Documentation of Nursing Care

FACTORS LIMITING DOCUMENTATION OF NURSING CARE IN PATIENTS’

FILES; A CASE STUDY OF MBARARA REGIONAL REFFERRAL HOSPITAL

MFITUMUKIZA VALENCE

2006/BNC/014/PS

A RESEARCH REPORT SUBMITTED TO THE DEPARTMENT OF NURSING IN

PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF

THE BACHELOR OF NURSING SCIENCE DEGREE OF MBARARA

UNIVERSITY OF SCIENCE AND TECHNOLOGY

SUPERVISOR: MS MUWANGUZI PATIENCE

MAY 2008

Factors limiting documentation of nursing care

DECLARATION

I, Mfitumukiza Valence, declare that the work presented in this research report is my

original work and has never been presented to any other university/institution for any other

award.

Signed

……………………… Date …………………………...

Mfitumukiza Valence

Author

Supervisor’s approval

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

approval.

Signed

…………………………. Date………………………

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

Supervisor

Mfitumukiza Valence 2006/BNC/014/PSi


DEDICATION

To my dear and loving parents, Mr.Rwabutogo Benard and Mrs. Venancia Rwabutogo.

To my brothers, Innocent, Denis, John Baptist, Didas and my sisters Evangelist& Winfred

For the un measurable support, encouragement, love and tolerance, “May God bless you

abundantly”

Mfitumukiza Valence 2006/BNC/014/PSii


ACKNOWLEDGEMENTS

The almighty God be praised for granting me a gift of life, his endless love, knowledge and

strength enabled me accomplish this dissertation. May his name be honored and glorified.

I wish to extend my sincere thanks to my Parents who brought me up, nurtured and sent me

to school and whose parental love, encouragement and support enabled me accomplish this

study.

My brothers and sisters for their financial, social, moral support and encouragement

extended to me through all seemingly tough times. May the almighty God richly bless you.

I am particularly grateful to my supervisors Ms Betty Kinkuhaire & Ms Muwanguzi

Patience who despite their tight schedules used their precious time, efforts and knowledge

to supervise this work from an idea till accomplishment. You showed me direction and I

had to follow. May God bless you abundantly.

To my cousin sister Jane for support and encouragement rendered to me throughout the

course.

To Mr.Kumakech Edward, who encouraged me to do the study and also helped me in

analysis, Mr. Mwizerwa Joseph and Ms. Fortunate Atwine for their technical advice and

proofreading my work and all the lecturers in the department who taught me.

To my course mates (both directs and completion students) and more particularly

Barebereho J.B (housemate), Kazungu & Nimwesiga for their kindness, cooperation and

support in pursuit of a common goal.

Last but not least, to my friends Davis, Tom, George, Enid,Nathan & John and others for

their continuous support and encouragement helped me accomplish this study.

Mfitumukiza Valence 2006/BNC/014/PSiii


TABLE OF CONTENTS DECLARATION.....................................................................................................................i

DEDICATION.......................................................................................................................ii

ACKNOWLEDGEMENTS..................................................................................................iii

LIST OF TABLES.................................................................................................................vi

LIST OF FIGURES...............................................................................................................vi

LIST OF MAPS.....................................................................................................................vi

LIST OF ABBREVIATIONS/ACRONYMS...................................................................viiDEFINITION OF CONCEPTUAL TERMS......................................................................viii

ABSTRACT..........................................................................................................................ix

CHAPTER ONE.....................................................................................................................1

1.0 INTRODUCTION............................................................................................................1

1.1 Background.......................................................................................................................2

1.2 Problem Statement............................................................................................................3

1.3 Objectives of the Study.....................................................................................................4

1.3.1 Broad objective............................................................................................................41.3.2 Specific objectives........................................................................................................41.3.3 Definition of variables.................................................................................................41.4 Significance of the Study..................................................................................................4

CHAPTER TWO....................................................................................................................5

2.0 LITERATURE REVIEW.................................................................................................5

2.1 Introduction.......................................................................................................................5

2.2 Barriers to nursing care documentation in patients’ files.................................................5

2.3 Strategies that can be employed to improve nursing care documentation........................7

2.4 Conceptual Framework.....................................................................................................9

2.5 DEFINITION OF OPERATIONAL TERMS................................................................11

CHAPTER THREE..............................................................................................................12

3.0 METHODOLOGY.........................................................................................................12

3.1 Area of study...................................................................................................................12

3.2 Research design..............................................................................................................12

3.3 Study population.............................................................................................................12

3.4 Inclusion criteria.............................................................................................................12

3.5 Exclusion criteria............................................................................................................12

3.6 Sampling.........................................................................................................................13

3.6.1 Sample size..................................................................................................................13

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3.6.2 Sampling procedure.....................................................................................................13

3.7 Data collection tools.......................................................................................................13

3.8 Data generation procedures............................................................................................14

3.9 Reliability & Validity.....................................................................................................14

3.10 Data analysis.................................................................................................................14

3.11 Ethical considerations...................................................................................................14

3.12 Dissemination of findings.............................................................................................15

4.0 RESULTS.......................................................................................................................16

4.1 Demographic characteristics of participants...................................................................16

4.2. Documentation practices among the participants..........................................................17

4.3. Perceptions and beliefs about data for documentation..................................................19

4.4. Factors limiting documentation of nursing care............................................................21

4.5. Strategies that can be employed to improve nursing care documentation.....................23

5.0 DISCUSSION OF RESULTS........................................................................................24

5.1 Demographic characteristics of respondents..................................................................24

5.2 Documentation practices among the participants...........................................................24

5.3 Factors limiting nursing care documentation.................................................................25

5.4 Strategies that can be employed to improve nursing care documentation......................26

5.5 Limitations......................................................................................................................28

6.1 Nursing implications.......................................................................................................29

6.2 Recommendations...........................................................................................................29

6.3 Areas for future research................................................................................................30

REFERENCES.....................................................................................................................31

APPENDIX A: INFORMED CONSENT FORM................................................................35

APPENDIX B: QUESTIONNAIRE.....................................................................................37

APPENDIX C: BUDGET.....................................................................................................44

APPENDIX D: INTRODUCTORY LETTER.....................................................................45

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LIST OF TABLES

Table 1: Demographic characteristics of participants.......................................................17

Table 2: Factors limiting documentation of nursing care..................................................22

Table 3: Strategies that can be used to improve documentation of nursing care..............24

LIST OF FIGURES

Figure 1: Conceptual framework for nursing care documentation using King’s theory

.......................................................................................Error! Bookmark not defined.

Figure 3: Frequency of documentation among nurses..........................................................19

Figure 4: Forms that are poorly documented by nurses.......................................................20

Figure 5: Perceptions on patients’ data that should be documented.....................................20

Figure 6: Perceived self-competence in documentation of nursing care..............................23

Figure 7: Perceived knowledge and skills in documentation...............................................23

Figure 8: The perceived importance of documenting nursing care among the participants.24

LIST OF MAPS

Map 1: Map of Uganda Showing Mbarara District...........................................................47

Map 2: Map of Mbarara District........................................................................................48

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LIST OF ABBREVIATIONS/ACRONYMS

AIDS Acquired Immune Deficiency Syndrome.

BNS Bachelor of Science Nursing

CNE Continuous Nursing Education

CME Continuous Medical Education

CRNBC College of Registered Nurses of British Columbia.

FREC Faculty Research and Ethics Committee

GONR Goal Oriented Nursing Record

HIV Human Immune Virus

MOH Ministry of health

MRRH Mbarara Regional Referral Hospital.

NANDA North American Nursing Diagnosis Association

NHS National Health System

PI Principal Investigator

SPSS Statistical Package for Social Scientists

SU Supervisor

UEN Uganda Enrolled Nurse

UEM Uganda Enrolled Midwives

UECN Uganda Enrolled Comprehensive Nurse

URN Uganda Registered Nurse

URCN Uganda Registered Comprehensive Nurse

UNMC Uganda Nurses and Midwives Council

NMC Nursing and Midwifery Council

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DEFINITION OF CONCEPTUAL TERMS

Nurse A person who has undergone formal training and has skills and knowledge to care

for the sick, disabled or of aiding in the maintenance of health (Rosskerr &Sirotnik, 1997).

Documentation any written or electronically generated information about a client that

describes the care or service provided to that client (College of registered nurses of British

Columbia 2005).

Limitations Boundaries or terminal points considered as confining or restricting (Oxford

English dictionary).

Nursing care Activities done by a nurse to the patient aimed at improving and promoting

health (CDC, 2006)

Patient Is an individual who is receiving needed professional services that are directed

by licensed practitioner of the healing arts towards maintenance, improvement or

protection of health or lessening of illness, disability or pain (CDC 2006).

Mfitumukiza Valence 2006/BNC/014/PSviii


ABSTRACT

Nursing requires documentation to ensure continuity of care, planning and accountability.

This promotes evidence based practice. However, studies show that nursing documentation

is still insufficient. Therefore, this study was aimed at identifying the factors limiting

nursing care documentation in MRRH.

The study employed a quantitative descriptive design, data was collected from a convenient

sample of 30 nurses with varying levels of education, practicing in medical & surgical

wards using self administered questionnaire. Data was analyzed with descriptive statistics

using SPSS.

The study findings revealed so many limiting factors to nursing documentation which

include; lack of policy/guidelines from ministry of health, nursing council & hospital

(88.9%), lack of training (CNE/CME) about nursing care documentation (86.2%), lack of

specific forms for documentation of nursing care (79.3%) and lack of time for nursing care

documentation (79.3%). Another reported barrier to nursing care documentation was low

nurse-patent ratio (63.3%).

It is evident from the study findings that lack of policies, training, low nurse-patient ratio

and inadequate forms are the limiting factors to nursing care documentation in patient’s

files. This implies that the practitioners should always try to document whatever they do to

promote evidence based practice.

In view of the above finding, it was recommended that the following strategies be

employed to uplift nursing care documentation; the hospital managers should always

organize CME/CNE about nursing care documentation to improve on knowledge and skills

for nurses. Ministry of health /hospital should develop policy/guidelines about nursing care

documentation.

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CHAPTER ONE

1.0 INTRODUCTION

There is currently a considerable interest throughout the world within the health care

sector to increase the quality of nursing documentation. This is being accomplished

through creating new systems, re-evaluating old systems and analyzing limitations for

nursing documentation (Bjorvell, 2002).

Documentation is any written or electronically generated information about a client that

describes the care or service provided to that client (College of registered nurses of

British Columbia 2005). It is also defined as anything written or printed that is relied on

as a record of proof for authorized person (Rosskerr &Sirotnik 1997).

Nursing documentation has been one of most important functions of nurses since

Florence Nightingale’s time because it serves multiple and diverse purposes. Health care

systems require documentation to ensure continuity of care, serve as a tool for

communication, research, audit, education, monitoring and evaluation of patients’

progress, planning and furnishes as evidence in courts of law. The patient record is a

principal source of information in which the nursing documentation is an essential

component. However, nursing documentation has not served such objectives because of

its complexities (Cheevakasemsook, 2006).

This study arose from the need to identify the limitations of nursing documentation in a

hospital setting.

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1.1 Background

In the past few decades the nursing profession has witnessed a change towards a more

independent practice with explicit knowledge of nursing care. With this change, there has

come an obligation to document not only the performed interventions medical and

nursing but also the decision process, explaining why a specific nursing action has been

prompted and outcomes (Björvell, 2002).

Record keeping is a tool of professional practice and one that should help the care

process. It is not separate from this process and it is not an extra option to be fitted in if

circumstances allow. For quality documentation and reporting, factual basis, accuracy,

completeness, currency, organization and confidentiality must be observed .This should

done by someone having personal knowledge of the matter then being recorded (Rosskerr

& Sirotnik ,1997).

Health records may be paper or electronic documents such as electronic medical records,

faxes, e-mails, audiotapes and images. These records include demographic data,

admission nursing history, consent forms, reports of physical examination, reports of

diagnostic studies, medical diagnosis, flow sheets, nursing care plans, records of care,

treatment forms, and discharge plan (Roskerr& Sirotnik 1997).

There are so many ways of documentation of nursing care interventions, but commonly

used methods are; the problem-oriented medical record that is increasingly recognized as

a method which provides a client centered problem solving approach to care. There is

also traditional client record system, which is source-oriented record keeping. (College of

registered nurses of British Columbia, 2005).

Through documentation, nurses communicate their observations, decisions, actions and

outcomes of these actions for clients. Documentation is an accurate account of what

occurred and when. This helps nurses to monitor and evaluate patients’ progress. These

records also serve as a data source for nursing research, clinical audit and educational

tool. It may also be used as evidence in legal proceedings and disciplinary hearings

through professional bodies (College of registered nurses of British Columbia, 2005).



Documentation is one of the most functions a nurse performs, unless information about a

patient/client’s care is documented and communicated with careful thought, serious

errors can occur (Porter and Perry, 1989). Nursing care must have been excellent,

however “care not documented is care not done in courts of law” (Roskerr & Sirotnik,

1997).

1.2 Problem Statement

Documentation is a vital aspect of nursing practice. Overtime, the format and quality of

documentation have evolved, but the focus continues to be a positive impact on client

care. Today the most challenging issues in nursing are how to document quality client

care with constraints imposed by regulations, meager resources and finances (Bjorvell,

2002)

The ideal documentation system should provide comprehensive client information,

address client outcomes and standards, a facilitate re-imbursement from government and

serves as a legal document (Rosskerr et al, 1997).

According to studies done in Ontario; a review of charts suggested that documentation in

the patients’ record did not accurately reflect the care that was given (Oldfield, 2007).

There is no similar published study that was carried out in Uganda and MRRH in

particular. However, according to my own observations while on clinical rotations on

medical and surgical wards, documentation of nursing care interventions was not

effectively done.

If this continues, it will jeopardize quality of nursing care and gaps in records may be

used as patients’ weapon to accuse nurses or institutions they serve of negligence of duty

in courts of law. Hence a need to do a study to identify factors that limit documentation

of nursing care interventions in medical and surgical wards of MRRH.



1.3 Objectives of the Study

1.3.1 Broad objective

To assess limiting factors and ways of improving documentation of nursing care in

MRRH.

1.3.2 Specific objectives

i. To assess barriers to nursing care documentation in MRRH

ii. To identify ways of improving nursing care documentation in MRRH

1.3.3 Definition of variables

Factors limiting nursing care documentation refers to personal, systematic and policy

issues that hinder nurses from documenting nursing care activities in patients’ files.

Ways of improving nursing care documentation refers to strategies that nurses think

can be used to uplift documentation of nursing care in patients’ files.

1.4 Significance of the Study

The study findings will help the policy makers and managers to set policies or develop

tools that will help in documentation of nursing care interventions and improve on

logistical design.

It will help in identifying barriers to nursing documentation and stimulate the nurses to

look for solutions to these barriers.

This study will help in emphasizing the need for documentation while carrying out

clinical teaching

This study will act as a baseline for future research in nursing documentation.



CHAPTER TWO

2.0 LITERATURE REVIEW

2.1 Introduction

The purpose of the study was to identify factors limiting documentation of nursing care

interventions in MRRH.

The literature review to underpin this study was obtained from mainly studies done in

western world, as there are no similar published studies done in Africa and Uganda in

particular. Literature search was got from Internet, textbooks and Nursing Journals.

2.2 Barriers to nursing care documentation in patients’ files

Clinical records are the most basic of clinical tools. Aggregated, they form a permanent

account of individual considerations, reasons for decisions, essential for effective

communication and good clinical care. However, they are often accorded low priority, are

poorly maintained and not readily available. Independent inquiries, health reports and the

courts have repeatedly criticized the quality of records and the resulting failings of care

(Pullen and Loudon, 2006)

There is no standard guideline/model for nursing documentation. A relatively recent

review of clinical record-keeping and communication in Scotland noted the lack of a

standard model across the National Health Service (NHS) for documenting and

communicating information in patients’ health records (Pullen and Loudon, 2006). This is

non exceptional for Uganda.

Tapp (1990) in her study found that nurses lack distinct professional identity and

language in nursing and a redundancy of forms result into inaccurate and devalued

documentation of nursing care. She also reported other barriers such as lack of time,

space and place, inadequate charting system, lack of value and use of record entries,

environmental disruptions, inaccessibility of the record, a work group norm of a negative

attitude to documentation and perceived difficulty in phrasing correctly.

However, Haertfield (1996) attributed inhibitors to nursing documentation to the attitude

of nurses itself. Nurses have a resistance to becoming visible with their knowledge.



Hence, their documentation consists of passive descriptions of observations and

responses unlike other professions who write about their judgments and examinations.

Allen (1988) revealed that nurses’ attitudes were contradictory in the sense that they

valued the nursing process as a means of professionalism, but they found it difficult to

bring it to terms with their work on the wards. Thus, nursing process is based on model of

one-to -one nurse patient relationship, whereas nurses in most hospital realities have

multiple patients’ assignments, this becomes difficult to document their nursing care.

Tornkvist, Gardulf, Strender (1997) cited in Bjorvell (2002) reported on the options held

by 164 district nurses regarding their documentation and barriers they experienced. It was

revealed that lack of a consistent record system and routines, lack of time, lack of

knowledge about what should be documented, environmentally related condition such as

inadequate computers, interruption and lack of support from supervisors and colleagues.

Ehrenberg, cited in Bjorvell (2002) found that nursing documentation is further hindered

by lack of time, lack of knowledge, organizational obstacles, difficulty in writing and

inappropriate forms. Difficulties are described on the individual level as well on the

administrative organizational level.

According to Bjorvell (2002), a study about nursing documentation in clinical practice

revealed that 20% of the nurses thought that they did not have time to document nursing

care and 71% stated that they did not have time to develop nursing documentation. It

further showed that the greatest barrier was lack of time, which was ranked first. Other

findings were increased paper work due to increased turnover, interruptions in thought,

increased workload exemplified by sicker patients and less staffing. Sterling (1996) in her

study about methods of wound assessment documentation concurs with the above.

Guttery (2007) affirms that 81% indicated that documentation reduces and directly

affects time spent in providing direct care. 61% of respondents that they often or very

often are kept from spending as much time with patients as needed. 54% indicated that

the percentage of their shift /visit completing patients’ documentation was between 25-



50% while 29% reported that completing patient documentation for greater than 50% of

the shift. 73% indicated that the demand for completing patient documentation caused

them work beyond their work hours some times often, very often.

Documentation shortcuts pose risk management issues, since the record must defend the

professional judgment and standard of care for both the facility and the practitioner.

2.3 Strategies that can be employed to improve nursing care documentation

Quality assurance monitoring can help improve nursing documentation. Audit can play a

vital part in ensuring the quality of care being delivered to patients/clients. This applies

equally to the process of record keeping. By auditing records, registrants are able to

assess the standard of record keeping and identify areas for improvement and staff

development. Audit tools should therefore be devised at local level to monitor the

standard of record keeping and to form a basis both for discussion and measurement

(NMC, 2003).

Communication can improve nursing care documentation. Periodic meetings between

hospital staff and nurses in each clinical specialty can help improve communication and

provide targeted education. The participation of coding professionals boosts the value of

these meetings, as they can provide insight into how terminology used by nurses

translates into code assignments. Some hospitals present case studies at monthly

meetings. Others post documentation tip sheets where nurses typically dictate or

complete their records. (Rind, Kohane, Szolovits, et al.1997).

Groves (1996) argues that another effective way to promote better documentation is to

appoint a suitable liaison to assist with nursing communication, preferably a nursing

advisor who would come to the department to review documentation problems. The

liaison is responsible for contacting nurses when staffs have questions regarding

documentation. Liaisons can also be charged with education and advising on nursing staff

rules and regulations related to nursing record issues. .

WHO (2003) stressed that Hospital Management must develop policies and procedures

so that when nurses identify documentation deficiencies; the next steps are clearly

defined. The process should determine how clarification from the nurses should be both



requested and received. A statistically significant improvement was found in the use of

Functional Health Patterns for documentation of nursing assessment, NANDA for

nursing diagnoses and Nursing Interventions Classification for nursing interventions in

documentation of daily nursing care for in patients. At all organizational levels

intervention aimed at putting policy regarding documentation into clinical practice

considerably improved daily use of standardized nursing languages.

Nurses need to use standardized language to document patient care data in the health

record and to demonstrate contributions to nursing care (Thoroddsen & Ehnfors, 2007).

Groenman et al (1992) described attitude as an enduring cluster of beliefs, feeling and

behavioral tendencies relating to any person, object or issue. People will have positive or

negative feeling or emotions about a person, object or issue, these feelings and beliefs

will influence the behavior directed at the person or object. Norms and values will also

play an important role in the concept of attitude. In the light of these definitions a change

in behavior as in this case nursing documentation behavior needs to involve a change in

attitudes towards documentation. Thus, a positive attitude towards nursing care

documentation is essential in ensuring a smooth follow of documentation in it self.

Williams (2000) observed that all health practitioners in public health facilities

who had access to knowledge of documentation should use it as continuing

medical/nursing education as it is part of the professional requirement. In services

training can be made mandatory for nurses who do not meet identified documentation

standards in order to keep abreast with the rest. He however noted that lower level health

centers are generally more likely to use gathering of information as second priority due to

congestion and the high flow of cases to attend to. Even then, documentation should take

center stage as a means of tracking medical cases mainly for two reasons; ongoing

treatment and referral.

Recent advances in electronic documentation are at the heart of social and economic

transformation taking place in both the industrialized and many developing countries. As

the cost of computers continues to fall and their capabilities increase, their applications

are becoming vital in all sectors of the economy and the society including nursing

documentation. According to Mansell and Wehn (2004), the increasing spread of



information tracking through diverse media requires thorough documentation. The use of

documents in the medical set up opens up new opportunities for developing countries to

improve on service delivery to serve their development goals.

It is the nurses themselves who have to change the nurses’ impact on the health care

politics as well as the nursing role to improve the nursing care for patients (Bell 2004).

2.4 Conceptual Framework

This is based on Imogene King’s general systems Framework; which focuses on the three

interacting systems; personal, interpersonal and social system. This model employs

theory of goal attainment that is met through the transaction between nurse and client.

King describes her model as conceptual system and the goal of nursing as bringing a

person closer to the health state (King 1981).King defines health as “the way individual

deals with stresses of growth and development while functioning within the cultural

pattern”. Nursing practice is directed towards helping individuals maintain their health so

that they can perform their roles.

King’s conceptual frame is a system of processes which include processes of perception,

communication, purposeful interactions, information and decision-making .It helps

nurses in hospital and community health agencies in delivery of nursing services to use

goal oriented nursing record (GONR) to document nursing care related to goals for each

client (Riehl-Sisca 1989). This makes it applicable to nursing documentation in nursing

practice hence a necessary tool for guiding a study to identify limiting factors to nursing

care documentation.



Figure1: Conceptual framework for nursing care documentation using King’s theory.

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

Mfitumukiza Valence 2006/BNC/014/PS

Proper Documentation of Nursing care

Proper Communication among staff

Coordinated nursing care

Proper Accountability

Proper planning Basis for research and education

Good Patients Management

10


2.5 DEFINITION OF OPERATIONAL TERMS

Nurse A person educated and trained to care for the sick

Documentation Written information about the patient that describes the care given

and its outcomes

Limitations Factors that hinder documentation of nursing care.

Nursing care These are interventions done by a nurse to patient to prevent

complications and improve his wellbeing.

Patient A sick person who needs care.



CHAPTER THREE

3.0 METHODOLOGY

3.1 Area of study

The study was carried out in Mbarara Regional Referral Hospital (MRRH) that is found

along the Mbarara-Kabale high way, adjacent to Mbarara University of Science and

Technology in Mbarara district.

MRRH also acts as university teaching hospital, so students in the faculty of medicine in

their clinical rotation also take part in provision of health services to the clients under

supervision. The study was conducted on the medical and surgical wards.

3.2 Research design

This study employed a quantitative descriptive design. Through descriptive studies, the

researcher discovers new meaning, describe what exits, determine the frequency with

which something occurs, and categorize information. (Burns & Grooves, 2003). This

design helped to identify factors limiting documentation of nursing care in patients’ files.

3.3 Study population

The participants were Nurses working in medical and surgical wards of MRRH.

3.4 Inclusion criteria

The nurses included in the study are;

Those who were qualified (enrolled nurses, registered nurses, BSN nurses).

Those working in medical& surgical wards at MRRH

Those who consented to participate in the study

3.5 Exclusion criteria

Those excluded are;

Other health workers who were not nurses.

Nurses working on other wards

Those who did not consent to participate in the study.


PerceptionClient

12


3.6 Sampling

3.6.1 Sample size

This was a subset of the population selected to participate in the research study and is a

representative of the total population. In this study, sample size were calculated using

Kish and Leslie’s formula (Kish 1965)

No= Z2PQ/D

2

No= Sample size

Z = Z-score (n a normal distribution curve corresponding to a 95% confidence interval)

=1.96.

P= Estimated proportion of population with characteristics under study≈ 80%

Q =1- P

D= Absolute precision of 5% = .0.05

N0 =1.962 x 0.8(1-0.8) / 0.052

No = 3.8146 x 0.16 / 0.0025

No = 245

However, this sample size is for a large population and my study covered a small

population, thus according to Israel (1995) to get a sample size for a small population the

above sample size was substituted in this formula below

n = No / 1 + (No -1) /N

n = 245 / 1 + (245-1) / 35

n= 30.7

=31 People.

n = Sample size

N0 = Original sample size of a big population.

N = total population under study.

3.6.2 Sampling procedure

Convenience sampling was used; the researcher offered the questionnaires to only those

who were on duty at the time of data collection.

3.7 Data collection tools

Data was collected by use of self administered structured questionnaires.



3.8 Data generation procedures

A structured questionnaire was used to generate information. The respondents were asked

to fill the questionnaire according to realities they experience on the ground.

3.9 Reliability & Validity

The questionnaire was pre tested by giving it to 5 nurses not involved in the study to

answer it and this enabled the researcher to identify problems encountered while

answering the questionnaire then necessary corrections and adjustments were made.

The questionnaire was given to research experts to review first before it was administered

to ensure face validity

To ensure quality control, the researcher administered the questionnaire himself; this

didn’t allow respondents to discuss questions with other people. This also offered the

researcher an opportunity to probe further where necessary.

During the interview, questions were explained thoroughly to make sure they were

understood and hence provided answers which were relevant to questions.

3.10 Data analysis

Data collected from the study was analyzed using Statistical package for Social Scientists

(SPSS) version 10 to obtain descriptive statistical correlation and results were presented

in form of tables and figures.

3.11 Ethical considerations

Permission was sought from MUST Faculty Research & Ethics Committee (FREC) for

approval and an introductory letter from Department of Nursing was obtained.

Permission was also sought from the Medical superintendent, Principal nursing officer

and In-charges of medical and surgical wards of MRRH.

A written consent form by the researcher was given to the study participants and their

consent sought prior to their involvement in the study.

Participants were informed that participation was voluntary and that they were free to opt

out at any time they wished and this would not affect their relationship with the

researcher or their working relations with those who participated.



Privacy and confidentiality were ensured, no names used; only codes and a private place

were used for the interview.

3.12 Dissemination of findings

Copies of the dissertation will be presented to the Department of Nursing, the MUST

library, and MRRH. Findings will also be presented in conferences and published in

nursing journals.



CHAPTER FOUR

4.0 RESULTS

This chapter presents the key findings from data analysis. The findings are arranged into

three sections namely, demographic characteristics of participants, documentation

practices, opinions and beliefs about documentation and factors limiting documentation

of nursing care.

4.1 Demographic characteristics of participants

The demographic profile of the participants is presented in table 1 below. The minimum

age was 50 years and above (6.7%) and maximum age was 20-29 and 30-39 years (with

the same percentage 36.7%).The majority of participants were married (63.3%).

Table 1: Demographic characteristics of participants

Demographic characteristics Frequency (n) Percentage (%) Age

20-2930-3940-4950 and above

Total

111162

30

36.736.7206.6

100

SexMaleFemale

Total

1119

30

36.763.3

100Marital status Single Married Widow/Widower Total

10191

30

33.363.33.3

100

Educational level Certificate Diploma Degree

Total

17103

30

56.733.310

100

Qualification



Uganda enrolled nurseUganda registered nurseUganda registered comprehensive nurseUganda registered nurse & midwifeBachelor of nursing science nurse

Total

715

3

2

3

30

23.350

10

6.7

10

100

Current position Staff nurse Nurse-in charge Intern nurse

Total

2532

30

83.310.06.7

100Years in service 1-5yrs 6-10yrs 11-15yrs 16yrs >Total

1277430

40.023.323.313.3100

Involved in planning at hospital level Involved Not involved

Total

723

30

23.376.7

100

4.2. Documentation practices among the participants

4.2.1 Sufficiency of nursing care documentation

The study findings indicate that the majority of the participants document the care given

and the patient’s responses (90%) as shown in figure 2 below. Furthermore, the majority

(70%) noted that nursing documentation is insufficient

Figure 2: Documentation practices among nurses



4.2.2 The frequency of documentation among the participants

The majority (57.1%) of respondents reported that they do documentation occasionally or

rarely as shown in figure3 as shown below.

Figure 3: Frequency of documentation among nurses

4.2.3. Forms that are poorly documented

The study findings indicate that the forms that are most poorly documented as shown in

figure 4 include assessment forms (82.8%), patient progress notes (79.3%) and fluid

balance charts (72.4%).

Figure 4: Forms that are poorly documented by nurses


Documentation practices among nurses

Document 90%

Don't document,

10%

Frequency of documentation

Occasionally 57.1%

Always, 49.2%

18


Forms that are poorly documented

82.8 79.372.4

41.4

3.4

0

10

20

30

40

50

60

70

80

90

Ass

essm

ent f

orm

s

Pt p

rogr

ess

note

s

Flui

d ba

lanc

e ch

arts

Obs

erva

tion

char

ts

Trea

tmen

t for

ms

Nu

mb

er o

f n

urs

es (

%)

4.3. Perceptions and beliefs about data for documentation

4.3.1 Data that should be documented

The nurse’s perception on the patient data that should be documented is shown in figure 5

indicate observations (73%) and nursing interventions (79%) to be the data reported by

majority of the participants. Other patient data the participants felt should be documented

were fluid intake and output (20.0%), nursing care-plan (16.7%), feeding habits (16.7%),

behaviors (16.7%) and bowel motions (6.7%).

Figure 5: Perceptions on patients’ data that should be documented

4.3.2 Data that should not be documented


Data to be documented

73.3 70

53.340 40

23.3 23.3

01020304050607080

Ob

serv

atio

ns

Nsg

inte

rve

ntio

ns

Tre

atm

en

ts

Ass

ess

me

nt

find

ing

s

Pt p

rog

ress

La

bo

rato

ryre

sults

Pts

' wo

rrie

sa

nd

con

cern

sNo

nu

rse

s r

ep

ort

ing

(%

)

19


On the other hand, the nurses felt that some patient data should not be documented and

these include those not necessary (11.1%), patients’ private lifestyle (11.1%), non-health

related issues (11.1%) and nurse’s routine procedures such as bed making (11.1%).

4.3.3 Perceptions and beliefs about people who will read documented nursing care

The majority of the nurses believed that data documented by nurses shall be read by

mainly fellow nurses (figure 6) and they will be looking for the care-plan and its

implementation (68.8%) and patient progress (37.5%).

Figure 6: Nurses beliefs on the category of people who read nursing note



4.4. Factors limiting documentation of nursing care

4.4.1: Factors reported as limiting documentation of nursing care

The factors shown in table 2 were reported to be limiting documentation of nursing care.

Table 2: Factors limiting documentation of nursing care

Factor Frequency

(n)

Percentage

(%)

Lack of policy at the hospital level 24 88.9

Lack of policy /guidelines from the MOH/Nursing council 25 86.2

Lack of CNE/CME about documentation 23 79.3

Lack of specific forms for documenting nursing care 23 79.3

Lack of time for documenting nursing 21 70

Perception of documentation as reducing the time for direct

patient care

19 63.3

Inadequate forms for documenting nursing care 19 63.3

Low nurse-patient ratio 19 63.3

Perception of documentation as a routine activity rather than a

means of communication

17 56.7

Lack of materials and equipment for assessment and

documenting nursing

12 40

4.4.2 Assessment of the participants’ perceived self-competence in documentation of

nursing care as a factor

The participants perceived self competence in documenting nursing care was examined

as a factor affecting documentation. The findings are shown in figure 7 and 8 which

indicates that the perceived self-competence in documenting is not a factor because the

majority of the participants (93.3%) saw themselves as competent in documenting

nursing care.



Figure7: Perceived self-competence in documentation of nursing care

Figure 8: Perceived knowledge and skills in documentation

4.4.3 Assessment of the participants’ perceived importance of documentation as a

factor

The perceived importance of documentation among the participants was assessed as a

factor affecting documentation. The findings shown in figure 9 indicate that the majority

of the participants perceived documentation of nursing care as something very important

(93.3%).


Knowledge and skills in documentation

Very good, 26.7%

Excellent, 3.3%

Good, 5%

Fair, 16.7%

Very poor, 3.3%

22


Figure 9: The perceived importance of documenting nursing care among the participants

4.5. Strategies that can be employed to improve nursing care documentation

The factors in table 3 below were reported as strategies that can be employed to improve documentation of nursing care in patients’ files.

Table 3: Strategies that can be used to improve documentation of nursing care

Strategies Frequency(n)

Percentage (%)

Organize workshops /CNE/CME about nursing documentation

25 83.3

Employ enough nurses 17 56.7

Supply enough forms and other supplies

15 50

Motivate nurses through rewards, gifts, promotions, tea, and increase salaries

10 33.3

Policy/guidelines about nursing care documentation should be put in place

7 23.3

Internal/External supervision team to be put in place

5 16.7

Create enough time for documentation 2 6.7

Emphasize documentation in nursing schools; include it in syllabus

2 6.7

Team work should be encouraged 2 6.7

Disciplinary measures should instituted 1 3.3

Appraisal form to include documentation 1 3.3

Involved in ward round

1 3.3



CHAPTER FIVE 5.0 DISCUSSION OF RESULTS

The study was about factors limiting documentation of nursing care in patients’ files.

5.1 Demographic characteristics of respondents

The demographic characteristics included; age, sex, level of education, marital status and

experience. There was no significant correlation between age, sex, education, marital

status, experience and documentation of nursing care.

5.2 Documentation practices among the participants

The study findings indicate that the majority of the participants document the care given

and the patients’ responses (90%). These findings differ from studies done by Briggs&

Dean (1998) who found that nursing care was poorly documented and that the nursing

record differed from the patient’s report. Souder & Sullivan (2000) also found no nursing

documentation on patients’ cognitive status in 42 patient records. However, it was noted

that nursing documentation was insufficient (70%) and 51.7% reported that they

document occasionally.

The forms which were reported to be poorly documented included; assessment forms,

patients’ progress notes and fluid balance charts. This is in line with Davis et al (1994)

who discovered that assessment was poorly documented as were details of interventions.

He further reported that there were insufficient re-assessment and updating. It should be

noted that assessment is documented in assessment forms.

The majority of the participants indicated that observations, nursing- interventions &

treatment were the data that should be documented. Other patient data the participants felt

should be documented were fluid intake, nursing-care plan, feeding habits, bowel

motions & patients’ behaviors. The participants believed that their fellow nurses and

doctors are the ones who read the data documented by nurses, and that they look for care-

plans, implementation and patients ‘progress (Figure 6).This can be argued that since the

nurses’ primary responsibility is to take patients observations, give treatment and other



nursing interventions then its their responsibility also to document what is done to prove

their actions.

5.3 Factors limiting nursing care documentation.

The study found that lack of policy/guidelines for nursing care documentation from

MOH/UNMC and Hospital was the most limiting factor for documentation of nursing

care. This concurs with the study by Pullen & Loudon (2006) which revealed that there

was lack of policies and standard model across the National Health Services (NHS) for

documenting & communicating in formation in patients’ files. This greatly affects

nursing care documentation since there are no proper guidelines to follow.

Many participants reported that they lacked CNE/CME about documentation

(79.3%).This is in line with Ehrenberg (cited in Bjorvell 2002) who reported that nursing

care documentation was hindered by lack of knowledge and difficulty in writing. Also

Tapp (1990) found that nurses lack professional identity and language in nursing. This

implies that nurses lack knowledge and skills about nursing care documentation since

they don’t get on job training about documentation

The study findings also revealed that there were no specific forms for documenting

nursing care and those forms which were there were inadequate. This is in agreement

with the a study by Tornkvist et al(1997) who reported that lack of a consistent record

system & routines was one of the significant barriers of nursing care documentation. This

denotes that sometimes nurses don’t document because they lack forms to use.

Also among the most significant findings about barriers to nursing care documentation

was lack of time (70%).This is in line with a study by Gugerty et al (2007) who found

that among the barriers of nursing care documentation; lack of time ranked number one.

Ehnfors (1993), Tapp (1990) also reported lack of time among other barriers to nursing

care documentation. This most likely is attributed to work overload.

The research findings indicate that documentation reduces the time for patients care as

reported by many respondents (63.3%).These findings are in agreement with Gugerty et

al (2007) who noted that 81% of participants believed requirements for patient care



documentation reduced time spent with patients; and 63% felt this happens often or very

often. These findings indicate that documentation consumes time for patient care and

most nurses take “hands on care” a priority over documentation (Tapp 1990). This

significantly affects nursing care documentation and has a negative impact since care not

documented is care not done in courts of law (Roskerr &Sirotnik 1997).

There is also low nurse-patient ratio (63.3%).This is in line with Mwizerwa (2000) who

found that understaffing in Mulago affected the delivery of health care to patients.

Beebwa (2004) also reported that 87% are over worked and 63.3% don’t finish assigned

work on time. Since there are many patients compared to the nurses; there is work

overload and hence nurses lack time to do documentation of nursing care. This implies

that nurses get burnout and easily forget to document the care they have rendered to

patients hence a negative impact on documentation.

Many participants reported they do documentation as a routine activity other than a

means of recording and communicating important information (56.7%).This concurs with

Gugerty et al (2007) who reported that 55% do routine documentation for reasons other

than communicating pertinent information. This can be argued that they don’t mind

whatever they record since they don’t know the importance of documenting. Thus their

documentation will be insufficient hence a barrier to nursing care documentation.

Among barriers of nursing care documentation reported was lack of materials and

equipment for assessment and documentation. This supports Draiko (2004) who found

that lack of supplies greatly affects nursing care and its documentation. Lack of logistical

support is a major setback in nursing care documentation since nurses fail to access what

to use in documentation like forms. It is evident that lack of policies, education,

inadequate forms and low nurse-patient ratio compromises nursing care documentation in

MRRH.

5.4 Strategies that can be employed to improve nursing care documentation.

The hospital should organize workshops/CNE/CME about nursing documentation. This

was reported by majority of participants (83.3%) and is in line with Williams (2000) who

observed that all health practitioners in public health facilities who have knowledge of



documentation should use it in medical/nursing education and emphasized that in service

training is mandatory for those who don’t meet identified documentation standards in

order to be on the same level with the rest. This would equip the nurses with knowledge

of what to document and when to document and also realize its significance.

A big number of participants also suggested that more nurses be employed (56.7%).This

is supported by Beebwa (2004) who reported that 84% of respondents suggested

recruitment of more nurses could improve shortage of nurses. It would reduce on patient-

nurse ratio and consequently work load hence the nurses will enjoy their job and

documentation is also anticipated to improve

Supplying enough documentration forms and other supplies was also suggested to be a

way of improving nursing care documentation. Since inadequate forms was reflected as a

barrier of nursing care documentation; if more forms would be availed then nurses would

be free to record and documentation would improve.

Motivating nurses through increasing salaries, offer rewards like gifts, promotions and

prepare tea for staffs on duty was also raised to be among the ways that can be employed

to improve documentation of nursing care. These concurs with Kingman (2003) who

noted that giving incentives in form of monetary and non monetary values to community

nurses would motivate them and make them more focused on their work; This would

improve documentation of nursing care as well.

The participants also suggested that developing policies/guidelines for nursing

documentation would enhance their documentation. This is supported by Thoroddsen &

Ehnfors (2007) who suggested that nurses need to use standardized language to document

patient care data in the health records and to demonstrate contributions of nursing care.

WHO (2003) also stressed that hospital management must develop policies and

procedures so that when nurses identify documentation deficiencies then steps can be

clearly defined through guidelines.



Other suggested ways of improving nursing care documentation include; instituting

internal & external supervision team, encourage team work and emphasis documentation

in schools.

5.5 Limitations

The study findings cannot allow fair generalization since the sample size was

small hence a similar larger study can be repeated or carried out in other areas.

The use of questionnaires as instrument for data collection may have limited the

participants to give detailed information about the variables under study.

Data was not collected from other members of the health care team such as

medical officers and allied health professionals, some factors could probably have

been missed.



CHAPTER SIX

6.0 Conclusions

The study findings indicate the following to be the factors limiting nursing care

documentation in patients’ files; Lack of policies/guidelines for nursing care

documentation, Lack of CNE/CME about nursing documentation, Lack of specific forms

for nursing care documentation. Lack of time for documentation; and it was found out

that documentation reduces time for direct care.

The study further revealed that there is low nurse-patient ratio; this implies that there few

nurses compared to patient and has a significant impact to nursing documentation.

Documentation was also perceived as a routine activity rather than a means of

communication.

6.1 Nursing implications

The practitioners should always try to document every procedure performed, patients’

concerns and outcomes. Though nurses in practice are ever busy; they should always

record their activities and observations as care not documented is care not done; this will

promote evidence based practice. Since documentation is a legal tool, they need to pay

the necessary attention while documenting the care offered.

.

6.2 Recommendations

Ministry of health/nursing council /hospital should design policies and guidelines

about nursing care documentation.

The Hospital managers should organize CNE/CME about nursing documentation so

as to improve on their documentation.

More nurses should be recruited and retained to reduce heavy workload and its

effects.

The government/employers should motivate nurses through rewards, promotions,

increase salaries and improve on working conditions.

Internal and external support supervision should be instituted.

Put more emphasis on documentation in nursing schools.



6.3 Areas for future research

Other studies are needed to be carried out in other areas and nationally.

A study to develop a tool to advance nursing documentation.

Future research about factors limiting nursing documentation should consider

collecting data from medical doctors and allied health professionals.

Future research could explore the use of focused group discussion or in-depth

interviews so as to get detailed data about factors affecting documentation.



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Journal of Advanced Nursing ,27,123-1230

Bebwa ,E.,(2004) Effects of low staffing levels on quality nursing care of MRRH.(U.P)

Bell, k., (2004). Nursing care in African context, a qualitative study from Haydom

Lutheran hospital Tanzania. GegcA- NuFu.vol 9

Bjorvell, C., (2002., Nursing documentation in clinical practice. retrieved at

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Briggs, M. & Dean, K., (1998) .A qualitative analysis of the nursing documentation of

post operative pain management. Journal of clinical nursing, 7(2), 155-163 retrieved at

www.blackwell-synergy.com on 19/09/2007.

Burns, N. & Grooves, S., (2003). Understanding nursing research 3rd ed. George Indiana

USA. p.256.

CDC, (2006).Definition of nursing terms ;Retrieved at

http://www.cdc.gov/nchs/datawh/nchs on 20/05/2008

Cleevakasemsook, A., (2006). The study of Nursing documentation complexities.

International Journal of Nursing practice. 12(6): 366-374 retrieved at

http://www.pt.wkhealth.com/pt/re/ijnp/abstract. On 12/10/2007

College of registered nurses British Columbia (2005). Documentation of nursing care

policy .retrieved online at www.crnbc.ca on 17/08/2007

Davis,B.,Billings,J.,& Ryland,R.(1994).Evaluation of nursing process documentation.

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http://www.cdc.gov/nchs/datawh/nchs

http://www.blackwell-synergy.com/

http://diss.kib.ki.se/2002/91-7349-29703


Draiko, E., (2006). Factors affecting provision of nursing care in west Moyo HSD (U.P).

Ehnfors,M.,& Smedby,B., (1993). Nursing care as documented in patient records.

Scandinavian Journal of Caring Services, 7,209-220.

Groves T. (1996). SatelLife: getting relevant information to the developing world. BMJ;

313:1606–9.

Groenman,N.H.,Slevin,O.D’A. & Buckenham,M.A.(1992).Social and behavioural

sciences for nurses. Edinburgh: Campion press Ltd

Gugerty ,B.,Beachley,M.,Navarro,V.,Newbold,S.,et al .,(2007).Challenges and

opportunities in documentation of nursing care of patients.A report of the Maryland

Nursing workforce commission. Accessed online at:

http://www.mbon.org/commission2/documentation challenges.pdf. On 14/07/2007

Hale, C. Thomas, L. Bond, S. & Todd, C., (1997). The nursing record as a research tool

to identify nursing interventions. Journal of clinical Nursing,6,207-114

Heartfield, M.,(1996). Nursing documentation and nursing practice. Journal of Advanced

Nursing,24,98-103.

Kish, L., (1965). Survey Sampling; New York. John Wiley and Sons, Inc

King, I. M. (1981), A theory of nursing: Systems, concepts, process; 2nd edition Albany, New York, Delmar.

Kingma, M., (2003).Economic incentive in community nursing; attraction, rejection or

indifference. Human resources for health, 1:2doi:10, 1186/1478-4491-1-2.Accessed at

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Mandil, S. H., (1998). Informatics and telamatics, Present and future. Retrieved at

http://www.emro.who.int/publications. on 23/9/2007


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

London .Oxford University.

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Mwizerwa, J., (2000) Factors affecting the delivery of nursing care to in patients of new

Mulago hospital. (U.P).

NMC (2003).Record keeping guidance .Accessed online at http://nmc-uk.org/a display

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Oldfield,M., (2007). Changing behaviors to improve documentation and optimize hospital

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Porter, A. P. and Perry, A .G., (1989). Fundamentals of nursing concepts, process and

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Rossker,J. & Sirotnik,M., (1997). Canadian fundamentals of nursing. ST.Louis

Baltimore. Mosby

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assessment of cognitive status in hospitalized medical patients. Applied Nursing

Research, 13(1), 29-36.

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The Oxford English dictionary (1978).Vol VI.Oxford; Clarendon Press.

Thoroddsen, A. & Ehnfors, M., (2007). Putting policy into practice: pre- and posttests of

implementing standardized languages for nursing documentation. .Journal of Clinical

Nursing 16, 1826–1838

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23/02/2008


http://www.who.int/3by5/publications/briefs/monitoring

http://www.annals.org/cgi/content.%20%20On%2018/09/2007


APPENDIX A: INFORMED CONSENT FORM

I am Mfitumukiza Valence, a fourth year Bachelor of Nursing Science student at

Mbarara University of Science and Technology, seeking your permission to participate in

the study to “Assess factors limiting documentation of nursing care interventions in

patients’ files in MRRH.”

The research is a partial fulfillment for the award of the Bachelor of Nursing Science

Degree of Mbarara University of Science and Technology.

In this study, a questionnaire will be given. The respondents will be required answer

questions by ticking the check boxes and filling in the spaces provided. The information

that you will provide during the study will be kept confidential. Only the Researcher will

have access to them.

Your participation in this study is voluntary and you have the right to refuse to participate

or answer any question that you feel uncomfortable with. If you change your mind about

participating during the course of the study, you have the right to withdraw at any time.

The decision to withdraw will not affect your relationship with the researcher.

If there is anything that is unclear or you need further information, I will be delighted to

provide it. Your agreement to participate in this study will be highly appreciated



Declaration of the volunteer

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

need be.

I have read the above information, or it has been read to me. I have had the opportunity to

ask questions about it and any questions that I have asked have been answered to my

satisfaction. I consent voluntarily to participate as a subject in this study and understand

that I have the right to withdraw from the study at any time without in any way affecting

my relationship with the researcher.

Mfitumukiza Valence

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

Name/signature of volunteer/ Name/signature of investigator

Parent/Guardian contact Tel: 0772-974952

Date ……………………………….. Date………………….…



APPENDIX B: QUESTIONNAIRE

This questionnaire will be used in a study to assess factors that limit documentation of

nursing care in patients’ files on surgical and medical wards of MRRH.

Section A: Demographic information

1. Age.................years

20-29 years

30-39 years

40-49 years

50 years and above

2. Sex

Male

Female

3. Marital status

Single Divorced

Married Widow/Widower

4. What is your nursing educational level?

Certificate

Diploma

Degree

5. What is your current qualification?

UEN UEM URMN

URN URM UECN

URCN BNS other specify...........



6. Which ward are you working on?

Medical ward surgical ward

7. What is your current position?

Nurse-in charge staff-nurse

Other specify

8. How many years have you spent in service .................years?

1-5yrs 6-10yrs

11-15yrs >20yrs

B. Nursing care documentation

9. Are you often involved in rendering nursing care to patients?

Yes No

10. Do you document the care given & patients’ responses in patients’ files?

Yes No

If yes

11.If yes, How often do you document?

Always

Occasionally

Rarely

12. Do you think that documentation of nursing care in patients’ files is sufficient?

Yes No

13. What could be done better?

..........................................................................................................................................

..........................................................................................................................................

.................................................................................................................................



14. Do you think that documentation of nursing care in patients’ files is a true

reflection of care given?

Yes No

15. Which of these is documented well?

Assessment forms

Observation charts

Treatment forms

Patient progress notes

Fluid balance chart

Others specify……………………..

16. Which of these is poorly documented?

Assessment forms

Observation charts

Treatment forms

Patient progress notes

Fluid balance chart

Others specify…………………………

C. Knowledge and skills of nursing care documentation

17. Is there policy/guidelines from MOH/Nursing council about nursing care

documentation?

Yes No

18. Does the hospital/institution you are serving have its own nursing care

documentation policy / guidelines? If no, go to no .19

Yes No



19. If yes, have you ever read them?

Yes No

20. Do you think lack of policy/guidelines about nursing documentation affects the

way how you record nursing care?

Yes No

21. Are you involved in planning / decision making of the institution?

Yes No

22. Have your institution ever organized CNE/CME about documentation

Yes No

23. Do you think lack of CNE/CME contributes to inadequate nursing care

documentation in patients’ files?

Yes No

24. Are you competent enough to do documentation of nursing care in patients’ files?

Very competent competent not competent

25. How do you gauge your knowledge & skills about documentation of nursing

care?

(a) Excellent b) Very good

(c) Good d) Fair

(d) Poor e) very poor

26. Do you feel you have enough time to document the care you have given?

Yes No

27. If no, how much time would you need? .................................................

28. Does the process of and requirements for patient care documentation reduce the

amount of time spent by you in providing direct patient care

Yes No



29. If you answered yes to No 27, how often does the documentation process prevent

or keep you from spending as much time with patient as needed

Never

Rarely

Some time

Often

Very often

30. What percentage of your shift is actually spent in completing patient care

documentation?

Less than 25%

25%-50%

51%-75%

More than 75%

31. Are you routinely required to document care given other than to record and

communicate important information related to a health care to team members

Yes No

32. Who should write in patients’ files?

Nurse involved in direct care

Doctor involved in direct care

Other health workers involved in direct care

All health workers who are involved in direct care

33. Are there specific forms / papers nurses are supposed to write on different from

those doctors are supposed to write on?

Yes No

34. Do you think it’s important to document nursing care given and its outcomes in



patients’ files?

Very important important Not important

35. Have you ever been rebuked /stopped from documenting nursing care in patients’

files?

Yes No

36. In your view what should be documented and what should be left out? And please

give reasons for your answer?

Things to be documented

………………………………………………………………………………………….

………………………………………………………………………………………….

…………………………………………………………………………………………..

..........................................................................................................................................

..........................................................................................................................................

Things not to be documented

..........................................................................................................................................

..........................................................................................................................................

..........................................................................................................................................

..........................................................................................................................................

..........................................................................................................................................

........................................................................................................................................

37.When you document, who do you think reads your notes and what do they look

for?...................................................................................................................................

..........................................................................................................................................

.........................................................................................................................................

38. Are there enough forms to be used for documenting nursing care?



Yes No

39. What could be other factors that hinder nurses from documenting of nursing care

in patients’ files?

……………………………………………………………………………………

……………………………………………………………………………………

……………………………………………………………………………………

……………………………………………………………………………………

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40. What could be the strategies that can be employed to improve nursing care

documentation in patients’ files……………………………...................................

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THE END, THANK YOUAPPENDIX C: BUDGET

ACTIVITY ITEM QUANTITY UNIT TOTAL


44

43


PRICE

Proposal writing

Stationery

Flash disk

Internet Typing, Printing

and photocopying

2 reams

1

8000/=

50,000/=

100,000=

16,000/=

50,000/=

100,000/=

Data collectioninstruments

Pens

printing and photocopying of questionnaire

25

40

200/=

50000=

5000/=

50000/=

Transport

To Mbarara town

Interviews.

Contingency

50,000=

5,000/=

200,000=

50,000/=

50,000/=

200,000=

Data processing

Statistician

Compiling the dissertation

4 copies

150,000/=

100,000/=

150,000/=

400,000/=

TOTAL 1,071,000/=

APPENDIX D: INTRODUCTORY LETTER



MAP 1: MAP OF UGANDA SHOWING MBARARA DISTRICT





MAP 2: MAP OF MBARARA DISTRICT


Documents

Documentation of Nursing Care