Nursing Documentation Practice and Associated Factors Among Nurses in East Guji, West Guji and Borena Zone Public Hospitals Southeastern, Ethiopia

Abstract

Background: In health care systems, nursing care documentation is a vital and powerful tool that ensures continuity of care and communication between health personnel for better patient outcomes. The practice of nurses towards nursing care documentation affects the quality and coordination of patients’ care. Hence, this study aimed to assess the practice of documentation and its associated factors among nurses working in the Guji and Borena Zone public hospitals. Method: A hospital-based cross-sectional study design with a convergent mixed-method approach was employed from April 1 to May 30, 2022, among 502 sampled nurses working in East Guji, West Guji, and Borena Zone public hospitals in Ethiopia. Data were collected using self-administered structured and open-ended questionnaires for quantitative and qualitative data, respectively. Key informant interviews were conducted with nine respondents. Epi Data 4.6 was used for data entry, and SPSS version 26 software was used for data analysis. A logistic regression model was used to identify the determinants of nursing documentation practice, and statistical significance was declared at P < 0:05. A thematic analysis approach was applied for the qualitative data analysis. Result: A total of 486 respondents provided complete responses, resulting in a response rate of 97%. The documentation practice was found to be 46.9%. Factors associated with good nursing documentation practice included the availability of guidelines [(AOR = 2.1), 95% CI (1.1-3.9)], education received in governmental institutions [(AOR = 2.6), 95% CI (1.7-4.0)], in-service training [(AOR = 1.7), 95% CI (1.01-2.7)], motivation [(AOR = 2.1), 95% CI (1.2-2.7)], favorable attitude [(AOR = 2.3), 95% CI (1.5-3.5)], documentation audit [(AOR = 2.0), 95% CI (1.0-3.7)], and good knowledge [(AOR = 2.1), 95% CI (1.2-3.5)]. The key informant interview explored factors like in-service. training, lack of supply, academic background, and educational status, as well as the vast nursing care format and lack of commitment, have a major impact on nursing documentation. Conclusion: In this study, the overall nursing documentation practice was poor. Therefore, it is important to make extra efforts to improve documentation practice by providing planned training on standards of documentation to all nurses, enhancing favorable attitudes, and increasing their knowledge by motivating them to develop a culture of good nursing documentation.