Nursing care documentation practice: The unfinished task of nursing care in the University of Gondar Hospital

Abstract

Introduction: Even though nursing care documentation is an important part of nursing practice, it is commonly left undone. The objective of this study was to assess nursing care documentation practice and the associated factors among nurses who are working at the University of Gondar Hospital.

Methods: An institution-based cross-sectional study was conducted among 220 nurses working at the University of Gondar Hospital inpatient wards from March 20 to April 30, 2014. Data were collected using a structured and pre-tested self-administered questionnaire. Data were entered into Epi Info version 7 and analyzed with SPSS version 20. Descriptive statistics, bivariate, and multivariate logistic regression analyses were carried out.

Results: Two hundred and six nurses returned the questionnaire. Good nursing care documentation practice among nurses was 37.4%. A low nurse-to-patient ratio AOR = 2.15 (95%CI [1.155, 4.020]), in-service training on standard nursing process AOR = 2.6 (95%CI[1.326, 5.052]), good knowledge AOR = 2.156(95% CI [1.092, 4.254]), and good attitude toward nursing care documentation AOR = 2.22 (95% CI [1.105, 4.471] were significantly associated with nursing care documentation practice.

Conclusion: Most of the nursing care provided remains undocumented. Nurse-to-patient ratio, in-service training, knowledge, and attitude of nurses toward nursing care documentation were factors associated with nursing care documentation practice.

Keywords: Care left undone; documentation; documentation practice; evidence-based practice; nursing care process.