patient progress notes (79.3%) and fluid balance charts (72.4%).

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Figure 4: Forms that are poorly documented by nurses

Forms that are poorly documented 90 80 70 60 50 40 30 20 10 0 82.8 79.3

Number of nurses (%)

72.4

41.4

3.4

ha r ts

ha r ts

for ms

at io nc

res s

nc ec

ssm en t

pr o g

ba la

er v

4.3. Perceptions and beliefs about data for documentation 4.3.1 Data that should be documented The nurses perception on the patient data that should be documented is shown in figure 5 indicate observations (73%) and nursing interventions (79%) to be the data reported by majority of the participants. Other patient data the participants felt should be documented were fluid intake and output (20.0%), nursing care-plan (16.7%), feeding habits (16.7%), behaviors (16.7%) and bowel motions (6.7%). Figure 5: Perceptions on patients data that should be documented

(%)

Flu

Ob s

As

Pt

id

Tre a

se

tm en t

f or ms

no

tes

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4.3.2 Data that should not be documented On the other hand, the nurses felt that some patient data should not be documented and these include those not necessary (11.1%), patients private lifestyle (11.1%), non-health related issues (11.1%) and nurses routine procedures such as bed making (11.1%). 4.3.3 Perceptions and beliefs about people who will read documented nursing care The majority of the nurses believed that data documented by nurses shall be read by mainly fellow nurses (figure 6) and they will be looking for the care-plan and its implementation (68.8%) and patient progress (37.5%). Figure 6: Nurses beliefs on the category of people who read nursing note
People who read nursing notes
No nurses reporting (%) 80 60 40 20 0 Nurses Doctors Students Other health w orkers 30.3 39.4 70 60

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4.4. Factors limiting documentation of nursing care 4.4.1: Factors reported as limiting documentation of nursing care The factors shown in table 2 were reported to be limiting documentation of nursing care. Table 2: Factors limiting documentation of nursing care Factor Lack of policy at the hospital level Lack of policy /guidelines from the MOH/Nursing council Lack of CNE/CME about documentation Lack of specific forms for documenting nursing care Lack of time for documenting nursing Perception of documentation as reducing the time for direct Frequency (n) 24 25 23 23 21 19 Percentage (%) 88.9 86.2 79.3 79.3 70 63.3 63.3 63.3 56.7 40

patient care Inadequate forms for documenting nursing care 19 Low nurse-patient ratio 19 Perception of documentation as a routine activity rather than a 17 means of communication Lack of materials and equipment for assessment and 12 documenting nursing

4.4.2 Assessment of the participants perceived self-competence in documentation of nursing care as a factor The participants perceived self competence in documenting nursing care was examined as a factor affecting documentation. The findings are shown in figure 7 and 8 which indicates that the perceived self-competence in documenting is not a factor because the majority of the participants (93.3%) saw themselves as competent in documenting nursing care.

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Figure7: Perceived self-competence in documentation of nursing care

Competence

Incompetent, 6.7% Very competent, 30% Competent, 63.3%

Figure 8: Perceived knowledge and skills in documentation

Knowledge and skills in documentation

Very poor, 3.3% Fair, 16.7%

Very good, 26.7%

Excellent, 3.3%

Good, 5%

4.4.3 Assessment of the participants perceived importance of documentation as a factor The perceived importance of documentation among the participants was assessed as a factor affecting documentation. The findings shown in figure 9 indicate that the majority of the participants perceived documentation of nursing care as something very important (93.3%).

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Figure 9: The perceived importance of documenting nursing care among the participants
Importance of documentation
Important, 6.3%

Very important, 93.3%

4.5. Strategies that can be employed to improve nursing care documentation The factors in table 3 below were reported as strategies that can be employed to improve documentation of nursing care in patients files. Table 3: Strategies that can be used to improve documentation of nursing care Strategies Organize workshops /CNE/CME about nursing documentation Employ enough nurses Supply enough forms and other supplies Motivate nurses through rewards, gifts, promotions, tea, and increase salaries Policy/guidelines about nursing care documentation should be put in place Internal/External supervision team to be put in place Create enough time for documentation Emphasize documentation in nursing schools; include it in syllabus Team work should be encouraged Disciplinary measures should instituted Appraisal form to include documentation Involved in ward round 23 Frequency (n) 25 17 15 10 7 5 2 2 2 1 1 1 Percentage (%) 83.3 56.7 50 33.3 23.3 16.7 6.7 6.7 6.7 3.3 3.3 3.3

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CHAPTER FIVE 5.0 DISCUSSION OF RESULTS The study was about factors limiting documentation of nursing care in patients files. 5.1 Demographic characteristics of respondents The demographic characteristics included; age, sex, level of education, marital status and experience. There was no significant correlation between age, sex, education, marital status, experience and documentation of nursing care. 5.2 Documentation practices among the participants The study findings indicate that the majority of the participants document the care given and the patients responses (90%). These findings differ from studies done by Briggs& Dean (1998) who found that nursing care was poorly documented and that the nursing record differed from the patients report. Souder & Sullivan (2000) also found no nursing documentation on patients cognitive status in 42 patient records. However, it was noted that nursing documentation was insufficient (70%) and 51.7% reported that they document occasionally. The forms which were reported to be poorly documented included; assessment forms, patients progress notes and fluid balance charts. This is in line with Davis et al (1994) who discovered that assessment was poorly documented as were details of interventions. He further reported that there were insufficient re-assessment and updating. It should be noted that assessment is documented in assessment forms. The majority of the participants indicated that observations, nursing- interventions & treatment were the data that should be documented. Other patient data the participants felt should be documented were fluid intake, nursing-care plan, feeding habits, bowel motions & patients behaviors. The participants believed that their fellow nurses and doctors are the ones who read the data documented by nurses, and that they look for careplans, implementation and patients progress (Figure 6).This can be argued that since the nurses primary responsibility is to take patients observations, give treatment and other

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nursing interventions then its their responsibility also to document what is done to prove their actions. 5.3 Factors limiting nursing care documentation. 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 dont 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 dont 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 25
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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% dont 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 dont mind whatever they record since they dont 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 26
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documentation should use it in medical/nursing education and emphasized that in service training is mandatory for those who dont 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 patientnurse 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.

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Other suggested ways of improving nursing care documentation include; instituting internal & external supervision team, encourage team work and emphasis documentation in schools. 5.5 Limitations The study findings cannot allow fair generalization since the sample size was small hence a similar larger study can be repeated or carried out in other areas. The use of questionnaires as instrument for data collection may have limited the participants to give detailed information about the variables under study. Data was not collected from other members of the health care team such as medical officers and allied health professionals, some factors could probably have been missed.

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CHAPTER SIX 6.0 Conclusions The study findings indicate the following to be the factors limiting nursing care documentation in patients files; Lack of policies/guidelines for nursing care documentation, Lack of CNE/CME about nursing documentation, Lack of specific forms for nursing care documentation. Lack of time for documentation; and it was found out that documentation reduces time for direct care. The study further revealed that there is low nurse-patient ratio; this implies that there few nurses compared to patient and has a significant impact to nursing documentation. Documentation was also perceived as a routine activity rather than a means of communication. 6.1 Nursing implications The practitioners should always try to document every procedure performed, patients concerns and outcomes. Though nurses in practice are ever busy; they should always record their activities and observations as care not documented is care not done; this will promote evidence based practice. Since documentation is a legal tool, they need to pay the necessary attention while documenting the care offered. . 6.2 Recommendations Ministry of health/nursing council /hospital should design policies and The Hospital managers should organize CNE/CME about nursing More nurses should be recruited and retained to reduce heavy workload The government/employers should motivate nurses through rewards, Internal and external support supervision should be instituted. Put more emphasis on documentation in nursing schools.

guidelines about nursing care documentation. documentation so as to improve on their documentation. and its effects. promotions, increase salaries and improve on working conditions.

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6.3 Areas for future research Other studies are needed to be carried out in other areas and nationally. A study to develop a tool to advance nursing documentation. Future research about factors limiting nursing documentation should consider collecting data from medical doctors and allied health professionals. Future research could explore the use of focused group discussion or in-depth interviews so as to get detailed data about factors affecting documentation.

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REFERENCES Allen, D., (1998). Record keeping and routine nursing care: the view from the wards. Journal of Advanced Nursing ,27,123-1230 Bebwa ,E.,(2004) Effects of low staffing levels on quality nursing care of MRRH.(U.P) Bell, k., (2004). Nursing care in African context, a qualitative study from Haydom Lutheran hospital Tanzania. GegcA- NuFu.vol 9 Bjorvell, C., (2002., Nursing documentation in clinical practice. retrieved at http://diss.kib.ki.se/2002/91-7349-29703 on 10/12/2007 Briggs, M. & Dean, K., (1998) .A qualitative analysis of the nursing documentation of post operative pain management. Journal of clinical nursing, 7(2), 155-163 retrieved at www.blackwell-synergy.com on 19/09/2007. Burns, N. & Grooves, S., (2003). Understanding nursing research 3rd ed. George Indiana USA. p.256. CDC, (2006).Definition of nursing terms ;Retrieved at http://www.cdc.gov/nchs/datawh/nchs on 20/05/2008 Cleevakasemsook, A., (2006). The study of Nursing documentation complexities. International Journal of Nursing practice. 12(6): 366-374 retrieved at http://www.pt.wkhealth.com/pt/re/ijnp/abstract. On 12/10/2007 College of registered nurses British Columbia (2005). Documentation of nursing care policy .retrieved online at www.crnbc.ca on 17/08/2007 Davis,B.,Billings,J.,& Ryland,R.(1994).Evaluation of nursing process documentation. Journal of Advanced Nursing,19,960-968. Draiko, E., (2006). Factors affecting provision of nursing care in west Moyo HSD (U.P). Ehnfors,M.,& Smedby,B., (1993). Nursing care as documented in patient records. Scandinavian Journal of Caring Services, 7,209-220. 31
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Groves T. (1996). SatelLife: getting relevant information to the developing world. BMJ; 313:16069. Groenman,N.H.,Slevin,O.DA. & Buckenham,M.A.(1992).Social and behavioural sciences for nurses. Edinburgh: Campion press Ltd Gugerty ,B.,Beachley,M.,Navarro,V.,Newbold,S.,et al .,(2007).Challenges and opportunities in documentation of nursing care of patients.A report of the Maryland Nursing workforce commission. Accessed online at: http://www.mbon.org/commission2/documentation challenges.pdf. On 14/07/2007 Hale, C. Thomas, L. Bond, S. & Todd, C., (1997). The nursing record as a research tool to identify nursing interventions. Journal of clinical Nursing,6,207-114 Heartfield, M.,(1996). Nursing documentation and nursing practice. Journal of Advanced Nursing,24,98-103. Kish, L., (1965). Survey Sampling; New York. John Wiley and Sons, Inc King, I. M. (1981), A theory of nursing: Systems, concepts, process; 2nd edition Albany, New York, Delmar. Kingma, M., (2003).Economic incentive in community nursing; attraction, rejection or indifference. Human resources for health, 1:2doi:10, 1186/1478-4491-1-2.Accessed at http://www.human-health.com/content/1/1/2. On 23/04/2008 Mandil, S. H., (1998). Informatics and telamatics, Present and future. Retrieved at http://www.emro.who.int/publications. on 23/9/2007

Mansell, R. & Whehn, S., (2004). Information technology for sustainable development, London .Oxford University.

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Milberg, J., (2003). Adapting an HIV/AIDS clinical documentation and information system for use in Kampala, Uganda); HELINA (Health Informatics in Africa) conference in Johannesburg, South Africa: 445 Mwizerwa, J., (2000) Factors affecting the delivery of nursing care to in patients of new Mulago hospital. (U.P). NMC (2003).Record keeping guidance .Accessed online at http://nmc-uk.org/a display document.aspx. On 15/07/2007 Oldfield,M., (2007). Changing behaviors to improve documentation and optimize hospital revenue. Journal of nursing leadership, 20(1); 40-48 retrieved online at http://www.longwoods.com On 10/07/2007

Plaskitt, A. &Dettalle,C., (2006) ,Royal united hospital hospital NHStrust Nursing documentation policy retrieved at http://www.ruh.nhs.uk On 17/08/2007 Porter, A. P. and Perry, A .G., (1989). Fundamentals of nursing concepts, process and practice 2nd ed. Baltimore Toronto .C.V. Mosby company, St. Louis. P.329-330

Pullen .I. and Loudon .J. (2006). Improving standards in clinical record keeping; advances in Psychiatric treatment .vol 12,p.280-286.Retrieved at http://apt.rcpsych.org .on 13/01/2008 Riehl-Sisca, J., (1989). Conceptual models for nursing. 3rd ed. Norwalk, California. Appleton & Lange. P.149-155. Rind, D.M. & Kohane, I.S. et al. (1997). Maintaining the confidentiality of medical records. Ann Intern Med; 127(2), 138-141.Accessed at http://www.annals.org/cgi/content. On 18/09/2007. Rossker,J. & Sirotnik,M., (1997). Canadian fundamentals of nursing. ST.Louis Baltimore. Mosby Souder,E. & Osullivan, P.( 2000). Nursing documentation versus standardized 33
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assessment of cognitive status in hospitalized medical patients. Applied Nursing Research, 13(1), 29-36.

Sterling, C., (1996). Methods of wound assessment documentation. Nursing standard Journal.11, 10,38-41 Tapp,A.,(1990). Inhibitors and facilitators to documentation of nursing practice. Western Journal of Nursing Research, 12(2), 229-240. The Oxford English dictionary (1978).Vol VI.Oxford; Clarendon Press. Thoroddsen, A. & Ehnfors, M., (2007). Putting policy into practice: pre- and posttests of implementing standardized languages for nursing documentation. .Journal of Clinical Nursing 16, 18261838 World Health Organization (2003). The monitoring and evaluation (M&E) of the 3 by 5 initiative. Geneva. 23/02/2008 At: http://www.who.int/3by5/publications/briefs/monitoring. On

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APPENDIX A: INFORMED CONSENT FORM

I am Mfitumukiza Valence, a fourth year Bachelor of Nursing Science student at Mbarara University of Science and Technology, seeking your permission to participate in the study to Assess factors limiting documentation of nursing care interventions in patients files in MRRH.

The research is a partial fulfillment for the award of the Bachelor of Nursing Science Degree of Mbarara University of Science and Technology.

In this study, a questionnaire will be given. The respondents will be required answer questions by ticking the check boxes and filling in the spaces provided. The information that you will provide during the study will be kept confidential. Only the Researcher will have access to them.

Your participation in this study is voluntary and you have the right to refuse to participate or answer any question that you feel uncomfortable with. If you change your mind about participating during the course of the study, you have the right to withdraw at any time. The decision to withdraw will not affect your relationship with the researcher. If there is anything that is unclear or you need further information, I will be delighted to provide it. Your agreement to participate in this study will be highly appreciated

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Declaration of the volunteer I have understood the purpose of the study. I realize that I might be contacted again if need be.

I have read the above information, or it has been read to me. I have had the opportunity to ask questions about it and any questions that I have asked have been answered to my satisfaction. I consent voluntarily to participate as a subject in this study and understand that I have the right to withdraw from the study at any time without in any way affecting my relationship with the researcher.

Mfitumukiza Valence

.. Name/signature of volunteer/ Parent/Guardian

...................... Name/signature of investigator contact Tel: 0772-974952

Date ..

Date.

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APPENDIX B: QUESTIONNAIRE This questionnaire will be used in a study to assess factors that limit documentation of nursing care in patients files on surgical and medical wards of MRRH. Section A: Demographic information 1. Age.................years 20-29 years 30-39 years 40-49 years 50 years and above 2. Sex Male Female 3. Marital status Single Married Divorced Widow/Widower

4. What is your nursing educational level? Certificate Diploma Degree 5. What is your current qualification? UEN URN URCN UEM URM BNS URMN UECN other specify...........

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6. Which ward are you working on? Medical ward surgical ward

7. What is your current position? Nurse-in charge Other specify 8. How many years have you spent in service .................years? 1-5yrs 11-15yrs 6-10yrs >20yrs staff-nurse

B. Nursing care documentation 9. Are you often involved in rendering nursing care to patients? Yes No

10. Do you document the care given & patients responses in patients files? Yes If yes 11.If yes, How often do you document? Always Occasionally Rarely 12. Do you think that documentation of nursing care in patients files is sufficient? Yes 13. What could be done better? ......................................................................................................................................... ......................................................................................................................................... ................................................................................................................................... No No

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14. Do you think that documentation of nursing care in patients files is a true reflection of care given? Yes No

15. Which of these is documented well? Assessment forms Observation charts Treatment forms Patient progress notes Fluid balance chart Others specify.. 16. Which of these is poorly documented? Assessment forms Observation charts Treatment forms Patient progress notes Fluid balance chart Others specify

C. Knowledge and skills of nursing care documentation 17. Is there policy/guidelines from MOH/Nursing council about nursing care documentation? Yes No

18. Does the hospital/institution you are serving have its own nursing care documentation policy / guidelines? If no, go to no .19 Yes No 39
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19. If yes, have you ever read them? Yes No

20. Do you think lack of policy/guidelines about nursing documentation affects the way how you record nursing care? Yes No

21. Are you involved in planning / decision making of the institution? Yes No

22. Have your institution ever organized CNE/CME about documentation Yes No

23. Do you think lack of CNE/CME contributes to inadequate nursing care documentation in patients files? Yes No

24. Are you competent enough to do documentation of nursing care in patients files? Very competent competent not competent

25. How do you gauge your knowledge & skills about documentation of nursing care? (a) Excellent (c) Good (d) Poor b) Very good d) Fair e) very poor

26. Do you feel you have enough time to document the care you have given? Yes No

27. If no, how much time would you need? ................................................. 28. Does the process of and requirements for patient care documentation reduce the amount of time spent by you in providing direct patient care Yes No 40
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29. If you answered yes to No 27, how often does the documentation process prevent or keep you from spending as much time with patient as needed Never Rarely Some time Often Very often 30. What percentage of your shift is actually spent in completing patient care documentation? Less than 25% 25%-50% 51%-75% More than 75% 31. Are you routinely required to document care given other than to record and communicate important information related to a health care to team members Yes No

32. Who should write in patients files? Nurse involved in direct care Doctor involved in direct care Other health workers involved in direct care All health workers who are involved in direct care 33. Are there specific forms / papers nurses are supposed to write on different from those doctors are supposed to write on? Yes No

34. Do you think its important to document nursing care given and its outcomes in 41
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patients files? Very important important Not important

35. Have you ever been rebuked /stopped from documenting nursing care in patients files? Yes No

36. In your view what should be documented and what should be left out? And please give reasons for your answer? Things to be documented . . . ......................................................................................................................................... ......................................................................................................................................... ... Things not to be documented ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... .... 37.When you document, who do you think reads your notes and what do they look for?................................................................................................................................... ......................................................................................................................................... 42
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......................................................................................................................................... . 38. Are there enough forms to be used for documenting nursing care? Yes No

39. What could be other factors that hinder nurses from documenting of nursing care in patients files? . ................................................................................................................................. ................................................................................................................................. ................................................................................................................................. .... 40. What could be the strategies that can be employed to improve nursing care documentation in patients files................................... ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... 43 44
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......................................................................................................................................... ......................................................................................................................................... ...... THE END, THANK YOU APPENDIX C: BUDGET ACTIVITY Proposal writing ITEM Stationery Flash disk Internet Typing, Printing and photocopying 100,000= Data collection instruments Pens printing and photocopying of questionnaire 25 200/= 100,000/= 5000/= QUANTITY 2 reams 1 UNIT PRICE 8000/= 50,000/= TOTAL 16,000/= 50,000/=

40

50000=

50000/=

Transport To Mbarara town Interviews. Contingency Data processing Statistician Compiling the dissertation 100,000/= 4 copies TOTAL 400,000/= 1,071,000/= 50,000= 5,000/= 200,000= 150,000/= 50,000/= 50,000/= 200,000= 150,000/=

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APPENDIX D: INTRODUCTORY LETTER

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MAP 1: MAP OF UGANDA SHOWING MBARARA DISTRICT

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MAP 2: MAP OF MBARARA DISTRICT

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