DETERMINANTS OF NURSING DOCUMENTATION, ITS ASSOCIATED

FACTORS AND PERCEIVED IMPACTS AMONG NURSES IN UNIVERSITY OF

UYO TEACHING HOSPITAL, AKWA IBOM STATE

BY

ATTAI, ALICE AUGUSTINE

MATRIC NUMBER: 20002260

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF

THE DEGREE OF BACHELOR OF NURSING SCIENCE

FACULTY OF NURSING SCIENCES, LAUTECH OPEN AND DISTANCE

LEARNING CENTRE, OGBOMOSO, OYO STATE

JANUARY, 2024

i
 CERTIFICATION

This is to certify that this research project titled "DETERMINANTS OF NURSING

DOCUMENTATION, ITS ASSOCIATED FACTORS AND PERCEIVED IMPACTS

AMONG NURSES IN UNIVERSITY OF UYO TEACHING HOSPITAL, AKWA

IBOM STATE" was written by ALICE AUGUSTINE ATTAI, Matric number:

20002260, in the Department of Nursing Science LAUTECH, Open and Distance Learning

Centre, Ogbomoso, in Partial Fulfillment for the award of Bachelor in Nursing Science,

under my supervision.

................................................... .......................................
Dr (Mrs) A.O. Olajide Date
RN, RM, RPHN, Ph.D, FWAPCNM
(Project Supervisor)

............................................. ………. .............................

Dr (Mrs) A.O. Olajide Date
RN, RM, RPHN, Ph.D, FWAPCNM
(Programme Coordinator)

ii
 ABSTRACT

This study on Determinants of Nursing Documentation, its Associated Factors and Perceived
Impacts among nurses was conducted in University of Uyo Teaching Hospital. A number of
studies have been conducted on nursing documentation and many of these studies identified
deficiencies in the practice of documentation among nurses globally. For instance, a study by
Asmirajanti et al. (2019) showed that 54.7% of nursing documentation data were of poor
quality, and 71.6% were not complete. The researches increasingly confound inadequate
nursing documentation with related outcomes, while paying less or no attention to associated
factors that encourage or impede quality documentation in nursing. Thus, this study was
conducted to examine the Determinants of Nursing Documentation, its Associated Factors
and Percieved Impacts Among Nurses in UUTH, Akwa Ibom State. Three(3) research
questions and two (2) hypotheses were formulated to guide the study. A descriptive research
design was adopted for this study while the instrument used for data collection was a
structured self-administered questionnaire. Pilot Study done, showed an overall correlation
index of 0.969 of the questionnaire, which suggested that the questionnaire had good
reliability. Two hundred and twenty (220) respondents were selected for the study, using
Taro Yamane formula. A simple random sampling technique was adopted to select the
sample size that represented the entire population. Data analysis was carried out through the
use of frequencies, percentages and Chi-square statistics. Based on the analysis, it was
discovered that documentation is highly practiced among nurses in UUTH. However, paper
documentation is utilized more than electronic documentation. The factors influencing
quality nursing documentation in UUTH were discovered to include: inadequate documenting
sheets, poor user interface, unannounced system downtimes, poorly designed Electronic
Patient Records (EPR) System, inadequate information technology (IT) support, among
other things. Furthermore, the study revealed that adequate nursing documentation can
promote effective communication, ensure early detection of problems, promote complete
client care and patient safety and promote consistency/accuracy of medical records, among
other things. A significant relationship was found between determinants of nursing
documentation and level of practice of documentation among nurses in UUTH but no
significant relationship exist between socio-demographic characteristics of nurses and level
of practice of documentation among nurses in UUTH. Based on these findings, it was
concluded that there is need for continued attention and investment in documentation
processes, to support the overall well-being of patients. The study recommended, among
other things, the need for UUTH management to provide enhanced documentation
Infrastructures that can streamline the documentation processes in UUTH.

Word Count: 350 words

Keywords: Determinants, Documentation, Nursing, Nurses, Patients.

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 DEDICATION

This research study is dedicated to the Almighty God who made it possible for me to

complete this program successfully. May His Name be Praised.

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 ACKNOWLEDGEMENT

I am very grateful to the Almighty God who strengthened and endowed me with his

grace throughout the period of this work.

My special thanks goes to my project supervisor, Dr/Mrs A. Olajide, who spent her time to

direct me in the right way of writing research project and make this research work a

success. May God bless her.

I thank my Programme Coordinator, who is still Dr/Mrs A.O. Olajide for her words of

advice and encouragement.

I appreciate the dean of the faculty, Prof. F.O. Adeyemo and all my lecturers for their love

and lectures that make me what I am today.

I appreciate all my classmates for their support and also thank the Nurses in University of

Uyo Teaching Hospital, whose cooperation made this research work a success.

I really appreciate my Pastor, My Lovely Children and Daughter in-law, My grand-daughter,

My Mother and my Siblings, and other members of the family for their support and prayers

for me throughout the period of this program. God bless you all - Amen.

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 TABLE OF CONTENTS

CONTENTS PAGES

Title Page i

Certification ii

Abstract iii

Dedication iv

Acknowledgement v

Table of contents vi

CHAPTER ONE: INTRODUCTION 1

1.1 Background of the Study 3

1.2 Statement of Problem 6

1.3 Objective of the Study 6

1.3.1 General objective 6

1.4 Research Hypothesis/Questions 6

1.4.1 Research Questions 6

1.4.2 Research Hypothesis 7

1.5 Significance of the Study 7

1.6 Delimitation/ Scope of the Study 7

1.7 Operational Definition of Terms 8

CHAPTER TWO: LITERATURE REVIEW

2.1 Introduction 9

2.2 Conceptual Literature Review 9

2.2.1 Overview of Nursing Documentation 9

2.2.2 Importance of Nursing Documentation 11

2.2.3 Factors affecting Nursing Documentation 12

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2.2.4 Determinants of Nursing Documentation 13

2.2.5 Impacts of Nursing Documentation 19

2.2.6 Level of Pactice of Documentation among Nurses 21

2.3 Theoretical Framework 24

2.3.1 Appication of the Theory to the Study 26

2.4 Empirical Review 27

CHAPTER THREE: RESEARCH METHODOLOGY

3.1 Introduction 32

3.2 Research Design 32

3.3 Research Setting 32

3.4 Population of the Study 33

3.5 Sample Size Determination 33

3.6 Sampling Tec4hnique 34

3.7 Instrumentation 34

3.8 Pilot Study 34

3.9 Psychometric Properties of the Instrument 35

3.9.1 Validity of Instrument 35

3.9.2 Reliability of Instrument 36

3.10 Method of Data Collection 37

3.11 Method of Data Analysis 37

3.12 Ethical Consideration 37

CHAPTER FOUR: ANALYSIS AND PRESENTATION OF RESULTS

4.1 Answering of Research Questions 50

4.2 Test of Hypotheses 52

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CHAPTER FIVE: DISCUSSION OF FINDINGS, SUMMARY, CONCLUSION AND

RECOMMENDATIONS

5.1 Discussion of Findings 54

5.2 Summary 60

5.3 Conclusion 62

5.4 Recommendations 63

5.5 Limitation 64

5.6 Implication of the Study to Nursing Practice 64

REFERENCES 66

APPENDIX I 71

QUESTIONNAIRE 71

APPENDIX II

RELIABILITY OUTPUT 81

APPENDIX III

ETHICAL APPROVAL LETTER 82

viii
 LIST OF TABLES

Tables Title Page

4.1: Distribution of Respondents according to their Socio-demographic

Characteristics 39

4.2: Level of practice of documentation among nurses in UUTH 41

4.3: Factors Influencing Quality Nursing Documentation in UUTH 46

4.4: Perceived impacts of nursing documentation in UUTH 49

4.5: Relationship between determinants of nursing documentation and the

level of practice of documentation among nurses in University of Uyo

Teaching Hospital 52

4.6: Relationship between socio-demographic characteristics and the level

of practice of documentation among nurses in University of Uyo

Teaching Hospital 53

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 CHAPTER ONE

INTRODUCTION

1.1 Background of the Study

Nurses are the primary point of contact for patients, which means they have a great

deal of comes to documenting accurate patient care in their medical record. Nurses are also

accountable if information is incomplete and inaccurate, hence high quality standard is

required for recording of nursing documentation. Documentation is anything written or

electronically generated that describes the status of a client or the care or services given to

that client(Gizaw et al.,2018).

Nursing documentation can be viewed as the record of care, planned and or care provided

to patients. It is defined as a record of nursing care that is planned and delivered to

individual patients by qualified nurses or other caregivers under the direction of a qualified

nurse. Two studies, expressed their views regarding nursing documentation to involve a

description of nurses tasks, a method for problem solving and decision making as well as a

theoretical or philosophical model of thinking and describing the care process (Tasew et al.,

2019). Nursing documentation also refers to written or electronically generated client

information obtained through the nursing process. It is the process of preparing a complete

record of handwritten or electronic evidence regarding a patient's care(Woods,2019).

Nursing documentation is a vital component of safe, ethical and effective nursing practice

regardless of the context of practice or whether the documentation is paper based or

electronic. It is an integral part of nursing practice and professional patient care rather than

something that should be taken away from patient care, and it is not optional. Nursing

documentation must provide an accurate and honest account of what and when events

occurred, as well as identify who provided the care. In fact, it is an accurate account of what

has occurred and when it occurred. The documentation should be factual, accurate, complete,

1
current (timely), organized and compliant with standards-- Professional and Institutional

(Tasew et al., 2019).

Documentation in nursing covers a wide variety of issues, topics and systems. Such areas

of coverage include all aspects of nursing process, plan of care, admission, transfer, transport,

discharge information, client education, risk taking behaviours, incident reports, medication

administration, verbal orders, telephone orders, collaboration with other health care

professionals, date and time of any event as well as signature and designation of the record.

Globally, nursing documentation is very important in the health system (Asamani et

al,2019).

Accurate, timely, and comprehensive documentation of nursing intervention is essential

for other several reasons - It reflects on the care provided, improves patients outcomes,

increases the quality and safety of health care services, ensures practice accountability and

facilitates communication between various involved health care stakeholders to ensure

continuity of care, safety of the clients and promote individualised care. It also meets

professional and legislative standards and any treatment and education the patient still

requires. Proper documentation helps to demonstrates nursing knowledge and clinical

judgment skills. It also verifies that the patient received care according to the institution's

policy, industry standards, and state regulations(Woods, 2019).

Documentation in nursing also provides valuable data for research in nursing, which have the

potential to improve health outcomes. It may also be used for education and to help

organizations assess funding, professional education needs, and resource

management(Craven et al., 2021).

A good documentation improves credibility of the institution, and makes the nursing

profession visibe. This means that, documentation can affect the status of the health care

facilities because health care facilities are evaluated by the quality of documents they keep in

2
most cases. Poor documentation leaves the record open to questions, with no clear direction

to follow. Poor documentation has been shown to have negative impacts on the health care of

patients. Many studies identified deficiencies in the practice of documentation among nurses

globally. Assessment of nursing documentation has shown that records are incomplete, lack

continuity, and do not involve the psychosocial aspects of care. For example, a study

by Asmirajanti et al. (2019) showed that 54.7% of the nursing documentation data were of

poor quality, and 71.6% were not complete (Asmirajanti et al., 2019).

The global trend of missed, inappropriate or incomplete documentation of nursing care is

alarming and as with most developing countries such as Nigeria, struggling with inadequate

nursing staff and yet burdened with an increasing workload, the tendency for documentation

errors cannot be ignored. However, the researcher's concern is on determinants of nursing

documentation, its associated factors and perceived impacts among nurses in University of

Uyo Teaching Hospital, Akwa Ibom State.

1.2 Statement of Problem

Nurses are the front liners in providing patients care in all health care institutions

including hospitals, and they are expected to record all nursing actions in numerous

recording forms such as the nursing process forms. Documentation of nursing care is

important in providing quality and safe nursing care to patients, and also serves as the

indicator of the service quality, evidence of responsibility and accountability of nurses, and

database for research purpose or evidence-based policymaking(Palmer, Marengoni, Forjaz,

Jureviciene, Laatikainen,Mammarella, and Onder, 2018).

Despite the importance of documentation, studies assessing nursing care activities based

on documentation, have shown that the standard of nursing documentation is not

satisfactory(Vafaei et al 2018., Asmirajanti et al 2019). Many studies have identified

3
deficiencies in the practice of documentation among nurses globally. Assessment of nursing

documentation has shown that records are incomplete, lack accuracy and continuity, and do

not involve the psychosocial aspects of care. For example, a study by Asmirajanti et al.

(2019) showed that 54.7% of the nursing documentation data were of poor quality, and

71.6% were not complete (Asmirajanti et al., 2019).

Few studies that compared global standards with Iranian studies revealed that nurses in other

countries were more diligent regarding adherence to documentation principles and standards

(Vafaei et al., 2018).

A study assessing nurses' attitude towards documentation and its associated factors in

governmental hospitals of Hawassa city administration, Southern Ethiopia, indicated that

58.8% of nurses had a favorable attitude towards documentation. This finding was in line

with other studies conducted in Zambia 54%, Uganda 54%, Addis Ababa 55.7% (Hana,

2017), and Amhara region 50% (Andualem A, 2019). On the other hand, this finding is

higher than the findings from European Hospitals like Slovenia 44.4%, and Norway 46%

(Bjerkan & Olsen, 2017). This discrepancy could be related to differences in the size of the

study samples and the number of hospitals included in the studies. Moreover, this finding

was lower than the study conducted in Indonesia 83.3%, Iran 85.8%, India 98.8%, South

Africa 71.7% and Gondar 60.7% (Kebede, 2017). This discrepancy might be due to nurses'

lack of attention to nursing documentation as professional duties and responsibilities. It might

be due to the high workload since the country has a lownurse-to-patient ratio. Also, it might

be a lack of in-service training about documentation. On component-wise attitude, 49.6% of

respondents said documentation ensures continuity of care which was lower than the finding

of a study done in Nigeria 98.8% (Taiye, 2015).

High quality of nursing documentation aims to promote structured, consistent and

effective communication between caregivers, and facilitate continuity of care and patient

4
safety. A good documentation improves credibility of the institution, and makes the nursing

profession visibe. Poor nursing documentation has been shown to have negative impacts on

the health care of patients. Poor documentation causes inadequate communication between

caregivers which is associated with discontinuity of care, a factor that contributes to errors.

The consequences of discontinuity of care are linked to increased cost and length of hospital

stay, readmissions, poorer patient satisfaction, adverse events, delays in treatment and

diagnosis, inappropriate treatment and omission of care (Petersen, Marais, Abdulmalik,

Ahuja, Alem, Chisholm and Thornicroft, 2017). Documentation is the professional

responsibility of all health care practitioners, and it provides written evidence of the

practitioner’s accountability to the client, the institution, the profession and the society.

Literature has revealed that the tensions surrounding nursing documentation include the

amount of time spent in documenting, the number of errors in the records, the need for legal

accountability, the desire to make nursing work visible, and the necessity of making nursing

notes understandable to the other discipli ne(Seidu, et al., 2021).

A study conducted by Khani et al. (2018) revealed that fatigue, large number of patients,

high volume of nursing actions( workload), lack of continuous monitoring and evaluation,

lack of reward system (motivation) to staff by nursing management were important factors

affecting nursing records in hospitals. Ahn, Choi and Kim (2016) also identified that work

experience of nurses and nature of nursing shifts are other factors

that influence timely record-keeping in public hospitals.

Currently in Nigerian Teaching Hospitals, for example, Akwa Ibom State hospitals

especially Teaching Hospital Uyo, the nursing audit of patient records for quality assurance

purposes, peer review team meetings, mortality reviews and hospital management meetings

continuously led to complaints about the trend of poor record-keeping, despite the

introduction of electronic based documentation to improve record-keeping challenges.

5
Although evidence of poor documentation is still alarming (in Teaching Hospitals, eg

Uyo), there is limited information or attention on determinants of quality documentation.

Thus, the above exposition serves as yardstick in evaluating the project; Determinants of

nursing documentation, its associated factors and perceived impacts among nurses in

University of Uyo Teaching Hospital (UUTH), Akwa Ibom State.

1.3 Objective of the Study

1.3.1 General objective:

The general objective was to identify determinants of nursing documentation, its associated

factors and perceived impacts among nurses in University of Uyo Teaching Hospital, Akwa

Ibom State.

1.3.2 The Specific Objectives were to:

1. assess the level of practice of documentation among nurses in University of Uyo

Teaching Hospital.

2. assess factors influencing quality nursing documentation among nurses in

University of Uyo Teaching Hospital. .

3. identify the perceived impacts of nursing documentation among nurses in University

of Uyo Teaching Hospital.

4.

1.4 Research Hypothesis/Questions

1.4.1 Research Questions

1. What is the level of practice of documentation among nurses in University of Uyo

Teaching Hospital.

2. What are the factors influencing quality nursing documentation among nurses

in University of Uyo Teaching Hospital?

6
 3. What are the perceived impacts of nursing documentation among nurses in University

of Uyo Teaching Hospital.

1.4.2 Research Hypothesis

H1. There is no significant relationship between determinants of nursing documentation and

the level of practice of documentation among nurses in University of Uyo Teaching Hospital.

H2. There is no significant relationship between Socio-Demographic Characteristics of

Nurses and the level of practice of documentation among nurses in University of Uyo

Teaching Hospital.

1.5 Significance of the Study

This research project might provide in-depth knowledge on the importance of determinants

of nursing documentation in providing quality client care in nursing.

It might also proffer an appraisal of the factors militating against effective documentation

among Nurses in University of Uyo Teaching Hospital.

The research might provide relevant data for effective formulation and implementation of

policies to enhance realization of quality documentation, and also improve patients care and

satisfaction, add value to the status of the organisation and uplift the standard of nursing

profession.

It might provide reliable literature review for further research study.

1.6 Delimitation/ Scope of the Study

The geographic scope of this study was limited to University of Uyo Teaching Hospital.

Although the outcome of the research was generalized to all Nurses in the country, only

Nurses in the Medical, Obstetrics, Paediatrics and Surgical units of University of Uyo

7
Teaching Hospital were used for the study. The study assessed the level of practice of

documentation, factors influencing quality nursing documentation and the perceived impacts

of documentation among Nurses in University of Uyo Teaching Hospital. It also identify

ways in which the militating factors can be reduced.

1.7 Operational Definition of Terms

i. Determinant: Is a driven force that encourages Nurses in University of Uyo Teaching

Hospital, to perform their duties effectively and timely.

ii. Documentation: Is the process in which Nurses in University of Uyo Teaching

Hospital carried out recording and keeping of evidence of all actions and

interventions in each patient’s card(folder) in order to have an account of what

happened and when it happened.

iii. Nurse: Is professionally trained personnel who rendered nursing care to the patient

and also records all informations about the client's care and health status, on daily

basis, per shift duty.

iv. Nursing - Is an art or science of caring for the sick or anyone who needs medical

advice in a professional proven standards.

8
 CHAPTER TWO

LITERATURE REVIEW

2.1 Introduction

This centered on a general review of related literature on the project. However

conceptual review, theoretical and empirical review of of nursing documentation are

discussed in this chapter.

2.2 Conceptual Literature Review

Nursing documentation is described as any written or electronically generated

information about a patient status or the care or the service provided to that patient. Nursing

documentation is the record of nursing care that is planned and delivered to individual client.

Nursing documentation is varied, complex and time consuming, depends on the severity of

the patient condition. Records and reports are the essential components for implementation

and evaluation of patient care in the hospital or community. Hence, documentation is

considered as an integral part of nursing practice, and is necessary to ensure high quality of

patient care. Nursing documentation is considered a crucial phase in the nature of nursing as a

9
career with the purpose of determining the factors that help nursing process and others that

form the bases of nursing decision-making (Karkkaninen and Eriksson, 2018).

2.2.1 Overview of Nursing Documentation

The history of nursing documentation started since the early days of Nightingale. The

quality and coordination of patient care depend upon the extent and usefulness of

communication among all members of the patient's healthcare team, with the medical record

serving as the central vehicle of this interaction ((McCarthy et al.,2018).

Nursing documentation is the process of preparing a complete record of handwritten or

electronic evidence regarding a patient's care. It includes the nursing assessment (e.g., intake

and output, vital signs, head-to-toe assessment), nursing care plan (highlighting the patient's

healthcare needs and outcomes), interventions, education, and discharge planning(Woods,

2019).

It is essential that the record be clear, accurate, legible, timely, factual, documented by

the staff who performs the care, and Organized. Clear, accurate, and accessible

documentation is an essential element of safe, quality, evidence-based nursing practice.

Nurses practice across settings at different levels, from the bedside to the administrative

office. Nurses are responsible and accountable for the nursing documentation that is used

throughout an organization. This include documentation on nursing care that is provided by

nurses that can be used by other non-nurse members of the health care team or the

administrative records that are created by the nurse and used across organization settings.

Documentation of nurses’ work is critical for effective communication with each other

and with other disciplines. Nurses create a record of their services for use by the legal

system, government agencies, accrediting bodies, researchers, and other groups and

individuals directly or indirectly involved with health care. Documentation also provides a

10
basis for demonstrating and understanding nursing’s contributions both to patient care

outcomes and to the viability and effectiveness of the organizations that provide and support

quality patient care. Documentation is sometimes viewed as burdensome and even as a

distraction from patient care. High quality documentation, however, is a necessary and

integral aspect of the work of registered nurses in all roles and settings. This requires

providing nurses with sufficient time and resources to support documentation activities. At a

time when accessing, generating, and sharing information in health care is rapidly changing,

it is particularly important to articulate and reinforce principles that are basic to effective

documentation of nursing services (ANA, 2021).

Documentation can be done via:

Paper-based nursing Documentation

The paper-based nursing documentation has been in place for decades. Client's data are

recorded in paper documents. The information in these documents needs to be integrated for

sense-making in a nursing decision.

Electronic nursing documentation

Electronic nursing documentation is an electronic format of nursing documentation

increasingly used by nurses. Electronic nursing documentation systems have been

implemented in health care organizations to bring in the benefits of increasing access to more

complete, accurate and up-to-date data, and reducing redundancy, improving communication

and care service delivery. Evidence showed that electronic documentation systems were used

in the late 1980s for the first time, and this trend has gradually increased in hospita

worldwide (De Groot et al., 2019).

2.2.2 Importance of Nursing Documentation

Documentation of nursing care is important for

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 • Continuity of care across health care team members and across shifts.

• Communication between nurses and other professionals.

• Legal aspect of care in a court of law.

• Documentation is important to provide quality and safe nursing care to patients.

• Documentation also serves as the indicator of the service quality, evidence of

responsibility and accountability of nurses.

• Serves as database for research purpose or evidence-based policymaking.

• Documentation is used by insurance companies to determine reimbursement.

• The credentialing department uses documentation to make sure facilities are

practicing safe and quality patient care practices

• To monitor standards of care for quality assurance activities.

2.2.3 Factors affecting Nursing Documentation

Several factors have been reported to influence the practice of nursing documentation.

*A descriptive cross-sectional Study that investigated factors affecting documentation

practice among nurses in a hospital in Ethiopia revealed that the practice of nursing care

documentation was inadequate and factors associated with it included inadequacy of

documenting sheets and time(Andualem et al.,2019).

 In addition, Kamil et al., (2018b) asserted in a qualitative study among nurses in

Indonesia that nursing documentation remains a problem and pointed out factors

such as inadequate supervision on documentation, poor competency issues and lack

of confidence and motivation on documentation.

 Again, a cross-sectional study among nurses in Ethiopia revealed poor knowledge,

attitude and practice of documentation and pointed associated factors such as poor

staff saturation and lack of documentation guidelines (Andualem et al., 2019).

12
  In Uganda, organizational issues, inadequate knowledge on documentation, lack of

training and motivation were reported as barriers to effective nursing documentation

(Nakate et al., 2018)

 A study conducted by Khani et al. (2018) revealed that fatigue, large number of

patients, high volume of nursing actions, lack of continuous monitoring and

evaluation, lack of reward system to staff by nursing management were important

factors affecting nursing records in hospitals.

 Ahn, Choi and Kim (2016) also identified that work experience of nurses and nature

of nursing shifts are other factors that influence timely record-keeping in public

hospitals.

2.2.4 Determinants of Nursing Documentation

Determinant is a driven force that encourages anyone to perform his or her duties

effectively and timely.

Determinants of nursing documentation can be defined as tools or driven forces that

motivates nurses in carrying out quality and timely documentation for effective client care.

Determinants of nursing documentation can be grouped into four categories namely:

*Technological

*Organisational

*Social

*Individual

1.Technological

Technology plays a significant role in patient care. In today’s healthcare ecosystem,

digital health tools are becoming part of our healthcare structure, and these tools are playing

13
important roles in patient care, particularly in documentation of patient care

(Egunjobi,2023).

A study, described technological barriers as basic challenge reported by their

participants, which includes - unstable system access, deficient electronic patient records

usability, and poor user interfaces, together with scarce technical support, that did not support

their nursing practice needs. The respondents struggled to document and access sufficient

information to perform daily care(Woods, 2019). Similar findings were reported by

Priestman et al. (2018), where nurses reported that EPR does not support their nursing

practice. WHO(2016), also emphasized the increased use of technical devices in primary care

to improve patient safety. The report admitted that poorly designed EPR systems might create

more work and frustration among staff. A literature review by Gesulga et al. (2018) also

recognized barriers, such as user resistance arising from data security concerns.

Technological tools, such as EPRs aim for, but do not necessarily achieve the prevention of

human errors and the improvement of information exchange. Such tools can also create

additional human work or new ways of working. Thus, the nursing staff became dependent

on technological usability and stability to provide nursing care and secure patient

safety(Gesulga et al.2018).

Unsteady system access- is one of the main technological challenges in nursing

documentation. Nurses in a study described experiencing time-consuming log-in procedures,

lasting more than 5minutes each time and not particularly connect to the electronic patient

records(EPR) system itself but to the municipal server setup system requiring several levels

of log-on procedures. This leads to nurses, leaving the computer without logging off as

expected or asking a colleague to perform documentation on their behalf to avoid using their

time waiting for system access. This practices can lead to poor patient care outcomes

(Williams, 2019).

14
 Another challenge caused by technology is planned and/or unannounced system

downtime due to random and unforeseen internet issues, which could occur in the middle of

documentation or while using the electronic patient records (EPR) system for shifts reports.

Furthermore, respondents in a study presented EPR System as incomplete, with deficient

system usability and user interface that did not support their needs and requirements for daily

nursing and documentation routines, resulting in the use of a paper-based documentation

system as a supplement to secure documentation, information exchange and patient safety.

Deficient system usability and user interface are risk factors for adverse events. Multiple

areas may be used to document the same information within the EPR system, which makes

documentation fragmented and difficult to re-discover when needed. The electronic patient

records system may not follow the logical nursing planning structure that nurses were trained

for, which also increases the potential for adverse events. Usability and interface problems

also includes small fronts and compressed text that make information difficult to read which

is also risk for poor documentation and adverse events(Kutney-Lee et al., 2019).

Information technology support(IT) is another technological determinant of quality

nursing documentation. When there is inadequate or poor technical support in an

Organisation, such as the system being down or log-on problems which can only be

addressed during a normal working day between 8am to 4pm, with no support offered during

night shifts, weekends, or holidays, documentation suffers(McCarthy et al., 2019).

Electronic medical records are an essential part of any healthcare institution. And nurses

has to evolve to understand these systems and leverage them to help improve the quality of

care rendered to patients(Egunjobi, 2023).

In order to maintain quality nursing documentation, technology must be seen as a basic

determinant of nursing documentation in an organisation and it must have a steady system

access, complete EPR system with efficient system usability and friendly user interface,

15
proper technical support that prevent regular or unannounced system downtimes and also,

organization must organised regular in-service training for nurses on importance of

documentation and the proper use of electronic based patient records system.

2. Organizational

Healthcare organisations have unique roles to play in encouraging the development of

proper documentation culture among nurses. When organisations fails to put proper structures

and policies in place that make it easy for nurses to practice appropriate documentation

culture, patient care outcomes suffer (Egunjobi, 2023).

A study assessing factors influencing documentation practice, identified some

organizational factors that impacted positively on documentation practices such as the

availability of operational standards for nursing care, in-service training on documentation

and availability of documentation sheets. Standard operating procedures are crucial in

maintaining the operational integrity of an organization. They play a vital role in setting clear

expectations, ensuring quality and efficiency, and keeping all team members aligned towards

the common goals of the organization. In-service training helps nurses to improve and

acquire more knowledge, skills, experience, competence and attitudes that they need in order

to perform their work effectively for the achievements of their organizational goals.

Availability of documentation sheets aids timely and quality documentation and prevent

postponement and delays in documentation of patient care(Seidu et al., 2021).

The study also mentioned some hindrance factors to include lack of adequate staff, no

obligation from the facility and lack of motivation from supervisors. Poor staff saturation

causes high work-load, and with limited time, nurses viewed documentation as a burden

and distraction from focusing on patients care. No obligation from the facility and lack of

motivation encourages poor attitude towards documentation practice. Other factors identified

include lack of time and nurses’ apathy towards documentation, which also determine the

16
level of documentation practices(Seidu et al., 2021). Similar findings were reported by a

study undertaken among registered nurses and midwives in Tamale Teaching hospital Ghana,

and organisational factors that hindered nursing documentation were mentioned to include

the absence of nursing process policy, lack of further nursing process training and lack of

nursing process clinical skills (Wahab, 2017).

Organisations with poorly designed documentation policies and routines will experience poor

documentation practice(Egunjobi, 2023).

In Accra, Ghana, another cross-sectional study reported factors that influenced nurses

inability to practice nursing documentation to include inadequate practical knowledge, work-

overload and management's inability to provide the needed materials and time constraints

(Clark, 2017).

In Iran, the findings of a study showed that, working problems and lack of motivation

affected nursing records, lack of knowledge about the principles and standards of nursing

were factors increasing poor nursing documentation (Bijani et al., 2018). WHO,(2016) in its

study identified incomplete or inaccurate documentation routines and fragmented

documentation structure to be documentation errors by use of the EPR systems caused by

deficiencies in the organizational structure in a care unit, such as patient transfers,poorly

written or illegible discharge summaries.

A study assessing barriers to nursing documentation, reported inappropriate

documentation routines in which the complete and expected re-organisation of

documentation routines was simply never initiated after implementing the electronic patient

records (EPR), and this might be associated with lack of in-service training on quality

documentation and the proper use of EPR system(Williams,2019).

Health institutions must endeavour to provide documentation training regularly to improve

nurses knowledge and awareness whilst ensuring better access to documentation supplies.

17
3. Social

Patient-centred activities take priority in a typical care unit or ward over any other

activity. The mind of nurses are primed to put the patient first before any other thing, so when

there isn’t even enough time during a shift, the little time available is given to patient-centred

activities while documentation becomes a secondary activity(Egunjobi, 2023). A study found

that spending time documenting had a lower priority than other tasks and that in some units,

the nurses showed avoidance behavior toward documenting practices(Seidu et al., 2021).

Similar negative attitudes toward documentation have been reported previously, such as

in Bøgeskov and Grimshaw-Aagaard (2019) research, in which nurses in hospitals perceived

documentation as being a meaningless burden that hindered them from focusing on the

patient.

Another study assessing Patient Safety through Nursing documentation identified

that, the main social barrier associated with an increased risk of adverse events was

that documentation had lower priority compared with other tasks in the caring unit. Practical,

daily tasks and patient-oriented work had higher priority and were more accepted among the

nursing staff than spending time on the computer. During hectic shifts, nurses would rather

relieve their colleagues than update the EPR. Thus, documentation tasks were

postponed(Williams, 2019).

When patient care documentation is perceived as a secondary activity, there will definitely be

a lack of thoroughness and devotion to it, giving room for malpractice and poor

practices(Egunjobi, 2023).

Poor Care Culture by managements/Supervisors can also determine documentation

practices, thus Nurses must be encouraged, motivated and educated to understand that

documentation is integral to patient care. Without it, the care rendered is

incomplete(Egunjobi, 2023).

18
 Overall Attitude Towards Documentation: Documentation in clinical practice is the

primary mode of communication among clinical professionals. The data nurses extract from

patient care is used by other professionals to design care paths for the patient. Nurses should

understand how important documentation is to improving patient care outcomes. If they

know its importance, their overall attitude towards documentation will change, and they will

begin to implement strategies that will enable them to inculcate the documentation culture in

patient care(Egunjobi, 2023).

4. Individual

There are also individual factors that contribute to proper/malpractice in patient care

documentation. And they fall under the following categories:

*Lack of knowledge regarding correct documentation procedures and importance of nursing

documentation: Nurses knowledge of correct procedures used in nursing documentation will

determine how they approach patient care documentation.

*Ignorance of the implications of malpractices in nursing documentation: There’s a legal side

to healthcare practice. One way nurses and healthcare professionals can ensure they are not

caught in the web of litigation is to develop a culture of proper patient care documentation.

*Poor time management practice: A Nurse should be able to plan the nursing activities to be

rendered and set priorities. Patient-centred activities and documentation must take the top

priority when planning.

*Complacency: Feeling of smug or having an excessive pride in oneself or one's

achievements.

*Negligence: Breach of duty of care which result in damage.

*Procrastination: Act of delaying or putting off tasks until the last minute.

*Lack of enthusiasm towards career advancement. (Egunjobi, 2023).

19
2.2.5 Impacts of Nursing Documentation

 Nursing documentation is an attempt to present the issues that occurred in the nursing

process and the information that leads to decision-making including admission,

nursing diagnoses, interventions, and the evaluation of progress and outcome

(Karkkainen and Eriksson 2018).

 Nursing documentation based on the nursing process facilitates effective care as

patient’s needs can be traced from assessment and nurses are empowered in clinical

decision-making. Criteria for effective or quality documentation include use of

common vocabulary, legible writing, use of authorized abbreviations and symbols

((Gizaw et al., 2018).

 Quality criteria of nursing documentation includes completeness, quantity,

legibility,patient identification, chronological report of events, comprehensiveness of

description, nursing assessment, objective information, signature, date and timeliness

(Doenges, Moorhouse and Murr,2016).

 High quality of nursing documentation aims to promote structured, consistent and

effective communication between caregivers, and facilitate continuity of care and

patient safety

 Despite the importance of documentation, nursing reports are frequently incomplete

and of poor quality which compromises patient care and undermines the credibility of

the nurse (Buunaaisie et al., 2018).

 Improper charted vital signs imply wrong treatment plans and uncharted served

medication imply probable over dose of patients which may lead to poor patient

outcomes and increased health care cost(Okaisu et al., 2014;Obioma, 2018).

 Poor documentation causes inadequate communication between caregivers which is

associated with discontinuity of care, a factor that contributes to errors.

20
  The consequences of discontinuity of care are linked to increased cost and length of

hospital stay, readmissions, poorer patient satisfaction, adverse events, delays in

treatment and diagnosis, inappropriate treatment and omission of care (Petersen,

Marais, Abdulmalik, Ahuja, Alem, Chisholm and Thornicroft, 2017).

2.2.6 Level of Practice of Documentation among Nurses

Nursing documentation Practice is the daily available record of patient information

done by nurses in practical time or clinical area that is used as shreds of evidence for the care

of the patients. It can also be defined as the process of recording and keeping evidence about

the patients or client's data or information by Nurses during service provision(Yitayew et al.,

2019). Nurses play an important role in the care of patients and what they put into writing

determines the standard and quality of care rendered to patients. One of the qualities of a

healthcare service delivery system has been measured using standard documentation practice.

Hence, appropriate nursing documentation practice is crucial for legal value, decreasing

medication error, continuity of patient care, effective communication between professionals,

and evidence-based decision-making(Yitayew et al., 2019).

Proper nursing documentation practice is also crucial for providing quality health care

service to individual patients and the community in general. Hence nursing documentation

practice is the responsibility of nurse practitioners in outpatients and bedside positions or

leaders to perform clear, accurate, and standardized documentation in evidence-based

practice (Stewart et al., 2018).

According to global health perspectives, nurses should be empowered with advanced

knowledge and education to improve the healthcare delivery system toward adopting national

and global policies by spending 15–20% of their work time on documentation. Globally,

21
there is a well-accepted saying “If a procedure or work is not documented, it was not

done”(Moldskred et al.,2021).

The criteria of good documentation practice include using operational standards,

patient identification, comprehensive nursing assessment as subjective and objective data,

date, timeline, common vocabulary, legible writing, chronological event reports, using

authorized abbreviations, symbols, and signatures(Abd El Rahman et al.,2021).

Studies revealed that professionals across the globe gives less attention to documentation

practice and besides this, the records are often incomplete, lack accuracy and have poor

quality, for instance the level of documentation practice showed -- Netherlands 95%, USA

67.7%, African countries -Ghana 26% (Tamir et al., 2021). Studies in developed countries

show that over a million people get injured annually and one individual dies due to poor

documentation practice and medical errors(Krishna & khyati, 2017). Evidences in developed

countries suggested that documentation practice was limited even though there is a high

penetration rate of digital technology in the healthcare system. In England 47%, Indonesia

33.3%, and Iran 50%. The medical documentation practice has been a major challenge in

developing countries, especially in Africa, due to the low digital technology penetration rate

in the healthcare system and health information consumption to improve the health of the

people (Gurung,2022).

According to a study conducted in Ghana, 46% of patient care data and progress notes

were left undocumented after the first day of patient admission(Seidu, et al. 2021). Evidences

reported in South Africa only 42.9% of healthcare providers have good knowledge about

documentation of patient information(Petersen at al., 2018).

World Health Organization (WHO) states that 98,000 Americans die in hospitals each year as

a result of medical errors. In addition, 60% of deaths in Low and Middle-Income Countries

22
comes from willing conditions by healthcare workers as unsafe and poor-quality of

care(WHO, 2021).

A study conducted to estimate the pooled level of good documentation practice among

healthcare professionals in Ethiopia was low 50.11%, poorly practiced and left undone. In

Ethiopia, documentation practice ranges from 37.4% −56.1% in Amhara region, 51.1% in

Mettu Oromia, 47.8% in Tigray, West Gojjam 47.5%, Gondar 46.8% and 47.5% in Harari &

Dire Dawa. However, the study finding is higher than the former study conducted in Gondar,

Ethiopia 37.4% and Indonesia 33.3% (Tamir et al.,2021). This discrepancy could be due to

the difference in study participants, study period, and information communication

technology deployment in the healthcare system Recent evidences indicates up to 87%–88%

medications have been wrongly documented. Having good knowledge, favorable attitude

towards documentation, receiving training, and availability of documentation guidelines in

the organization were found to be factors affecting documentation practices (Tamir et

al.,2021).

A recent study assessing nursing documentation practice & associated factors among

nurses working at the University of Gondar comprehensive specialized hospital, Gondar,

Ethiopia, revealed that, the level of nursing documentation practice was slightly increased

compared to the previous studies and that age, working unit, good knowledge and favorable

attitude towards nursing documentation, familiarity with nursing documentation standards,

and availability of adequate time were the determinant factors towards nursing

documentation practice (Demsash,2023).

In Nigeria, as well as Akwa Ibom state, most healthcare providers have poor knowledge

of documentation and practice. This is due to some challenges like, lack of training,

resources, comprehensive nursing education, time, high nurse-to-patient ratio, and attitude

towards documentation practice. Poor documentation practice creates a great problem when it

23
comes to the evaluation of client care and it's a key factor in miscommunication among

nurses and physicians, care discontinuity, medical errors, increased length of hospital stays,

readmissions, poor patient satisfaction, adverse events, delaying treatment and diagnosis,

wrong treatment, omission of care, and increased medical costs(Petersen et al., 2018).

Poor nursing documentation can place patients, staff, as well as organizations at

considerable risk of physical and legal harm(Tasew et al., 2019).

Training of Nurses on knowledge and importance of documentation practice, increasing their

attitude, and raising availability of documentation guidelines in every healthcare organization

will increase their culture of good documentation practices among healthcare professionals.

2.3 Theoretical Framework

Nursing informatics and the VIPS --Välbefinnande, Integritet, Prevention, Säkerhet

(Well-being, Integrity, Prevention, and Security) model is the framework guiding this study.

Florence Nightingale recognized the need to collect data for the care of the individual, as well

as to collect data systematically about care for larger groups of patients and to analyze these

data statistically (Nightingale, 1860; 1863). Both types of data collection and registration are

important in order to be able to communicate information about the health status of the

patient with other nurses, physicians, hospital managers and policy makers. The clinical data

collected by Nurses support the care processes of clinicians and the aggregated data support

the decisions of hospital managers, researchers, educators and policy makers (Goossen,

2013).

Wearly & Lang (1988) proposed a Nursing Minimum Data Set (NMDS) that contains

four nursing elements: nursing diagnosis, nursing interventions, nursing outcome and nursing

intensity. During the past decade, there has been increased attention throughout the world on

the development of a uniform nursing language and classification of nursing practice. This

24
increase has been parallel to the development of scientifically based nursing by the expansion

of international communication and exchange of professional knowledge(Ehnfors et al.,

2018). The introduction of electronic patient records has further accentuated the need for

finding concepts that describe nursing practice systematically.

A number of minimum nursing data sets and classification systems have been developed

across the world:

* Nursing Minimum Data Set – NMDS.

• North American Nursing Diagnosis Association – NANDA.

• Home Health Care Classification system – HHCCS

• Nursing Intervention Lexicon and Taxonomy – NILT.

• Nursing Intervention Classification - NIC.

• Nursing sensitive outcome classification - NOC.

• International Classification of Nursing Practice – ICNP.

• International Nursing Minimum Data Set - I-NMDS and

• Nursing Minimum Data Set Netherlands – NMDSN.

In 1991, a new documentation model was developed and tested in Sweden by Ehnfors,

Thorell-Ekstrand and Ehrenberg. The model entitled VIPS, an acronym formed from the

Swedish words(Välbefinnande, Integritet, Prevention, Säkerhet) meaning - well-being,

integrity, prevention and security, all of which are seen as major goals of nursing care. This

model is designed to be used in nursing documentation following the nursing process and

therefore includes a nursing care plan. The model also includes a nursing discharge note. The

purpose of the model is to guide the RN in the sequences of assessment, problem

identification, aim, planning of interventions, implementation and evaluation of results and

thereby to make nursing documentation structured, adequate and easy to use in clinical care.

25
 In the VIPS model, 14 keywords are used for classifying patient related information

collected by the RN into categories e.g., communication, nutrition and psychosocial status.

Ten keywords classify nursing interventions into categories such as information, support and

environment. The use of keywords simplifies information retrieval; however, to retrieve the

information asked for, a consensus regarding definitions of categories must be reach. The

VIPS model provides such a lexicon in which each category, labelled by a keyword, has a

definition, a description and prototypical examples given in a manual and described with

scientific base and references. Keywords may be seen as a first step toward a unified nursing

language in patient care.

The VIPS model has been received with great interest and appreciation by RNs in

Sweden and is now the most commonly taught and used model for nursing documentation in

hospitals and primary health care.

Although this model has been accepted and recognised as a standard for what to document,

difficulties have been reported as to how to use it in daily practice (Ehrenberg & Ehnfors,

2018).

2.3.1 Appication of the Theory to the Study

Nursing informatics and the VIPS model play a crucial role in understanding and

improving nursing documentation practices. By leveraging technology, standardization, and

professional training, healthcare organizations can enhance the quality, accuracy, and

accessibility of nursing documentation. Also, by applying nursing informatics concepts and

utilizing the VIPS model as a theoretical framework, the current study can provide a

comprehensive understanding of the determinants of nursing documentation, its associated

factors and perceived impacts on healthcare, thereby contributing to improving

26
documentation practice, enhancing patient care, and supporting evidence-based decision

making in nursing practice.

2.4 Empirical Review

A number of researches have been conducted on nursing documentation. These studies

corroborate the importance of documentation in nursing/health care. For instance, Jefferies,

Johnson and Griffiths (2018) saw the purpose of documentation as being to: “provide

effective communication to the health-care team; provide for a person’s effective continuing

care, enable evaluation of a person’s progress and health outcome and retain integrity over

time". Nursing documentation is an essential function of professional nursing practice. The

documentation should be factual, current, and comprehensive to provide consistent

information about the assessment, care provided, and evaluation of patient responses to

care(Perry, Potter and Ostendorf, 2019).

To enhance patient outcomes that include patient safety, accurate and complete clinical

information is required as a valid and reliable source to be used for communication, quality

improvements, research and policymaking (Akhu‐Zaheya, Alloubani and Awwad, 2018).

Despite the importance of documentation, studies assessing nursing care activities based

on documentation have shown that the standard of nursing documentation is not

satisfactory(Vafaei et al.,2018., Asmirajanti et al.,2019). Many studies identified deficiencies

in practice of documentation among nurses globally. Assessment of nursing documentation

has shown that records are incomplete, lack accuracy and continuity, and do not involve

psychosocial aspects of care. For example, a study by Asmirajanti et al. (2019) showed that

54.7% of the nursing documentation data were of poor quality, and 71.6% were not complete

(Asmirajanti et al., 2019).

27
 On his part, Mamseri (2014) found that poor nursing documentation has been shown to

have negative impacts on the health care of patients and the impact may lead to harmful

consequences like exposing the care provider for medication administration error. Mamseri

(2015) also found that quality of patient care can also be hindered by an absence of sufficient

documentation of data; and that lack of appropriate nursing documentation causes various

problems, such as difficulty in knowing what care has been provided, lack of support when

ethical and legal problems arise (such as disciplinary action) due to lack of evidence on

sensitive issues, and difficulty in performing retrospective audits and research activities.

A study assessing barriers to nursing documentation, reported inappropriate

documentation routines in which the complete and expected re-organisation of

documentation routines was simply never initiated after implementing the electronic patient

records (EPR), and this might be associated with lack of in-service training on quality

documentation and the proper use of EPR system(Williams,2019).

A study undertaken among registered nurses and midwives in Tamale Teaching hospital

Ghana, identified an organisational factors that hindered nursing documentation to include

the absence of nursing process policy, lack of further nursing process training and lack of

nursing process clinical skills (Wahab, 2017).

Studies in Iran have also shown that the standard of nursing documentation is not

satisfactory. Few studies that compared global standards with the results in Iranian studies

revealed that nurses in other countries were more diligent regarding adherence to

documentation principles and standards (Vafaei et al., 2018).

Furthermore, studies have reported a number of factors affecting nursing documentation. In

Accra, a cross-sectional study reported factors that influenced nurses inability to practice

nursing documentation to include inadequate practical knowledge, work-overload and

management's inability to provide the needed materials and time constraints (Clark, 2017).

28
 In their study Khani et al. (2018) revealed that fatigue, large number of patients, high

volume of nursing actions (workload), lack of continuous monitoring and evaluation, lack of

reward system (motivation) to staff by nursing management are important factors affecting

nursing records in hospitals. Ahn, Choi and Kim (2016) also identified that work experience

of nurses and nature of nursing shifts are other factors that influence timely record-keeping in

public hospitals.

A descriptive cross-sectional study that investigated factors affecting documentation

practice among nurses in a hospital in Ethiopia revealed that the practice of nursing care

documentation was inadequate and factors associated with it includes inadequacy of

documenting sheets and time(Andualem et al., 2019). The study found that spending time

documenting had a lower priority than other tasks and that in some units, the staff groups

showed avoidance behavior toward documenting practices. Similar negative attitudes toward

documentation have been reported previously, such as in Bøgeskov and Grimshaw-Aagaard

(2018) research, in which nurses in hospitals perceived documentation as being a

meaningless burden that hindered them from focusing on the patient. The study also

identified that familiarity with operational standard for nursing documentation is one of the

factors affecting nursing documentation which is comparable with a finding in Netherlands

where knowledge of hospital policy regarding documentation was found to be one of the

factors determining the prevalence of nursing diagnosis documentation(Andualem et al.,

2019). Documentation is the professional responsibility of all health care practitioners, and it

provides written evidence of the practitioner’s acountability to the client, the institution, the

profession and the society. Literature has revealed that the tensions surrounding nursing

documentation include the amount of time spent in documenting, the number of errors in the

records, the need for legal accountability, the desire to make nursing work visible, and the

necessity of making nursing notes understandable to the other discipline(Seidu,et al., 2021).

29
WHO (2016) confirmed, in line with others results, “workload and time pressure” and “lack

of accuracy in the patient record” as factors that increased the risk of patient safety harm.

This is also found by other studies (Al-Jumaili and Doucette 2018).

In addition, Kamil et al., (2018b) asserted in a qualitative study among nurses in Indonesia

that nursing documentation remains a problem and pointed out factors such

as inadequate supervision on documentation, poor competency issues and lack of confidence

and motivation on documentation. Again, a cross-sectional study among nurses in Ethiopia

revealed poor knowledge, and attitude towards the practice of documentation and pointed

associated factors such as poor staff saturation and lack of documentation guidelines

(Andualem et al., 2019).

In Uganda, organizational issues, inadequate knowledge on documentation, lack of training

and motivation were reported as barriers to effective nursing documentation (Nakate et al.,

2018).

Some of the reviewed researches do not align with the fundamental assumption of the

nexus between certain determinant factors and proper/adequate documentation in nursing.

The researches increasingly confound inadequate nursing documentation with related

outcomes, while paying insufficient or no attention to associated factors that encourages or

impedes quality documentation in nursing. Where such researches linked inadequate or poor

nursing documentation with associated factors (e.g Khani et al., 2018; Ahn, Choi and Kim,

2016), it was restricted to inadequate manpower and other inadequacies on the part of

hospital management. Much more, the focus and thrust of these studies have been towards

developed countries. Little research has been done to test the determinants and efficacy of

nursing documentation in tertiary health care institutions in a developing country like

Nigeria. Overall, not much is known about the determinants of nursing documentation and it's

impact among nurses in tertiary health care facilities in Nigeria. The present study is

30
therefore an attempt at closing the identified gap in literature, as the determinants of nursing

documentation, its associated factors and perceived impacts among nurses in University of

Uyo Teaching Hospital (UUTH), serves as a problem that needs urgent attention and redress

for better practice in nursing and documentation.

31
 CHAPTER THREE

RESEARCH METHODOLOGY

3.0 Introduction

This chapter entailed how the research was designed. It focusd on the method applied in

describing and analyzing this research study and its includes the following sub-headings:

Research design, Research Setting, Population of study, Sample Size Determination,

Sampling Technique, Instrumentation, Pilot Study, Psychometric Properties of instrument--

(Validity of Instrument, and Reliability of instrument), Method of data collection, Method of

data Analysis, and Ethical Consideration.

3.1 Research Design

This research study adopted a descriptive design to described the variables in this study,

since descriptive design is mainly concerned with describing events as they are without any

manipulation being observed. It is often used for studies which aimed at collecting data and

describing in a systematic manner, the characteristic features or facts about a given

population. The design was suitable for this study since the researcher was describing nursing

documentation and it's associated practices, without the manipulation of variables involved

in the study.

3.2 Research Setting

The study was conducted at the University of Uyo Teaching Hospital. The hospital

is the only Teaching Hospital in Akwa Ibom State. The hospital is one of the largest

hospitals in Nigeria and it's located at Ediene Ikot Obio Imo along Abak Road, Uyo. The

hospital started as Akwa Ibom State Specialist Hospital, formed by Akwa Ibom State

Government in the year 1994 under the administration of Yakubu Bako. It was later renamed

32
Sani Abacha Specialist Hospital in 1997. The Federal Government of Nigeria renamed it

Federal Medical Centre, Uyo in 1999. Thus, upgraded to University of Uyo Teaching

Hospital (UUTH) in 2008. The Nurses in medical, Obstetric, Paediatric and Surgical units

of this hospital were used for the research study.

3.3 Population of the Study

The population of the study were all Nurses in University of Uyo Teaching Hospital

(UUTH). A total number of 400 nurses are in the hospital.

3.4 Sample Size Determination

This was determined through the adoption of Taro Yamane formular. The formular is as

follows:

n = N/ (1+N (e)2)

Where:

n - signifies the sample size

N - signifies the population under study

1 = Constant

e - signifies the limit of sample error = 0.05

This was computed as shown below:

n = 400/ (1+400(0.05)2)

n = 400/ (1+ 400(0.0025)

n = 400/ (1+1)

n = 400/2

n = 200

Attrition rate = 10%

33
 = 200 /100 ×10

Attrition = 20

n = 200 + 20

= 220

3.5 Sampling Technique

The study adopted a simple random sampling technique to select the sample size that

represented the entire population of the study. The techniqe was better since the entire

members of population had an equal chance to be chosen or selected.

3.6 Instrumentation

Data collection was done using a structured self-administered questionnaire. The

questionnaire had four sections - A, B, C, and D.

Section - "A" was used for the demographic data of the respondents.

Section - "B" was used to assess of level of practice of documentation among Nurses in

University of Uyo Teaching Hospital.

Section - "C" was used to assess factors Influencing quality nursing documentation among

Nurses in University of Uyo Teaching Hospital, and

Section - "D" Perceived impacts of nursing documentation among Nurses in University of

Uyo Teaching Hospital.

3.7 Pilot Study

A pilot study is the first step of the entire research protocol and is often a smaller-sized

study assisting in planning and modification of the main study. Thus, the first step of this

study was conducted in Federal Medical Centre( Uniuyo hospital), Akwa Ibom State, using

10% of the main sample size of the target population. Twenty two Nurses (22 - being the

34
10% of the main population) was used, comprising of five (5) volunteers each from

Emergency unit and Intensive care unit, and six(6) volunteers each from Orthopaedic and

Dental care unit of the hospital, which are outside the units / hospital selected for the main

study.

The reliability of the questionnaire was evaluated using Cronbach’s α coefficients for

internal consistency and Pearson’s correlation coefficient for test-retest reliability. The

reliability index for each question, each construct and overall reliability of the questionnaire

were calculated and indicated. The overall correlation coefficient of the questionnaire was

0.969, which suggested that the questionnaire had good reliability. The result of the pilot

study was sent to the project Supervisor for evaluation and approval, and after proper

checking of the reliability index for each question and construct, an approval was given to

proceed to the main study.

3.8 Psychometric Properties of the Instrument

This comprised of Validity and Reliability of Instruments.

3.8.1 Validity of Instrument

In this study, literature was reviewed in line with specific objectives. Items contained in

the questionnaire was based on the research questions. The questionnaire was sent to the

project Supervisor for face and content validation and checking of measurement

appropriateness. Corrections and suggestions was made by my project supervisor and same

effected accordingly to ensure the validity of the instrument. Approval was given by the

supervisor before administration of the instrument.

3.8.2 Reliability of Instrument

A test, re-test method was use to test the reliability of the instrument. This was done by

administration of the corrected questionnaire to Twenty two Nurses(22) in Federal Medical

35
Cenre( Uniuyo hospital), comprising of five (5) volunteers each from Emergency unit and

Intensive care unit, and six(6) volunteers each from Orthopaedic and Dental care unit of the

hospital, which are different from the units/hospital selected for this study. The same

questionnaire was given to the same nurses after two weeks, then the results was analyzed

to ascertain the instrument's reliability.

The reliability of the questionnaire was evaluated using Cronbach’s α coefficients for

internal consistency and Pearson’s correlation coefficient for test-retest reliability. The

Correlation coefficients between the two administrations of 0.7 to 0.9 were common, and

more than 0.7 can be indicated as very good reliability.

The Cronbach’s α coefficients of the total questionnaire and level of practice of nursing

documentation, factors Influencing quality nursing documentation and perceived impact of

nursing documentation, respectively were 0.822, 0.830, 0.752 and 0.700. The Cronbach’s α

coefficients were acceptable for each construct. The coefficients for the level of practice of

nursing documentation, factors Influencing quality nursing documentation and perceived

impact of nursing documentation were more significant than 0.586 (range: 0.586–1.000),

0.798 (range: 0.798–1.000) and 0.687 (range: 0.687–1.000), respectively, which indicated

that each scale of the items had higher correlation. The overall correlation coefficient of the

questionnaire was 0.969, which suggested that the questionnaire had good reliability.

The reliability index for each question, each construct and overall reliability of the

questionnaire were sent to the project Supervisor for evaluation and approval, and after

proper checking of the reliability index for each question and construct, an approval was

given to proceed to the main study.

36
3.9 Method of Data Collection

A letter of introduction and permission was collected from the co-ordinator of

LAUTECH ODL Centre and presented to the nursing services of UUTH, Uyo. After

clearance by the HOD, appointment date was fixed to meet with the respondents for

explanation of the objectives of the study, method of instrument administration and

retrieval, and also obtained informed consent. The respondents were informed about the

duration of data collection to get them ready and for proper decision making by the

respondents.

A structured, self- administered questionnaire was used for data collection and after

completion, all filled questionnaire were collected from the respective respondents and

checked to ensure that all fields are completed.

3.10 Method of Data Analysis

All computations were done using the statistical package for social sciences (SPSS). The

research questions were answered using frequency count and percentages while the Chi-

square statistics was used in testing the null hypotheses formulated for the study at 0.05 level

of significance.

3.11 Ethical Consideration

A letter of introduction and permission was collected from the co- ordinator of

LAUTECH, ODL,Centre and presented to the nursing services of UUTH, Uyo. Clearence

was obtained from the HOD nursing department of University of Uyo Teaching Hospital,

after full explanation of the purpose of this research. She then forwarded the introductory

letter to the Institutional Health Research Ethical committee of the Hospital, for further action

and approval. After explanation and presentation of the requested copies of the research

proposal to the Ethical Committee, an approval with reference number UUTH/AD/

37
S/96/VOLXXI/562, was issued to me as evidence of acceptance to carry out the research

work. All the study participants were informed about the objective of the study and their

verbal informed consent obtained.

Additionally, confidentiality and privacy of the informations were kept, and all the

respondents were treated equally. All respondents were given equal rights to withdraw at

any point if they no longer want to participate in the research work.

38
 CHAPTER FOUR

ANALYSIS AND PRESENTATION OF RESULTS

4.0 Introduction

This chapter presents results of data analyzed for the study. Results are presented in

accordance with the research questions and hypotheses that were formulated to guide the

study. Data gotten from the field can only be meaningful if it is analyzed and presented in a

way that is easy to understand, and from it, inferences can be drawn. In this study, analyses of

data were based on the outcome of questionnaires that were administered to the research

respondents.

4.1 Presentation of Data

39
Table 4.1: Distribution of Respondents according to their Socio-demographic
Characteristics (N = 220)
Characteristics Frequency Percentage
Age (in years)
21-25 10 4.54
26-30 23 10.45
31-35 62 28.18
36-40 92 41.81
41 and above 33 15
Sex
Male 3 1.36
Female 217 98.63
Marital Status
Single 46 20.90
Married 174 79.09
Widowed 0 0
Divorced 0 0
Religion
Christianity 220 100
Islam 0 0
Others 0 0
Educational Level
RN 0 0
RM 0 0
RN/RM 102 46.36
BNSc and above 118 53.63
Work Experience (in
years)
5 and less 57 25.90
6 – 10 69 31.36
11 – 15 71 32.27
16 – 20 20 9.09
21 and above 3 1.36
Working Unit (Current)
Medical Ward 100 45.45
Surgical Ward 30 13.63
Pediatrics Ward 40 18.18
Obstetrics Ward 50 22.72

Source: Field data (2023).

40
The data in Table 4.1 shows the socio-demographic characteristics of the research

respondents. Accordingly, it could be seen that majority 92(41.81%) of the the respondents

were between the ages of 36-40 years. Most, 217(98.63%), of the respondents were female.

Among these respondents, majority 174(79.09%) were married. The respondents were all

christians-220(100%). Majority (102 or 46.36%) of the respondents have RN/RM.

Furthermore, most of the respondents (71 or 32.27%) had between 11 - 15 years work

experience. Lastly, in terms of the respondents work unit, majority of the research

respondents (100 or 45.45%) worked in medical ward.

41
 Table 4.2: Level of practice of documentation among nurses in UUTH (N=220)
S/NO Items Never (%) Sometimes (%) Always (%)

1 Do you document the assessments you have 0 30 (13.63%) 190

done for every patient? (86.36%)
2 Do you document the nursing diagnosis 0 40 (18.18%) 180 (81.81)
problems you have found for every patient?
3 Do you document the intervention you have 0 20 (9.09%) 200 (90.90)
done for every patient?
4 Do you document the response to your 10 (4.54%) 30 (13.63%) 180
intervention for every patient? (81.81%)
5 Do you document the fluid you have 0 30 (13.63%) 190
administered to every patient? (86.36%)
6 Do you document the fluid balance status of the 0 40 (18.18%) 180
patient? (81.81%)
7 Do you document the medication you have 0 40 (18.18%) 180
administered to every patient? (81.81%)
8 Do you document the education or advice you 0 130 (59.09%) 90 (40.90%)
have provided to a patient?
9 0 90 (40.90% 130
Is all your documentation done immediately (59.09%)
care is provided to the patient?
10 Do you document other procedures that don’t 20 (9.09%) 90 (40.90%) 110 (50%)
require charting (Eg.Wound dressing)

11 Do you write time and date during 0 30 (13.63%) 190

documentation? (86.36%)
12 Do you read colleagues notes? 10 (4.54%) 50 (22.72%) 160
(72.72%)
13 Do you use a computerized documentation 140 70 (31.81%) 10 (4.54%)
system? (63.63%)
14 Do you document for colleagues or ask 90 110 (50%) 20 (9.09%)
colleague to document for you. (40.90%)
15 Do you make entries ahead of time? 170 20 (9.09%) 30 (13.63%)
(77.27%)
16 Do you discard original writings when torn or 160 50 (22.72%) 10 (4.54%)
dirty. (72.72%)
17 Do you report medical error in documentation 40 130 (59.09%) 50 (22.72%)
voluntarily. (18.18%)
18 Do you sign notes with names or initials? 10 (4.54%) 50 (22.72%) 160
(72.72%)
19 I typically use abbreviations and short 170 50 (22.72%) 0
hands for documentation (77.27%)

20 Is vital sign sheet attached to patient chart? 0 0 220 (100%)

21 Vital signs of the patients are completed and 0 10 (4.54%) 210

documented well. (95.45%)

42
22 0 10 (4.54%) 210
Was medication ordered? (95.45%)
23 Is the medication administration sheet attached 0 20 (9.09%) 200
to patient chart? (90.90%)

24 Accurate nursing report about medication of the 0 10 (4.54%) 210

patient is documented well. (95.45%)
25 Was fluid ordered for the patient? 0 60 (27.27%) 160
(72.72%)
26 Is IV fluid administration record form attached 0 40 (18.18%) 180
to the patient chart? (81.81%)
27 Accurate Nursing report about administered 0 50 (22.72%) 170
intravenous fluid for the patient is documented (77.27%)
well.

28 Is the fluid balance chart attached to the patient 0 20 (9.09%) 200

chart? (90.90%)
29 The fluid balance status of the patient is 0 40 (18.18%) 180
completed and documented well. (81.81%)

30 Is the nursing process format attached to the 0 40 (18.18%) 180

patient chart? (81.81%)
31 0 60 (27.27%) 160
Is nursing admission assessment completed (72.72%)
within 24 hours and attached to the patient chart?
32 Is the nursing diagnosis of a patient complete 0 40 (18.18%) 180
and documented? (81.81%)
33 Is the nursing care plan documented well and 10 (4.54%) 50 (22.72%) 160
attached to the patient chart? (72.72%)
34 Is implementation of the care plan complete and 0 40 (18.18%) 180
documented in the nursing patient progress (81.81%)
report?
35 The progress report is documented at the end of 0 20 (9.09%) 200
each shift. (90.90%)
36 Timely evaluation of the implementation of care 0 30 (13.63%) 190
is completed and documented. (86.36%)
37 Is the record legible? 0 0 220 (100%)
Overall Level of Documentation Low Level Moderate High Level
23(10.5%) Level 148(67.2%)
49(22.3%)
Source: Field data (2023).

43
The analysis of data presented in table 4.2 revealed the level of practice of documentation

among nurses in UUTH. Accordingly, there is 23(10.5%) low level of documentation,

49(22.3%) moderate level of documentation and 148(67.2%) high level of documentation

among nurses in UUTH. Overall, the level of practice of documentation among nurses in

UUTH is high, judging from the data presented in Table 4.2. However, the nursing

documentation in UUTH is more paper-based than electronic.

44
 Table 4.3: Factors Influencing Quality Nursing Documentation in UUTH (N=220)

S/NO Items Yes (%) No (%)

1 Inadequate documenting sheets. 160 (72.72%) 60 (27.27%)
2 Unstable system access. 150 (68.18%) 70 (31.81%)
3 Poor user interface. 167 (75.90) 53 (24.09%)
4 Unplanned/unannounced system downtimes. 160 (72.72%) 60 (27.27%)
5 Poorly designed or incomplete Electronic Patient Records 160 (72.72%) 60 (27.27%)
(EPR) System with deficient system usability and user
interface that does not support nursing needs and
requirements for daily documentation routines.
6 Unfamiliarity with standard of nursing documentation, 60(27.27%) 160 (72.72%)
organizational policies and h.
7 Poor knowledge, skills, legible handwriting or standardised 42 (19.09%) 178 (80.90%)
terminology regarding documentation of patient information
in my unit.
8 No obligation from the hospital. 97 (44.09%) 123 (55.90%)
9 Inadequate supervision on documentation. 72 (32.72) 148 (67.27%)
10 Inadequate nurse to patient ratio. 176 (80%) 44 (20%)
11 Inadequate information technology (IT) support. 163 (74.09%) 57 (25.90%)
12 Inadequate time/Poor time management practice. 157 (71.36%) 63 (28.63%)
13 Poor competency issues and lack of self-confidence on 61 (27.72%) 159 (72.27%)
documentation practice.
14 Poor attitudes towards documentation practice. 129 (58.63%) 91 (41.36%)
15 Lack of care plans format in my unit. 72 (32.72%) 148 (67.27%)
16 Poor staff saturation/ Increased work-load. 197 (89.54%) 23 (10.45%)
17 Poor teamwork and collaboration. 138 (62.72%) 82 (37.27%)
18 Poor planning and prioritisation of nursing care tasks, 129 (58.63%) 91 (41.36%)
patient-centered activities being top priority, and nursing
documentation being placed as low priority.
19 Fatigue due to work load. 176 (80%) 44 (20%)
20 Large number of patients/ high volume of nursing actions. 164 (74.54%) 56 (25.45%)
21 Lack of training and motivation. 139 (63.18%) 81 36.81%)
22 Lack of documentation guidelines, policies and routines. 99 (45%) 121 (55%)
23 Lack of continuous monitoring and evaluations. 128 (58.18%) 92 (41.81%)
24 Lack of reward system to staff by management 167 (75.90%) 53 (24.09%)
25 Ignorance of the implications of malpractices in nursing 82 (37.27%) 138 (62.72%)
documentation
26 Unsatisfied monthly salary 166 (75.45%) 54 (24.54%)
27 Inexperienced nurses and nature of nursing shifts 137 (62.27%) 83 (37.72%)
28 Negligence of duty among nurses 82 (37.27%) 138 (62.72%)

Source: Field data (2023).

The results presented in Table 4.3 shows that the factors influencing quality nursing

documentation among nurses in UUTH are: inadequate documenting sheets 160(72.72%),

45
unstable system access 150(68.18%), poor user interface 167(75.90%),

unplanned/unannounced system downtimes 160(72.72%), poorly designed or incomplete

Electronic Patient Records (EPR) System with deficient system usability and user interface

that does not support nursing needs and requirements for daily documentation routines

160(72.72%), inadequate nurse to patient ratio 176(80%), inadequate information

technology (IT) support 163(74.09%), inadequate time/poor time management practice

157(71.36%), poor attitudes towards documentation practice 129(58.63%), poor staff

saturation/ increased work-load 197(89.54%), poor teamwork and collaboration

138(62.72%), poor planning and prioritisation of nursing care tasks/patient-centered activities

being top priority/nursing documentation being placed as low priority 129(58.63%), fatigue

due to work load 176(80%), large number of patients/ high volume of nursing actions

164(74.54%), lack of training and motivation 139(63.18%), lack of continuous monitoring

and evaluations 128(58.18%), lack of reward system to staff by management 167(75.90%),

unsatisfied monthly salary 166(75.45%), as well as inexperienced nurses and nature of

nursing shifts 137(62.27%).

46
 Table 4.4: Percieved impacts of nursing documentation in UUTH (N=220)

S/NO Items Yes (%) No (%)

1 Promotes effective communication 217 (98.63%) 3 (1.36%)

2 Ensures early detection of problems 213 (96.81%) 7 (3.18%)

3 Promotes continuity of individualized patient care 217 (98.63%) 3 (1.36%)

4 Promotes complete client care and patient safety 219 (99.54%) 1 (0.45%)

5 Encourages knowledge sharing 218 (99.09) 2 (0.90)

6 Promotes consistency, organization and accuracy of Medical 213 (96.81%) 7 (3.18%)

records
7 Provide information for legal purposes 211 (95.90%) 9 (4.09%)

8 Provides physical evidence of services delivered or 216 (98.18%) 4 (1.81%)

interventions implemented.
9 Promotes funding. 152 (69.09%) 68 (30.90%)

10 Prevention of treatment errors. 219 (99.54%) 1 (0.45%)

11 Decreased cost and length of hospital stay/ readmissions. 212 (96.36%) 8 (3.63%)

12 Promotes client satisfaction. 219 (99.54%) 1 (0.45%)

Source: Field data (2023).

The results presented in Table 4.4 reveals that all the items were acceptable by the

respondents as perceived impacts of nursing documentation in UUTH. The results revealed

that nursing documentation promotes effective communication 217(98.63%), ensures early

detection of problems 213(96.81%), promotes continuity of individualized patient care

217(98.63%), promotes complete client care and patient safety 219 (99.54%), encourages

knowledge sharing 218(99.09%), promotes consistency, organization and accuracy of

medical records 213(96.81%), provides information for legal purposes 211(95.90%),

provides physical evidence of services delivered or interventions implemented 216(98.18%),

promotes funding 152(69.09%), pevent treatment errors 219 (99.54%), decrease cost and

47
length of hospital stay/ readmissions 212(96.36%) and promotes client satisfaction

219(99.54%).

4.1 Answering of Research Questions

Research Question One: What is the level of practice of documentation among nurses in

University of Uyo Teaching Hospital?

The analysis of data presented in table 4.2 revealed the level of practice of documentation

among nurses in UUTH. Accordingly, it indicated 23(10.5%) low level of documentation,

49(22.3%) moderate level of documentation and 148(67.2%) high level of documentation

among nurses in UUTH. Based on the data presentation in Table 4.2, it was established that

the level of practice of documentation among nurses in UUTH is high, thus answering the

research question one which sought to examine the level of practice of documentation among

nurses in UUTH. Despite the high level of nursing documentation in UUTH, the nursing

documentation is, however, more paper-based than electronic.

Research Question Two: What are the factors influencing quality nursing

documentation among nurses in University of Uyo Teaching Hospital?

The results presented in Table 4.3 shows that the factors influencing quality nursing

documentation among nurses in UUTH are: inadequate documenting sheets 160(72.72%),

unstable system access 150(68.18%), poor user interface 167(75.90%),

unplanned/unannounced system downtimes 160(72.72%), poorly designed or incomplete

Electronic Patient Records (EPR) System with deficient system usability and user interface

that does not support nursing needs and requirements for daily documentation routines

160(72.72%), inadequate nurse to patient ratio 176(80%), inadequate information

technology (IT) support 163(74.09%), inadequate time/poor time management practice

48
157(71.36%), poor attitudes towards documentation practice 129(58.63%), poor staff

saturation/ increased work-load 197(89.54%), poor teamwork and collaboration

138(62.72%), poor planning and prioritisation of nursing care tasks/patient-centered activities

being top priority/nursing documentation being placed as low priority 129(58.63%), fatigue

due to work load 176(80%), large number of patients/ high volume of nursing actions

164(74.54%), lack of training and motivation 139(63.18%), lack of continuous monitoring

and evaluations 128(58.18%), lack of reward system to staff by management 167(75.90%),

unsatisfied monthly salary 166(75.45%), as well as inexperienced nurses and nature of

nursing shifts 137(62.27%). This has answered research question two which sought to find

out the factors that influence quality nursing documentation among nurses in UUTH.

Research Question Three: What are the perceived impacts of nursing documentation

among nurses in University of Uyo Teaching Hospital?

The analysis of data presented in Table 4.4 reveals that nursing documentation promotes

effective communication 217(98.63%), ensures early detection of problems 213(96.81%),

promotes continuity of individualized patient care 217(98.63%), promotes complete client

care and patient safety 219 (99.54%), encourages knowledge sharing 218(99.09%), promotes

consistency, organization and accuracy of medical records 213(96.81%), provides

information for legal purposes 211(95.90%), provides physical evidence of services

delivered or interventions implemented 216(98.18%), promotes funding 152(69.09%), pevent

treatment errors 219 (99.54%), decrease cost and length of hospital stay/ readmissions

212(96.36%) and promotes client satisfaction 219(99.54%). This has answered the research

question three which sought to discover the percieved Impacts of nursing documentation

among nurses in UUTH.

49
4.2 Test of Hypotheses

Hypothesis One: There is no significant relationship between determinants of nursing

documentation and the level of practice of documentation among nurses in University of

Uyo Teaching Hospital.

Table 4.5: Chi-square analysis of Relationship between determinants of nursing

documentation and the level of practice of documentation among nurses in
University of Uyo Teaching Hospital N = 220, p<0.05
2
Level of Practice of Total X Df P- Remark
Documentation value
Determinants Low Moderate High
of Nursing
Documentation
Technological 8 19 51 78 1 0.41 Significant
Organizational 9 16 49 74 1 0.18 Significant
Individual/Social 6 14 48 68 1 0.09 Significant
Total 23 49 148 220 29.1
Source: Field data (2023).

Table 4.5 reveals that the P-values for all items exceed 0.05. Therefore, the null

hypothesis one, which states that there is no significant relationship between determinants of

nursing documentation and the level of practice of documentation among nurses in University

of Uyo Teaching Hospital is rejected. This result means that there is significant relationship

between determinants of nursing documentation and the level of practice of documentation

among nurses in University of Uyo Teaching Hospital.

50
Hypothesis Two: There is no significant relationship between Socio-Demographic
Characteristics of Nurses and the level of practice of documentation among nurses in
University of Uyo Teaching Hospital.

Table 4.6: Chi-square analysis of relationship between socio-demographic

characteristics and the level of practice of documentation among nurses in University of
Uyo Teaching Hospital N = 220, p<0.05
Level of Practice of Total X2 Df P-value Remark
Documentation
Socio- Low Moderate High
Demographic
Characteristic
s
Age 6 9 46 61 1 0.02 Not
Significant
Sex 4 12 31 47 1 0.04 Not
0.04 Significant
Marital status 6 11 26 43 1 0.02 Not
Significant
Educational 2 7 22 31 1 0.01 Not
level Significant
Work 5 10 23 38 1 0.03 Not
Experience Significant
Total 23 49 148 220
Source: Field data (2023).

Table 4.6 reveales that the significant value for all the items are below 0.05.

Therefore, the null hypothesis two which states that there is no significant relationship

between socio-demographic characteristics of nurses and the level of practice of

documentation among nurses in University of Uyo Teaching Hospital is accepted. Thus, the

result show that there is no significant relationship between socio-demographic

characteristics of nurses and the level of practice of documentation among nurses in

University of Uyo Teaching Hospital.

51
 CHAPTER FIVE

DISCUSSION OF FINDINGS, SUMMARY, CONCLUSION AND

RECOMMENDATIONS

This chapter gives details of the research findings, conclusion and recommendations of what

have been discussed right from the beginning of this research.

5.1 Discussion of Findings

The discussion of the major findings of this study is as follows:

The data in Table 4.1 shows the socio-demographic characteristics of the research

respondents. Accordingly, it could be seen that majority 92(41.81%) of the the respondents

were between the ages of 36-40 years. Most, 217(98.63%), of the respondents were female.

Among these respondents, majority 174(79.09%) were married. The respondents were all

christians-220(100%). Majority (102 or 46.36%) of the respondents have RN/RM.

Furthermore, most of the respondents (71 or 32.27%) had between 11 - 15 years work

experience. In terms of the respondents work unit, majority of the research respondents (100

or 45.45%) worked in medical ward. This is in line with a recent study conducted by Demsash

(2023) which believed that that age and working Unit can be among the determinant factors

towards nursing documentation practice.

The results presented in Table 4.2 reveals that all items which were listed on the research

instrument to assess the level of practice of documentation among nurses in UUTH were

positively rated-148(67.2%). Based on the ratings, it was established that documentation is

highly practiced among nurses in the University of Uyo Teaching Hospital. A closer look at

the views of the respondents to the respective items revealed that the majority of the

respondents document the assessments they have done for every patient; document the

nursing diagnosis problems they have found for every patient, document the intervention they

52
have done for every patient, document the response to their intervention for every patient,

document the fluid they have administered to every patient and also document the fluid

balance status of thei patient, among other things.

The above findings of the study is in disagreement with the findings of Tamir et al. (2021).

Tamir et al., in an earlier study conducted in Netherlands, USA and Ghana in 2021,which

revealed that professionals across the globe give less attention to documentation practice and

besides this, the records are often incomplete, lack accuracy and have poor quality. The study

went further to demonstrate that the level of documentation practice showed 95% in

Netherlands, 67.7% in USA, 26% in African countries (Using Ghana as the basis for

generalization) (Tamir et al., 2021). However, the current study in the University of Uyo

Teaching Hospital, Nigeria has brought to fore the fact that nursing documentation is highly

practiced in the UUTH. This is in line with the recent study of Demsash (2023), who, in

assessing nursing documentation practice and associated factors among nurses working at the

University of Gondar comprehensive specialized hospital, Gondar, Ethiopia, revealed that,

the level of nursing documentation practice was slightly increased compared to the previous

studies and that age, working unit, good knowledge and favorable attitude towards nursing

documentation, familiarity with nursing documentation standards, and availability of

adequate time were the determinant factors towards nursing documentation practice

(Demsash, 2023).

In addition to these, the finding that nursing documentation in University of Uyo Teaching

Hospital is more of paper-based than electronic is closely associated with that of Gurung

(2022), who found that medical documentation practice has been a major challenge in

developing countries, especially in Africa, due to the low digital technology penetration rate

in Africa's healthcare system and low use of health information consumption to improve the

health of the people (Gurung, 2022).

53
 From the analysis of results presented in Table 4.3, it was discovered that the factors

influencing quality nursing documentation among nurses in University of Uyo Teaching

Hospital include: inadequate documenting sheets, unstable system access, poor user interface,

unplanned/unannounced system downtimes, poorly designed or incomplete Electronic Patient

Records (EPR) System with deficient system usability and user interface that does not support

nursing needs and requirements for daily documentation routines, inadequate nurse to patient

ratio, inadequate information technology (IT) support, inadequate time/poor time

management practice, poor attitudes towards documentation practice, poor staff saturation/

increased work-load, poor teamwork and collaboration, poor planning and prioritisation of

nursing care tasks, patient-centered activities being top priority/nursing documentation being

placed as low priority, fatigue due to work load, large number of patients/ high volume of

nursing actions, lack of training and motivation, lack of continuous monitoring and

evaluations, lack of reward system to staff by management, unsatisfied monthly salary, as

well as inexperienced nurses and nature of nursing shifts.

The findings above agree with the findings of Andualem et al. (2019), Kamil et al. (2018b),

Nakate et al. (2018), Khani et al. (2018) and Ahn et al. (2016). In a descriptive cross-sectional

study that investigated factors affecting documentation practice among nurses in a hospital in

Ethiopia, Andualem et al. (2019) revealed that the practice of nursing care documentation was

inadequate and factors associated with it included inadequacy of documenting sheets and

time. Again, Andualem et al. (2019) revealed poor knowledge, attitude and practice of

documentation among the nurses in Ethiopia and pointed associated factors such as poor staff

saturation and lack of documentation guidelines. Similarly, Kamil et al. (2018b) asserted in a

qualitative study among nurses in Indonesia that nursing documentation remains a problem

and pointed out factors such as inadequate supervision on documentation, poor competency

issues and lack of confidence and motivation on documentation. In Uganda, organizational

54
issues, inadequate knowledge on documentation, lack of training and motivation were

reported as barriers to effective nursing documentation by Nakate et al. (2018). A study

conducted by Khani et al. (2018) also revealed that fatigue, large number of patients, high

volume of nursing actions, lack of continuous monitoring and evaluation, lack of reward

system to staff by nursing management were important factors affecting nursing records in

hospitals.

Results from the analysis also showed that inexperienced nurses and nature of nursing shifts

affect quality nursing documentation in UUTH. This finding is consistent with that of Ahn et

al. (2016) who equally identified that work experience of nurses and nature of nursing shifts

are other factors that influence timely record-keeping in public hospitals.

The analysis of results in Table 4.4 shows the opinions of respondents on the perceived

impacts of nursing documentation among nurses in University of Uyo Teaching Hospital.

They were of the view that adequate nursing documentation can promote effective

communication, ensure early detection of problems, promote continuity of individualized

patient care, promote complete client care and patient safety, encourage knowledge sharing,

promote consistency, organization and accuracy of medical records, provide information for

legal purposes, provide physical evidence of services delivered or interventions implemented,

promotes funding, prevent treatment errors, decrease cost and length of hospital

stay/readmission and promote client satisfaction.

The results agree with the views and of Karkkainen and Eriksson (2018), Gizaw et al.

(2018) and Buunaaisie et al. (2018). Karkkainen and Eriksson 2018) opined that nursing

documentation is associated with decision-making including admission, nursing diagnoses,

interventions, and the evaluation of progress and outcome, while Gizaw et al. (2018) were of

the opinion that nursing documentation facilitates effective care, as patient’s needs can be

traced from assessment and nurses are empowered in clinical decision-making. Also, in line

55
with the findings of this study, Buunaaisie et al. (2018) pointed out that incomplete and poor

quality of nursing documentation compromises patient care and undermines the credibility of

the nurse. Adequate nursing documentation is therefore discovered to have positive impacts

on medical care.

Table 4.5 revealed that the significance values for all items exceeded 0.05. . This result

meant that there is significant relationship between determinants of nursing documentation

and the level of practice of documentation among nurses in University of Uyo Teaching

Hospital. Therefore, the null hypothesis one, which stated that there is no significant

relationship between determinants of nursing documentation and the level of practice of

documentation among nurses in University of Uyo Teaching Hospital was rejected.

In testing the relationship between determinants of nursing documentation and the level

of practice of documentation among nurses in University of Uyo Teaching Hospital, the

determinants of nursing documentation were grouped into three broad categories namely:

Technological - including unstable system access, poor user interface,

unplanned/unannounced system downtimes, poorly designed or incomplete Electronic Patient

Records (EPR) System with deficient system usability and user interface that does not

support nursing needs and requirements for daily documentation routines and inadequate

information technology (IT) support. This is similar to the findings of Woods (2019). In

Woods (2019) study, respondents described the following technological barriers as basic

challenge to nursing documentation - unstable system access, deficient electronic patient

records usability, and poor user interfaces, together with scarce technical support, that did not

support their nursing practice needs. The respondents struggled to document and access

sufficient information to perform daily care (Woods, 2019). Similar findings were reported

by Priestman et al. (2018), where nurses reported that EPR does not support their nursing

practice. WHO (2016), also emphasized the increased use of technical devices in primary

56
care to improve patient safety. The report admitted that poorly designed EPR systems might

create more work and frustration among staff. Usability and interface problems also includes

small fronts and compressed text that make information difficult to read which is also risk for

poor documentation and adverse events (Kutney-Lee et al., 2019)

Organizational - including inadequate documenting sheets, inadequate nurse to patient ratio,

poor staff saturation/ increased work-load, fatigue due to work load, large number of

patients/ high volume of nursing actions, lack of training and motivation, lack of continuous

monitoring and evaluations, lack of reward system to staff by management, unsatisfied

monthly salary and inexperienced nurses and nature of nursing shifts. This particular finding

is closely associated with the findings of Seidu et al. (2021). In a study assessing the factors

influencing documentation practice, Seidu et al. (2021) identified some organizational factors

that impacted positively on documentation practices such as the availability of operational

standards for nursing care, in-service training on documentation and availability of

documentation sheets. Availability of documentation sheets aids timely and quality

documentation and prevent postponement and delays in documentation of patient care (Seidu

et al., 2021). The study by Seidu et al. (2021) also mentioned some hindrance factors to

include lack of adequate staff, no obligation from the facility and lack of motivation from

supervisors. Poor staff saturation were also discovered to cause high work-load, and with

limited time, nurses viewed documentation as a burden and distraction from focusing on

patients care. No obligation from the facility and lack of motivation also encouraged poor

attitude towards documentation practice. Other factors identified included lack of time and

nurses’ apathy towards documentation, which also determine/impact the level of

documentation practices (Seidu et al., 2021).

57
Individual/Social - including inadequate time/poor time management practice, poor attitudes

towards documentation practice, poor teamwork and collaboration, poor planning and

prioritisation of nursing care tasks and patient-centered activities being top priority/nursing

documentation being placed as low priority. This finding supports the view of Egunjobi

(2023) who opined that there are also individual factors that contribute to proper/malpractice

in patient care documentation, and they fall under the following categories: lack of

knowledge regarding correct documentation procedures and importance of nursing

documentation; ignorance of the implications of malpractices in nursing documentation; poor

time management practice; complacency; negligence of duty; procrastination and lack of

enthusiasm towards career advancement.

Lastly, Table 4.6 revealed that the significant value for all the items were below 0.05.

This result showed that there is no significant relationship between socio-demographic

characteristics of nurses and the level of practice of documentation among nurses in

University of Uyo Teaching Hospital. Therefore, the null hypothesis two, which stated that

there is no significant relationship between socio-demographic characteristics of nurses and

the level of practice of documentation among nurses in University of Uyo Teaching Hospital

was accepted. This result is not too surprising because, if given the wrong/inappropriate work

environment as well as wrong tools and technology, then socio-demographic factors such as

educational level and years of experience can not sufficiently influence adequate

documentation practice.

5.2 Summary

This study examined the determinants of nursing documentation, it's associated factors and

percieved impacts among nurses in University of Uyo Teaching Hospital, Akwa Ibom State.

Three (3) research questions and two (2) hypotheses were formulated to guide the study. The

58
descriptive research design was adopted for the study, and the instrument used for data

collection was a structured self-administered questionnaire. The research questions were

answered using frequency count and percentages while the t-test statistics was used in testing

the null hypotheses formulated for the study at 0.05 level of significance.

The major findings reported in this study indicate:

i. That documentation is highly practiced among nurses in the University of Uyo

Teaching Hospital and that the paper-based documentation is used by nurses in

UUTH more than electronic documentation.

ii. That the factors influencing quality nursing documentation among nurses in UUTH

include: inadequate documenting sheets, unstable system access, poor user interface,

unplanned/unannounced system downtimes, poorly designed or incomplete Electronic

Patient Records (EPR) System with deficient system usability and user interface that

does not support nursing needs and requirements for daily documentation routines,

inadequate nurse to patient ratio, inadequate information technology (IT) support,

inadequate time/poor time management practice, poor attitudes towards

documentation practice, poor staff saturation/ increased work-load, poor teamwork

and collaboration, poor planning and prioritisation of nursing care tasks, patient-

centered activities being top priority/nursing documentation being placed as low

priority, fatigue due to work load, large number of patients/ high volume of nursing

actions, lack of training and motivation, lack of continuous monitoring and

evaluations, lack of reward system to staff by management, unsatisfied monthly

salary, as well as inexperienced nurses and nature of nursing shifts.

iii. That adequate nursing documentation can promote effective communication, ensure

early detection of problems, promote continuity of individualized patient care,

promote complete client care and patient safety, encourage knowledge sharing,

59
 promote consistency, organization and accuracy of medical records, provide

information for legal purposes, provide physical evidence of services delivered or

interventions implemented, promotes funding, prevent treatment errors, decrease cost

and length of hospital stay/readmission and promote client satisfaction.

iv. That there is a significant relationship between determinants of nursing

documentation and the level of practice of documentation among nurses in University

of Uyo Teaching Hospital; and that there is no significant relationship between socio-

demographic characteristics of nurses and the level of practice of documentation

among nurses in University of Uyo Teaching Hospital.

5.3 Conclusion

The study on the determinants of nursing documentation, it's associated factors and

percieved impacts among nurses in University of Uyo Teaching Hospital has provided

valuable insights into the critical role that documentation plays in healthcare. The findings of

the study highlight several key points: including the fact that Nursing Documentation serves

as a crucial communication tool among healthcare providers, ensuring that important patient

information is accurately conveyed and shared. Thus, accurate and comprehensive Nursing

Documentation can significantly enhance patient safety and quality of care by providing a

clear record of the patient's condition, treatment, and progress.

The study also underscores the importance of standardized documentation practices and the

use of electronic health records to improve efficiency and accessibility of patient information.

Furthermore, the research emphasizes the need for continued education and training of

nursing professionals to ensure proficiency in documentation practices, which ultimately

contribute to better patient outcomes.

In conclusion, the study reinforces the pivotal role of Nursing Documentation in shaping the

delivery of high-quality patient care. Its findings underscore the need for continued attention

60
and investment in optimizing documentation processes to support the overall well-being of

patients.

5.4 Recommendations

Based on the outcome of this study on determinants of nursing documentation, it's

associated factors and percieved impacts among nurses in University of Uyo Teaching

Hospital, the following policy recommendations are made:

1. Enhanced Documentation Infrastructure: There is need for the management of UUTH

to:

*Address the problem of inadequate documenting sheets by ensuring that there are enough

forms and templates available for nurses to use.

*Improve system stability and access by investing in robust IT infrastructure and network

support.

*Upgrade the Electronic Patient Records (EPR) System to ensure it is comprehensive, user-

friendly, and supports nursing needs for daily documentation routines.

2. Increased Nurse Support: UUTH management must:

*Address the inadequate nurse to patient ratio by considering hiring additional nursing staff to

help distribute the workload.

*Provide adequate IT support to assist nurses in navigating and using the electronic systems

effectively.

3. Training and Support: management must:

*Offer training and motivation programs for staff to improve their documentation practices

and attitudes towards it.

*Implement continuous monitoring and evaluations to identify areas for improvement and

provide necessary support.

61
 4. Improved Work Environment and Culture: UUTH management should endeavour

to:

*Foster a culture of teamwork and collaboration to help nurses prioritize and plan nursing care

tasks effectively.

*Recognize and address issues related to poor attitudes towards documentation practice and

poor time management.

5. Patient-Centered Care and Staff Well-being: It is important for the management of

UUTH to:

*Implement strategies to prevent fatigue due to workload, such as ensuring adequate breaks

and managing staff saturation.

*Consider patient-centered activities and nursing documentation as equally important, and

communicate this to the staff.

6. Recognition and Incentives:

*Introduce a reward system to recognize and appreciate staff for their efforts in maintaining

accurate and timely documentation.

7. Continuous Improvement:

*Establish a system for continuous feedback and improvement, where staff can provide input

on the challenges they face and contribute to finding solutions.

*By implementing these policy recommendations, the University of Uyo Teaching Hospital

can improve the quality and reliability of nursing documentation, leading to better patient

care, enhanced communication among healthcare professionals, and improved outcomes in

the hospital.

62
5.5 Limitation

The limitations include - Reluctance of the Nurses to accept and complete the

questionnaire due to pressure from work load.

The possibility that some respondents might not have been very honest with their responses

may serve as a limitation to the generalizability of the results of this study.

However, the researcher believes that, the given responses were a true representation of the

respondents’ opinions on the subject matter, and that the numbers of questionnaire responses

given was considered adequate for meaningful generalization of the results.

5.6 Implication of the Study to Nursing

5.6.1 Implication of the Study to Nursing Practice

This study has the following significant implications for Nursing Practice:

i. Standardization of documentation practices: The study has identified the need for

standardized documentation practices in nursing to ensure consistency, accuracy, and

completeness of patient records. This could lead to the development of best practices

and guidelines for nurses to follow.

ii. Improved patient care: Understanding the impacts of nursing documentation can

lead to the development of strategies to improve patient care through better

documentation. Accurate and comprehensive documentation can support continuity of

care, care coordination, and better-informed decision-making by healthcare .

iii. Enhanced communication: Effective nursing documentation can improve

communication among healthcare team members, leading to better collaboration and

coordination of care. Thus, the study's findings has highlighted the importance of

clear, concise, and timely documentation for effective inter-professional

communication.

63
 iv. Quality improvement: Insights from the study can contribute to quality improvement

initiatives within nursing practice by identifying how documentation impacts the

quality of care delivery. This could lead to efforts to enhance the accuracy, timeliness,

and relevance of nursing documentation.

Overall, the implications of the study for nursing practice is that it can lead to

improvements in documentation processes, patient care, communication, compliance,

and quality care within healthcare settings, ultimately benefiting both healthcare

providers and the patients they serve.

5.6.2 Implication to Nursing Education

i. Education and training: The findings of this study is capable of informing nursing

education and training programs, thereby helping to emphasize the importance of thorough

and accurate documentation practices among nursing students and professionals.

Understanding the implications of nursing documentation can help in identifying and

mitigating risks associated with incomplete or inaccurate documentation, which can impact

patient safety and legal liabilities.

5.6.3 Implication of the Study to Nursing Research

The data obtained from this study can be used by nurses as a reliable source of

information/ data for further research study on nursing documentation.

The result of the study can be published in nursing journals and the researcher can be

cited as Attai,(2024).

64
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 APPENDIX I

QUESTIONNAIRE

Instructions:

Answer all questions as honest as possible. Mark your answer in the space provided.

Your co-operation in filling out this questionnaire would be greatly appreciated.

Please do not write your name on the questionnaire. Your confidentiality is assured.

SECTION A

Socio-Demographic Characteristics of Nurses in UUTH, Uyo

1. Age group (in years)21–25□ 26–30□ 31–35□ 35 -- 40□ 41 and Above□

2. Sex: Male□, Female □ Obstetric

3. Marital Staus: Single □ Married □ Widowed□ Divorced □

4. Religion: Christian □ Muslim □ Others.....................................

5. Educational Level: RN□ RM□ RN/RM□, BNSc and above□

6. Work experience (in years): 5 and less□ 6–10□, 11 -- 15□, 16 -- 2O□ 21and above □

8. Working unit (current)Medical ward□ Surgical ward□ Pediatrics ward□ and Wards.□

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 SECTION B
Questions on level of practice of documentation among nurses

S/NO QUESTIONS NEVER SOMETIME ALWAYS

S
Do you document the assessments you have done
for every patient?
Do you document the nursing diagnosis problems
you have found for every patient?
Do you document the intervention you have done
for every patient?

Do you document the response to your

intervention for every patient?
Do you document the fluid you have administered
to every patient?
Do you document the fluid balance status of the
patient?
Do you document the medication you have
administered to every patient?
Do you document the education or advice you
have provided to a patient?

Is all your documentation done immediately

care is provided to the patient?

Do you document other procedures that don’t

require charting (Eg.Wound dressing)?
Do you write time and date during
documentation?
Do you read colleagues notes?
Do you uses a computerized documentation
system
Do you document for colleagues or ask colleague
to document for you.
Do you make entries ahead of time?
Do you discards original writings when torn or
dirty.
Do you reports medical error in documentation
voluntarily.
Do you sign notes with names or initials?
I typically use abbreviations and short
hands for documentation

Chart Review on Documentation Practice

among nurses

71
Is vital sign sheet attached to patient chart?

Vital signs of the patients are completed and

documented well.

Was medication ordered?

Is the medication administration sheet attached to
patient chart?

Accurate nursing report about medication of the

patient is documented well.
Was fluid ordered for the patient?
Is IV fluid administration record form attached to
the patient chart?
Accurate Nursing report about administered
intravenous fluid for the patient is documented
well.

Is the fluid balance chart attached to the patient

chart?
The fluid balance status of the patient is
completed and documented well.

Is the nursing process format attached to the

patient chart?

Is nursing admission assessment completed

within 24 hours and attached to the patient chart?
Is the nursing diagnosis of a patient complete and
documented?
Is the nursing care plan documented well and
attached to the patient chart?
Is implementation of the care plan complete and
documented in the nursing patient progress
report?
The progress report is documented at the end of
each shift.
Timely evaluation of the implementation of care
is completed and documented.
Is the record legible?

SECTION C
Factors Influencing Quality Nursing Documentation

72
S/NO QUESTIONS Yes No
What are the factors influencing quality nursing
documentation practice in UUTH?
Inadequate documenting sheets.
Unstable system access.
Poor user interface.
Planned/unannounced system downtimes.
Poorly designed or incomplete Electronic Patient Records
(EPR) System with deficient system usability and user
interface that does not support nursing needs and requirements
for daily documentation routines.
Unfamiliarity with standard of nursing documentation,
organizational policies and routines.
Poor knowledge, skills, legible handwriting or standardised
terminology regarding documentation of patient information in
my unit.
No obligation from the hospital.
Inadequate supervision on documentation.
Inadequate nurse to patient ratio.
Inadequate information technology (IT) support.
Inadequate time/Poor time management practice.
Poor competency issues and lack of self-confidence on
documentation practice.
Poor attitudes towards documentation practice.
Lack of care plans format in my unit.
Poor staff saturation/ Increased work-load.
Poor teamwork and collaboration.
Poor planning and prioritisation of nursing care tasks, patient-
centered activities being top priority, and nursing
documentation being placed as low priority.
Fatigue due to work load.
Large number of patients/ high volume of nursing actions.
Lack of training and motivation.
Lack of documentation guidelines, policies and routines.
Lack of continuous monitoring and evaluations.
Lack of reward system to staff by managemen
Ignorance of the implications of malpractices in nursing
documentation
Unsatisfied monthly salary
Inexperienced nurses and nature of nursing shifts
Negligence of duty among nurses

Others, please specify……………………………………….

SECTION D
Perceived Impacts of Nursing documentation

73
S/NO QUESTIONS Yes No
What are the perceived impacts of documentation in
nursing practice?

Promotes effective communication

Ensures early detection of problems

Promotes continuity of individualized patient care

Promotes complete client care and patient safety
Encourages knowledge sharing
Promotes consistency, organization and accuracy of Medical
record
Provide information for legal purposes
Provides physical evidence of services delivered or
interventions implemented.
Promotes funding.
Prevention of treatment errors.
Decreased cost and length of hospital stay/ readmissions.
Promotes client satisfaction.

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 APPENDIX II

RELIABILITY INDEX

Table 1: Showing the Reliability Coefficient of the questionnaire on Nursing

Documentation

Part A: Result on Level of Practice of Documentation among nurses

S/No Items Correlation Coefficient
1 Do you document the assessments you have done for every patient? 0.914
2 Do you document the nursing diagnosis problems you have found 1.000
for every patient?
3 Do you document the intervention you have done for every patient? 0.741
4 Do you document the response to your intervention for every 0.874
patient?
5 Do you document the fluid you have administered to every patient? 0.815
6 Do you document the fluid balance status of the patient? 0.703
7 Do you document the medication you have administered to every 1.000
patient?
8 Do you document the education or advice you have provided to a
patient? 0.987
9 0.731
Is all your documentation done immediately care is provided to the
patient?
10 Do you documents other procedures that don’t require charting 0.734
(Eg.Wound dressing).

11 Do you write time and date during documentation? 0.786

12 Do you read colleagues notes? 0.916
13 Do you use a computerized documentation system? 0.936
14 Do you document for colleagues or ask colleague to document for 0.804
you.
15 Do you make entries ahead of time? 0.706
16 Do you discard original writings when torn or dirty. 0.765
17 Do you report medical error in documentation voluntarily. 0.880
18 Do you sign notes with names or initials 0.802
19 I typically use abbreviations and short 0.901
hands for documentation

Chart Review on Documentation Practice among nurses

20 Is vital sign sheet attached to patient chart? 0.781

21 Vital signs of the patients are completed and documented well. 0.810

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22 Was medication ordered? 0.889

23 Is the medication administration sheet attached to patient chart? 0.798

24 Accurate nursing report about medication of the patient is 0.876

documented well.
25 Was fluid ordered for the patient? 0.879
26 Is IV fluid administration record form attached to the patient chart? 0.905
27 Accurate Nursing report about administered intravenous fluid for the 1.000
patient is documented well.

28 Is the fluid balance chart attached to the patient chart? 0.957

29 The fluid balance status of the patient is completed and documented 0.981
well.
30 Is the nursing process format attached to the patient chart? 0.879

31 0.893
Is nursing admission assessment completed
within 24 hours and attached to the patient chart?
32 Is the nursing diagnosis of a patient complete and documented? 1.000
33 Is the nursing care plan documented well and attached to the patient 0.811
chart?
34 Is implementation of the care plan complete and documented in the 0.944
nursing patient progress report?
35 The progress report is documented at the end of each shift. 0.843
36 Timely evaluation of the implementation of care is completed and 0.861
documented.
37 Is the record legible? 0.802

Part B: Result on Factors Influencing Quality Nursing Documentation

S/NO Items Correlation

Coefficient

1 Inadequate documenting sheets. 0.975

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2 Unstable system access. 0.880

3 Poor user interface. 0.882

4 Planned/unannounced system downtimes. 0.933

5 Poorly designed or incomplete Electronic Patient Records (EPR) 0.945

System with deficient system usability and user interface that

does not support nursing needs and requirements for daily

documentation routines.

6 Unfamiliarity with standard of nursing documentation, 0.997

organizational policies and routines

7 Poor knowledge, skills, legible handwriting or standardised 0.958

terminology regarding documentation of patient information in my

unit.

8 No obligation from the hospital. 0.910

9 Inadequate supervision on documentation. 0.957

10 Inadequate nurse to patient ratio. 0.717

11 Inadequate information technology (IT) support. 0.991

12 Inadequate time/Poor time management practice. 0.988

13 Poor competency issues and lack of self-confidence on 0.978

documentation practice.

14 Poor attitudes towards documentation practice. 0.952

15 Lack of care plans format in my unit. 0.957

16 Poor staff saturation/ Increased work-load. 0.787

17 Poor teamwork and collaboration. 0.932

18 Poor planning and prioritisation of nursing care tasks, patient- 0.976

77
 centered activities being top priority, and nursing documentation

being placed as low priority.

19 Fatigue due to work load. 0.973

20 Large number of patients/ high volume of nursing actions. 1.000

21 Lack of training and motivation. 0.890

22 Lack of documentation guidelines, policies and routines. 0.970

23 Lack of continuous monitoring and evaluations. 0.971

24 Lack of reward system to staff by managemen 0.898

25 Ignorance of the implications of malpractices in nursing 0.802

documentation

26 Unsatisfied monthly salary 0.943

27 Inexperienced nurses and nature of nursing shifts 0.912

28 Negligence of duty among nurses 0.923

Others, please specify::: Distractions from patient’s relatives.

Part C: Result on Perceived Impacts of Nursing documentation

S/NO Items Correlation

Coefficient

What are the perceived impacts of documentation in nursing

practice?

78
1 Promotes effective communication 0.960

Ensures early detection of problems 0.895

3 Promotes continuity of individualized patient care 0.862

4 Promotes complete client care and patient safety 0.919

5 Encourages knowledge sharing 0.938

6 Promotes consistency, organization and accuracy of Medical 0.898

records

7 Provide information for legal purposes 0.976

8 Provides physical evidence of services delivered or interventions 0.905

implemented.

9 Promotes funding 0.966

10 Prevention of treatment errors 0.941

11 Decreased cost and length of hospital stay/readmissions 0.897

12 Promotes client satisfaction 0.907

Correlation Coefficient for overall questionnaire = 0.969

Table 2: Showing Cronbach’s Coefficient Table for Internal Reliability

Items Cronbach’s α No. of Items
Overall 0.822 77
Level of Practice 0.830 37

79
Factors Influencing 0.752 28
Quality Nursing
Documentation

Perceived Impact of 0.700 12

Nursing Documentation

Reliability of the questionnaire

The reliability of the questionnaire was evaluated using Cronbach’s α coefficients for internal
consistency and Pearson’s correlation coefficient for test-retest reliability. Table 1, showed
the Pearson’s correlation coefficient for the test–retest reliability of the questionnaire.
Correlation coefficients
between the two administrations of 0.7 to 0.9 were common, and more than 0.7 can be
indicated as very good reliability.
As shown in Table 2, the Cronbach’s α coefficients of the total questionnaire and level of
practice of nursing documentation, factors Influencing quality nursing documentation and
perceived impact of nursing documentation, respectively were 0.822, 0.830, 0.752 and 0.700.
The Cronbach’s α coefficients were acceptable for level of practice of nursing
documentation, factors Influencing quality nursing documentation and perceived impact of
nursing documentation.
Based on Table 1, coefficients for the level of practice of nursing documentation, factors
Influencing quality nursing documentation and perceived impact of nursing documentation
were more significant than 0.586 (range: 0.586–1.000), 0.798 (range: 0.798–1.000) and 0.687
(range: 0.687–1.000), respectively, which indicated that each scale of the items had higher
correlation. Overall, the correlation coefficient to the questionnaire was 0.969, which
suggested that the questionnaire had good reliability.

APPENDIX III

ETHICAL APPROVAL LETTER

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