Nurses' Practice of Documentation in Critical Care Units: An observation from Egypt

Abstract

Background: Critical care nurses' are involved in many activities in critical care units from patient admission to discharge. Each nursing activities should be completely and accurately documented. Aim: This study aimed to assess critical care nurses’ practice of documentation in the critical care units. Setting: The study was carried out in three critical care units affiliated to a university hospital in Egypt. Method: A descriptive research design was utilized to conduct this study. Tool of the study: One tool was developed by the researcher after strength review of the relevant literature to assess critical care nurses’ practice regarding the documentation and consisted of two parts as follows: Part I: Nurses' socio-demographic characteristics, Part II: Critical Care Nurses’ Observational Checklist regarding Documentation: This tool was used to assess critical care nurses’ practice in critical care units during providing care for patients. Results: Revealed that most nursing interventions were either not or incompletely document and there were highly statistically significant p < 0.001 were found between documentation of nursing intervention in relation to routine care, changing position, range of motion exercises, and endotracheal tube care. Conclusion: The results of this study revealed that the practice of critical care nurses’ on nursing documentation were either not or incompletely document. Poor documentation may threaten the safety of patient care and needs urgent improvement. Recommendations: Improving nursing documentation in the critical care units through nursing practice supervision, evidence based practice, staff development and provide continuing training programs for nurses', and the handover should take place in the intensive care unit by educating critical care nurses’ to use the handovers checklists to improve the handover process.