bs_bs_banner

International Journal of Nursing Practice 2012; 18: 354–362

RESEARCH PAPER

Nursing documentation: Experience of the use of

the nursing process model in selected hospitals in
Ibadan, Oyo State, Nigeria
Bola Ofi RN PhD
Senior Lecturer, Department of Nursing, University of Ibadan, Ibadan, Oyo State, Nigeria

Olanrewaju Sowunmi RN PhD

Deputy Director (Nursing Training), Nurse/Midwife/Public Health Nurse Tutors Programme, University College Hospital, Ibadan, Oyo State,
Nigeria

Accepted for publication February 2012

Ofi B, Sowunmi O. International Journal of Nursing Practice 2012; 18: 354–362

Nursing documentation: Experience of the use of the nursing process model in selected hospitals in
Ibadan, Oyo State, Nigeria

The descriptive study was conducted to determine the extent of utilization of the nursing process for documentation of
nursing care in three selected hospitals, Ibadan, Nigeria. One hundred fifty nurses and 115 discharged clients’ records were
selected from the hospitals. Questionnaires and checklists were used to collect data. Utilization of nursing process for care
was 100%, 73.6% and 34.8% in the three hospitals. Nurses encountered difficulties in history taking, formulation of
nursing diagnoses, objectives, nursing orders and evaluation. Most nurses disagreed or were undecided with the use of
authorized abbreviations and symbols (34.3%, 40.3% and 69.5%), recording errors that occurred during care (37.1%,
56.1% and 52.2%) and inclusion of change in clients‘ condition (54.3%, 56.1% and 73.8%). Most nurses appreciated the
significance of documentation. Lack of time, knowledge and need for extensive writing are the major barriers against
documentation. Seventy-seven point four per cent of the 115 clients’ records from one hospital showed evidence of
documentation, no evidence from the other two. Study findings have implications for continuing professional education,
practice and supervision.
Key words: documentation, Nigerian hospitals, nurses, nursing process.

INTRODUCTION required by policy or standard. Documentation is the

Communication either verbal or non-verbal is an impor-
tant aspect of care delivery. Nurses spend a substantial
part of care communicating, reporting and recording the
process for continuity and sharing of information as
Correspondence: Olanrewaju Sowunmi, Nurse/Midwife/Public Health
Nurse Tutors Programme, University College Hospital, Ibadan, Oyo
State, Nigeria. Email: lanresowunmi@hotmail.com
evidence of care delivered, and nurses as coordinating
members of the health team must ensure effective docu-
mentation as required by standard of practice and organi-
zational policies. Nursing documentation is a fundamental
nursing responsibility, an accepted norm but often a
neglected part of nursing activities. Adequate documen-
tation of nursing activities fosters continuity of care with
evidence of nursing action whereas its inadequacy
reflects substandard care with implications for litigation.1,2

© 2012 Blackwell Publishing Asia Pty Ltd doi:10.1111/j.1440-172X.2012.02044.x

Problems of nursing care documentation
Documentation is a professional responsibility and
accountability to the clients, the institution and the soci-
ety.3 Adequate documentation poses major challenges to
nurse practitioners because of various complexities and
difficulties associated with it.4 This study identifies some
of these challenges and extent of documentation of
nursing care among professional nurses in selected hospi-
tals in Nigeria.
Documentation process involves stating clearly ‘what’,
‘where’, ‘how’, ‘when’ and ‘why’ of nursing care. Effec-
tive documentation is a written record of interaction
between and among health professionals; clients, their
families and health-care organizations.5 The document
also presents administration of tests, procedures, treat-
ment, clients’ education, results of clients’ responses to
diagnostic tests and interventions.6 Documentation has
been an integral part of nursing since the time of Florence
Nightingale, and various documentation systems have
evolved in response to changes in health care, paradigm
shift in nursing and advances in technology.
Documentation can be in form of charts or electronic.
Charting approach includes narrative, source-oriented,
problem-oriented that is exemplified to subjective and
objective data, assessment and plan (SOAP); SOAP-
Intervention, Evaluation (SOAPIE) and SOAPIE-
Reassessment (SOAPIER), problem-intervention-
evaluation, focus charting, charting by exception, critical
pathways or health-care maps, flow sheets3,7 among
others. Nursing process, an essentially cognitive activity
that requires both critical and creative thinking for pro-
viding care is also a charting format to document all care
activities and patient outcomes. The nursing process was
developed in the USA in the late 60s and has become
central to the definition of nursing in many parts of the
world. Since the 80s major health-related organizations
like the World Health Organization, International
Council of Nurses, The American Joint Commission on
Accreditation of Hospital Nursing Standards and the
United Kingdom Central Council recognized the use of
the nursing process as a standard tool for documenting
nursing care.8 A charting system similar to the nursing
process titled VIPS was developed by Ehnfors, Thorell-
Ekstrand and Ehrenberg,9 an acronym for Swedish words
Välbefinnande, Integritetet, Prevention, Säkerhet
meaning Well-being, Integrity, Prevention, Security.
Examples of electronic documentation are Electronic
Health Records10 and Electronic Patient Record.11 Cur-
rently, computerized charting is gaining dominance in the
355
developed nations because the approach reduces docu-
mentation workload and improves quality of information
especially where nurses have expertise in computer use.
However, despite the introduction of the nursing
process over five decades ago and its acceptance as a tool
for documenting care, literature12–16 abound on its low
utilization. Low implementation level is associated with
poor educational preparation of nurses on the concept,
lack of time, cumbersome documentation, shortage of
staff, lack of crucial content, lack of organizational
support and uncertainty of what to include in the patient’s
records, negative attitude to change, lack of consistent
recording system and short care episodes.12,13,16,17
DeLaune and Leidner3 explained low documentation
ability from the perspective of complexities which
includes three aspects: disruption, incompleteness and
inappropriate charting. Related factors for complexities
are limited nurses’ competencies, motivation and confi-
dence, ineffective nursing procedures, inadequate nursing
audit, supervision and lack of staff development. Further-
more, nursing documentation has not served its main
purposes of providing continuity of care, furnishing legal
evidence of the process of care and support evaluation of
quality of care because of its complexities.
Nursing documentation based on nursing process facili-
tates effective care because clients’ needs can be traced
from assessment, helps to conceptualize the nurse–client
relationship and empowers nurses with decision-making
skills.18,19
PROBLEM STATEMENT
Nursing process is a problem-solving framework to be
used in a multiplicity of health-care and educational set-
tings.20 In an economic-driven health-care industry that
exists in Nigeria, professional nurses are faced with a
changing health system that values measurement of out-
comes and performance because clients are becoming
more aware of their expectation of health care. They now
complain, demand, report, sue and constantly demand
quality care. Clients expect value for money and can
channel their demands through law suits. The only way
through which nurses will circumvent litigation and
authenticate nursing actions, reasons for nursing actions
and time of administering nursing actions is through
proper documentation.
The nursing process was adapted by the Nursing and
Midwifery Council of Nigeria (NMCN) as a tool for quality
care over two decades ago. All nursing training institutions
© 2012 Blackwell Publishing Asia Pty Ltd
356 B Ofi and O Sowunmi

and clinical settings were mandated by the NMCN to process records of clients were reviewed in the study.
utilize the five-step model namely: assessment, diagnosis, Data were collected after an ethical approval has been
planning, implementation and evaluation. Several work- obtained from Institutional Review Committee. The right
shops have been organized to disseminate the skills neces- of subject not to participate was observed. Descriptive
sary for the implementation of the nursing process and analysis was utilized to analyze the gathered data, and
documentation of its components parts. However, feed- results were presented in tables.
backs from clinical settings indicate that the nursing
process is not fully implemented and documentation of
RESULTS
care is inadequate. The main thrust of the study is to
Table 1 reflects gender and age distribution of nurses. All
ascertain how professional nurses effectively document
of them were females with appreciable number (31.4%)
nursing care utilizing the nursing process model.
of them between 38 and 43 years. From Table 2, few
nurses (21.7%, 15.7%, 10.5%) in the three hospitals
RESEARCH QUESTIONS stated the NMCN adopted five phases of the nursing
• To what extent is the nursing process utilized for care
process correctly. A large percentage of nurses in Hospital
in the selected hospitals?
A (55.7%) did not state the five phases correctly followed
• What are the difficulties currently encountered by
by Hospitals C (34.8%) and B (28.1%) nurses, respec-
nurses in the use of the nursing process?
tively. Appreciable percentage of nurses (24.6%) in
• What is the knowledge level of nurses about the
process of documentation utilizing the nursing process?
• What is the knowledge level of nurses about the sig- Table 1 Gender and age distribution of nurses in the three
nificance of nursing documentation? hospitals (n = 150)
• What are the barriers against documentation process?
• What is the level of documentation of the component Variable Hospital Hospital Hospital
parts of the nursing process in clients’ records in the A (%) B (%) C (%)
selected hospitals?
Sex
AIM OF THE STUDY Male — 12.2 13.0
To determine the extent of utilization of the nursing Female 100 87.7 87.0
process and documentation of nursing care by professional Age
nurses in selected hospitals in Ibadan, Oyo State, Nigeria. 20–26 5.7 3.5 13
27–31 5.7 12.2 30.4
METHODS 32–37 20 21.1 26.1
38–43 31.4 28.1 21.7
The descriptive design was utilized in the study. The study
44–49 17.1 17.5 —
was conducted in Medical, Surgical, Obstetrics/
50–55 20 17.5 8.7
Gynaecology and Paediatrics wards in three hospitals des- 56–61 — — —
ignated Hospitals A, B and C. A sample size of 150
professional nurses was selected by convenience from a
sample population of 420 nurses working in the medical,
Table 2 Knowledge of nurses about the phases of the nursing
surgical, obstetrical, gynaecological and paediatric wards
process in the three hospitals
of the three hospitals. Self-developed questionnaire with
reliability index of 0.69 and validated checklist were used Phase of the Hospital Hospital Hospital
to collect data. The questionnaire was used to collect data nursing process A (%) B (%) C (%)
on the utilization of the nursing process, documentation
of its component parts, process of documentation, signifi- 5 phases 15.7 10.5 21.7
cance of documentation and barriers to effective docu- 4 phases 22.9 36.8 39.1
mentation. A checklist was used to identify the extent of Incorrect 5 phases 55.7 28.1 34.8
documentation of the component parts of the nursing No response 5.7 24.6 4.3
process by nurses. One hundred and fifteen (115) nursing

© 2012 Blackwell Publishing Asia Pty Ltd

Problems of nursing care documentation
Table 3 Extent of nursing process utilization in the three hospitals
in percentages
Utilization Hospital A Hospital B Hospital C
Yes 100 73.6 34.8
No — 26.3 65.2
Hospital B did not demonstrate good knowledge of the
steps of the nursing process. Only one hospital (Table 3)
fully utilized the nursing process as a care and documen-
tation tool followed by Hospital B (73.6%) and Hospital C
(34.8%). A large percentage of nurses in Hospital C
(65.2%) did not utilize the nursing process in the care of
clients in their hospital.
Nurses indicated on Table 4, the component parts of
the nursing process that they found easy or difficult to
complete. Eighty per cent of respondents found it easy
to collect data in Hospital A, 64.9% in Hospital B and
56.5% in Hospital C. In Hospital C, however, 21.7% of
nurses indicated difficulty in collection of data whereas
another 21.7% were undecided followed by Hospital B
where 29.8% had difficulty whereas 5.3% were unde-
cided. Many nurses in the three hospitals conduct physi-
cal examination with ease but 30.4% of Hospital C
nurses were undecided. Least percentages were obtained
from nurses in Hospital C in formulation of nursing
diagnosis (56.5%), statement of objectives (56.5%),
writing of nursing orders (56.5%), scientific principles
(60.9%), evaluation (56.5%) and nursing round sheet
(52.2%). The area of documenting on discharge
summary sheet did not pose significant difficulty for
nurses in the three hospitals.
Knowledge of nurses on the process required for effec-
tive documentation was investigated (Table 5). Nurses in
Hospital A (84.3%) and Hospital B (89.5%) agreed that
common vocabulary is necessary for effective documen-
tation whereas only 43.5% of Hospital C nurses were in
agreement. Sixty-five point seven per cent of nurses in
Hospital A (highest agreement rate) agreed that effective
documentation required the use of authorized abbrevia-
tions and symbol. The least percentage (30.4%) was
recorded in Hospital C. In Hospital C, 47.8% disagreed
whereas 21.7% were undecided with the use of author-
ized abbreviations and symbols. The same trend was
observed in Hospital C where 13% were undecided and
34.8% disagreed with the need for factual and time-
357
sequenced organization in documentation. Sixty-two
point nine per cent of nurses in Hospital A, 43.6% in
Hospital B and 47.8% in Hospital C agreed that documen-
tation should include errors that occurred during care.
Appreciable number of nurses in Hospital B were unde-
cided (33.3%) and 22.8% disagreed that errors should be
included in documentation. Only 50% of nurses in Hos-
pital A, 45.6% in Hospital B and 39.1% in Hospital C
disagreed that documentation may not necessarily include
change in client’s condition; 45.7% (Hospital A) and
43.6% (Hospital B) agreed whereas 34.7% were unde-
cided. Thirty point four per cent of nurses in Hospital C
were undecided about including clients’ responses to an
intervention or expected outcome whereas 21.7% of
them disagreed. Data from Hospital C further showed
that 34.8% of nurses could not decide if documentation
should reflect complaints of clients or family members
whereas 21.7% disagreed.
Table 6 reflects the responses of nurses’ knowledge in
the three hospitals about the significance of documenta-
tion. Most nurses demonstrated good knowledge in these
areas except the item that deals with providing measure-
ment of nursing outcomes where nurses in Hospital A
recorded the lowest agreement rate (61.4%). Shortage of
staff, lack of stationery, inadequate organizational
support, excess workload, lack of knowledge of the
nursing process, lack of time and extensive writing were
some identified barriers to documentation by nurses in the
three hospitals (Table 7). Hospital A nurses ranked lack
of stationery highest, Hospital B nurses ranked shortage
of staff highest whereas Hospital C ranked shortage of
nurses, inadequate organizational support and excess
workload highest.
Table 8 contains the level of actual documentation of
care by nurses utilizing the nursing process model. All the
reviewed 115 nursing process records were from Hospital
A, Hospital B had no nursing process records whereas
Hospital C had no nursing process records but there were
few uncompleted nursing care plans in clients’ case notes.
The 115 notes were analyzed for complete documentation
of nursing process components parts as itemized in the
table. Seventy-seven point four per cent (89 case notes)
had nursing process records, hence the 77.4% (89 case
notes) were further analyzed. Reports of laboratory inves-
tigation were incomplete (55.1%) whereas documenta-
tion of evaluation of care (67.6%), discharge sheets
summary (67.6%), outpatient follow-up records (94.4%)
were inappropriate.
© 2012 Blackwell Publishing Asia Pty Ltd
358 B Ofi and O Sowunmi

Table 4 Documentation ability of nursing activities in percentages

Activity Difficult Undecided Easy

A B C A B C A B C

History taking 18.6 29.8 21.7 1.4 5.3 21.7 80 64.9 56.5
Physical examination 10 15.8 4.3 8.6 7.0 30.4 81.4 77.2 65.2
Nursing laboratory investigations 37.1 35.1 30.8 12.9 15.8 26.1 42.9 49.1 39.1
Nursing diagnosis 15.7 22.8 8.6 2.9 10.5 34.8 81.4 66.7 56.5
Nursing objectives 8.5 10.5 8.6 1.4 10.5 34.8 90 78.9 56.5
Nursing orders 5.7 14.0 — 8.6 14.0 43.5 85.7 71.9 56.5
Scientific principles 10 17.5 17.4 10 14.0 21.7 80 68.4 60.9
Evaluation 7.1 10.5 26.1 5.7 14.0 17.4 87.1 75.4 56.5
Nursing round sheet 4.2 10.5 30.4 8.6 14 17.4 87.2 75.4 52.2
Discharge summary sheet 8.6 7.0 — 8.6 15.7 17.4 82.9 77.2 82.6

Table 5 Knowledge of nurses in the three hospitals on the process of documentation in percentages

Item Agree Undecided Disagree

A B C A B C A B C

Effective documentation
-requires the use of common vocabulary 84.3 89.5 43.5 1.4 — 34.8 14.3 10.5 21.7
-requires legible writings 85.7 82.4 73.9 — 8.8 26.1 14.3 8.8 —
-is concerned with authorized abbreviations and symbols 65.7 59.6 30.4 4.3 17.5 21.7 30 22.8 47.8
-must be factual and time-sequenced organization 87.1 71.9 52.1 1.4 14.0 13 11.4 14.0 34.8
-includes errors that have occurred during care 62.9 43.6 47.8 10 33.3 26.1 27.1 22.8 26.1
-may not necessarily include a change in the client’s condition 45.7 43.6 26.0 4.3 10.5 34.7 50 45.6 39.1
-should include the measurement of client’s response to an 81.1 71.9 47.8 8.6 17.5 30.4 4.3 10.5 21.7
intervention or expected outcome
-should reflect complaints of clients or family members 97.1 77.2 43.4 — 10.5 34.8 2.8 12.3 21.7

DISCUSSION OF FINDINGS supported by findings of Davy,22 Dion,23 Adernzon24 and

Evidently, the result of the findings indicates that despite
that the nursing process has become a symbol of con-
temporary nursing as well as professional ideology, the
clinical settings that are involved in the training of stu-
dents are yet to utilize the approach as a tool for care
and documentation process. This is supported by
findings of other studies20,21 on non-utilization of
the concept. Causes of underutilization or non-
implementation of the nursing process obtained from the
study are shortage of staff, lack of stationery, inadequate
organizational support, excess workload, lack of knowl-
edge, lack of time and extensive writing. These data are
Varcoe.25 It was further noted by Varcoe25 that the cum-
bersome nature of documentation may be a very serious
problem in developing countries where both material
and personnel resources are stringent. Many nurses in
Hospital B and C have difficulties in nursing history
taking perhaps because of complexities of charting as
earlier reported.4 Inadequate history taking will diminish
the validity of data available for making effective nursing
diagnosis. This implies that incomplete information
would be documented that will affect the overall evi-
dence available to justify nursing care whenever ques-
tions are raised.

© 2012 Blackwell Publishing Asia Pty Ltd

Problems of nursing care documentation 359

Table 6 Nurses’ knowledge in the three hospitals about the significance of documentation in percentages

Item Agree Undecided Disagree

A B C A B C A B C

Effective documentation: Protects against litigation 91.4 84.2 60.9 2.8 5.3 8.7 5.7 10.5 30.4
Gives quick visual information on client’s care 95.7 91.2 95.7 — 1.8 4.3 4.2 7.0 —
Promotes professional autonomy 78.6 96.5 47.8 2.8 1.8 13 18.6 1.8 39.1
Prevents unnecessary repetition 81.4 89.4 95.7 5.7 7.0 4.3 12.9 3.5 —
Saves time 71.4 82.5 60.9 10 14.0 30.4 18.6 3.5 8.7
Provides a measurement of nursing outcomes 61.4 86 100 4.3 5.2 — 34.3 8.8 —
Promotes client’s participation in care 84.3 84 65.2 11.4 7.0 26.1 4.2 8.8 8.6
Provides data for development of standardized care plans 94.3 82.5 69.6 4.2 10.5 30.4 1.4 7.0 —
Promotes individualized care 91.4 86 69.6 5.7 5.3 30.4 2.8 8.7 —

Table 7 Responses of nurses on barriers to documentation

Item Agree Undecided Disagree

A B C A B C A B C

% n % n % n % n % n % n % n % n % n

Shortage of staff 55.7 (33) 80.7 (46) 56.5 (19) 2.8 (2) 3.5 (2) 26 (9) 41.4 (25) 15.8 (9) 17.4 (6)
Lack of time 45.7 (27) 55.7 (32) 52.2 (17) 5.7 (3) 5.3 (3) 30.4 (10) 48.5 (29) 26.3 (15) 17.4 (6)
Lack of stationery 70 (42) 78.9 (45) 39 (13) 8.6 (5) 12.3 (7) 34.8 (11) 21.4 (13) 8.7 (5) 26.1 (9)
Inadequate 60 (36) 66.6 (38) 56.5 (19) 10 (6) 14.0 (8) 26 (9) 30 (18) 19.3 (11) 17.4 (6)
organizational
support
Excess workload 67.1 (40) 73.7 (42) 56.5 (19) 14.3 (9) 8.7 (5) 34.8 (11) 18.6 (11) 17.5 (10) 8.6 (3)
Lack of knowledge 45.7 (27) 64.9 (37) 43.5 (14) 12.9 (8) 10.5 (6) 8.6 (3) 41.4 (25) 24.6 (14) 47.8 (16)
of the nursing
process
Requirement of 20 (12) 50.9 (29) 43.5 (14) 14.3 (9) 15.8 (9) 26.1 (9) 65.7 (39) 33.3 (19) 30.4 (10)
extensive
writing skills

Hospital A n = 60, Hospital B n = 57, Hospital C n = 33.

Nurses also expressed difficulty with clients’ physical
examination. This could be attributed to the fact that
nurses considered physical examination as synonymous
with clinical examination which is perceived as physicians’
responsibilities. Moreover, nursing curriculum laid less
emphasis on physical examination. Appreciable number of
nurses has difficulties in formulating nursing diagnosis,
statement of objectives, nursing orders, documenting
evaluation of nursing care and completion of nursing
round sheets. A factor that could cause deficiencies in
proper documentation of these component parts of the
nursing process is lack of knowledge which was supported
by literature.4,12,17 The findings of the study contradicts
the evidences that proper documentation emphasizes the
importance of the use of common language, authorized
abbreviation and symbols, time-sequenced organization of

© 2012 Blackwell Publishing Asia Pty Ltd

360 B Ofi and O Sowunmi

Table 8 Level of documentation in patients’ case notes—Hospital A: (n-115)

Yes No Complete Incomplete Appropriate Inappropriate

% % % %

Hospital A
Case notes with nursing process records 77.4 22.6 — — — —
History taking — — 45.2 54.8 — —
Physical examination — — 62.3 37.7 — —
Nurses’ laboratory investigation — — 44.9 55.1 — —
Ongoing assessment — — 71.4 28.5 — —
Statement of objectives — — — — 64.8 35.2
Statement of diagnosis — — — — 62.1 37.9
Statement of nursing orders — — — — 74 26
Scientific principle — — — — 58.4 41.6
Evaluation of care — — — — 32.4 67.6
Nurses round sheet — — — — 71.8 28.2
Discharge summary sheet — — — — 32.4 67.6
Outpatient follow-up — — — — 5.6 94.4
Hospital B
No nursing process records in clients’ case notes
Hospital C
No nursing process records but there were copies of uncompleted nursing care plans in patients’ case notes

facts, inclusion of errors that occurred during care and
change in clients’ conditions.3,26 These inadequacies facili-
tate breakdown in communication and inadequate records
to justify quality nursing care.
The findings support existing literature that effective
documentation protects against litigation though findings
in one hospital reflect low percentage support. This
bears relevance with the opinion of Dion23 that nursing
records provide evidence of professional ability and
competence. Records are often used as evidences before
a court of law, panel of enquiry or regulatory body. The
approach of examining documentation in law courts is
that, ‘if it is not recorded, it has not been done’. A
comparison of findings on responses of nurses and actual
documentation in the nursing process records of clients
reflects discrepancies. Most nurses claimed that nursing
process is utilized in the hospitals but only one hospital
has the records in the clients’ case notes that were
reviewed. Many aspects of the nursing process were not
well documented in the reviewed case notes. This obser-
vation could be due to shortage of manpower, lack of
organizational support, lack of stationery and motiva-
tion. Another possible contributory factor is resistant to
change. Older and experienced nurses still find it cum-
bersome to effectively utilize the nursing process
approach in caring situations. Most of the responsibility
is shifted to junior nurses thus reversing or eliminating
supervisory roles. The discrepancies observed between
responses and actual documentation obtained in clients’
case notes are supported by findings of Ehrenberg12
among nurses where data show sufficient knowledge of
documentation but clients’ records revealed inadequate
quality of nursing documentation. Computer-based
nursing documentation could relieve paper-based
systems problems associated with extensive writing.27
Standardized assessment instrument is also helpful28 but
the strategy lacks individuality, innovation and flexibility
in clients’ care.29
CONCLUSIONS
Conclusions from the study are that nurses in the three
hospitals have theoretical orientation of the nursing
process but the tool is utilized for care in only one of the
three hospitals. In the hospital where it is utilized, nursing
care was documented inadequately despite the acclaimed
usefulness of the tool for quality care. Underutilization

© 2012 Blackwell Publishing Asia Pty Ltd

Problems of nursing care documentation
and non-utilization were attributed to many barriers,
many of them also accounted for the initial resistance
experienced at the inception of the idea in clinical settings
in Nigeria. This observation has implications for nursing
education and practice because the hospitals under study
are used for training and examination of nursing students
and are also tertiary and secondary health-care facilities.
Nursing process provides guidance on how clients’
records should be written, an approach to harmonizing
the different systems nurses use for documentation thus
fostering a uniform universal standard approach for care in
diverse settings and geographical locations. Nurses need
be aware of the advantages of the nursing process typified
by enabling nurses think in a more reflective manner
about nursing care because it provides a structured way of
documentation. Reforms in nursing education and prac-
tice are impacting paradigm shift from medical technical
focus to a more nursing expertise orientation and to
combine ‘hands on clinical care’ with administrative and
secretarial nursing. The study confirms the importance of
continuing education, supervision of nursing documenta-
tion and institution of effective nursing audit in the study
setting. Nursing audit is an important component of risk
management process and quality assurance because audit-
ing of patient records reduces errors and poor standards.
There is further need for periodic seminars to update
knowledge practice, and ward managers should ensure
close supervision of nurses’ documentation skills.
ACKNOWLEDGEMENTS
We sincerely appreciate the support received from the
study participants in providing data and the staff of
the three hospitals both in the clinical and records
departments.
REFERENCES
1 Griffith B. Putting the record straight: The importance of
documentation. British Journal of Community Nursing 2004; 9:
122–125.
2 Chitty KK. Professional Nursing: Concepts and Challenges, 4th
edn. Philadelphia, Pennsylvania, USA: Saunders Elsevier,
2005.
3 DeLaune SC, Leidner PK. Fundamentals of Nursing Standards
and Practice. Albany, New York, USA: Delmar Publishers,
1998.
4 Cheevakasemsook A, Chapman Y, Francis K, Davies C. The
study of nursing documentation complexities. International
Journal of Nursing Practice 2006; 12: 366–374.
361
5 College of Nurses of Ontario (CNO). Nursing Documentation
Standards. Toronto, ON, Canada: College of Nurses of
Ontario, 2002.
6 Eggland ET, Heinemann DS. Nursing Documentation: Chart-
ing, Recording and Reporting. Philadelphia, PA, USA: Lippin-
cott, 1994.
7 Nurses Association of New Brunswick (NANB). Document-
ing Care: Standards for Registered Nurses. Fredricton, NB,
Canada: Nurses Association of New Brunswick, 2002.
8 Björvell C, Thorell-Eksrtand I, Wredling R. Development
of an audit instrument for nursing care plan in the patient
record. Quality in Health Care 2002; 9: 6–13.
9 Ehnfors M, Thorell-Ekstrand I, Ehrenberg A. Towards
basic nursing information in patients’ records. Vard i Norden
1991; 21: 12–13.
10 Moody LE, Slocunb E, Berg B, Jackson D. Electronic health
documentation in nursing: Nurses’ perception, attitudes
and preferences. Computers, Informatics, Nursing 2004; 22:
337–344.
11 Helleso R, Ruland CM. Developing a module for nursing
documentation in the electronic patient record. Journal of
Clinical Nursing 2002; 10: 799–805.
12 Ehrenberg A. Nurses perceptions concerning patients’
records. Vard i Norden 2001; 21: 9–14.
13 Törnkvist L, Gardulf A, Strender L. The opinion of nursing
documentation held by district nurses and by nurses at
primary healthcare centres. Vard i Norden 1997; 17: 18–25.
14 Jerlock M, Segeston K. Att dok umentera omvärdnaden-
vaarighteroch motstand. Sjukskötersketidningen 1994; 2:
43–48.
15 Ehnfors M. Nursing documentation practice at 153 hospital
wards in Sweden as described by nurses. Scandinavian
Journal of Caring Sciences 1993; 7: 210–217.
16 Tapp A. Inhibitors and facilitators to documentation of
nursing practice. Western Journal of Nursing Research 1990;
12: 229–240.
17 Ehrenberg A, Ehnfors M. Patients’ problems, needs and
nursing diagnosis in Swedish nursing homes records.
Nursing Diagnosis 1999; 10: 65–76.
18 Meleis AI. Theoretical Nursing: Development and Progress, 2nd
edn. New York: J.B. Lippincott Company, 1991.
19 Meleis AI. Theoretical Nursing: Development and Progress, 3rd
edn. New York: J.B. Lippincott Company, 1995.
20 O’Connel B. The clinical application of nursing process
in selected acute care setting: A professional mirage. The
Australian Journal of Advanced Nursing 1998; 15: 22–32.
21 Murphy K, Cooney A, Casey D, Connor M, Dineen B. The
Roper, Logan and Tierney (1996) Model: Perceptions and
operationalisation of the model in psychiatric nursing within
a Health Board in Ireland. Journal of Advanced Nursing 2000;
31: 1333–1341.
22 Davy M. The benefits of care plans in patient assessment and
care. Community Nurse 2001; 7: 17–19.
© 2012 Blackwell Publishing Asia Pty Ltd
362
23 Dion X. Record keeping and nurse prescribing: An area of
concern. British Journal of Community Nursing 2001; 6: 193–
198.
24 Adernzon E. Issues surrounding record keeping in district
nursing practise. British Journal of Community Nursing 2000;
5: 352–356.
25 Varcoe C. Disparagement of the nursing process: The
new dogma? Journal of Advanced Nursing 1996; 23: 120–
125.
26 Owen K. Documentation in nursing practice. Nursing Stand-
ard 2005; 19: 48–49.
© 2012 Blackwell Publishing Asia Pty Ltd
B Ofi and O Sowunmi
27 Ammenwerth E, Kutschna U, Kutscha A, Mahler C, Eich-
stadter R, Haux R. Nursing process documentation systems
in clinical routine—Pre-requisite and experiences. Interna-
tional Journal of Medical Informatics 2001; 64: 187–200.
28 Hansebo G, Kinlgren M, Ljunggren G. Review of nursing
documentation in nursing homewards-changes after inter-
vention for individualized care. Journal of Advanced Nursing
2000; 29: 1462–1473.
29 Ting-Ting L. Nursing diagnosis: Factors affecting their use
in charting standardized care plans. Journal of Clinical Nursing
2003; 14: 640–647.