Assessment of Nursing Documentation Practice and Associated Factors among Nurses Working in the University of Gondar Comprehensive Specialized Hospital: Supported by a qualitative study, 2022

Abstract

Abstract Introduction: Nursing documentation is essential evidence-based work for nurses. 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, patients, and communication for nurses and other disciplines, but limited reports in the study area. This study aimed to assess nursing documentation practice & associated factors among nurses working at the University of Gondar comprehensive specialized hospital, Gondar, Ethiopia, 2022. Methods:An institution-based quantitative supported by a qualitative study was conducted from June to July 2022 at the University of Gondar comprehensive specialized hospital. A simple random data collection technique was used for quantitative data. A pre-tested self-administered questionnaire & chart review were used for data collection. Two days of training were given to data collectors and supervisors. The data were cleaned, edited, and entered into Epi data 3.1 statistical packages and exported to Stata version 14 for analysis. Descriptive statistics were computed and results were presented in figures, tables, and texts. The binary logistic regression model was used for analysis. Bi-variable logistic regression analysis was done and variables with P. value <0.25 were entered into multivariable logistic regression analysis. P. value <0.05, adjusted odd ratio, and 95% CI were used to determine the strength of association with dependent variables. For the qualitative study, we used the purposive sampling technique. The interview was recorded with a digital sound recorder and field notes and jotted down until data saturation. Transcribed in verbatim words and all identifiers were removed before data analysis. ‘Open-code’ software was used to analyze the data based on the theme. Results: In this study, 373 participants enrolled, and 364(97.59%) responded. The mean age of the study subjects was 32.35+SD 5. The documentation practice was 51.65%, 95%CI (46.5-56.8). The determined factors were age 26-30 and 31-35[2.97,95%CI(1.09-8.14)], and [3.17, 95%CI:[(1.10-9.14)], medical and ICU units [4.47,95%CI(2.12-9.40)], [3.66,95%CI:(1.36-9.81)], knowledge and attitude[2.21,95%CI:(1.30-3.75)], and [2.72,95%CI:(1.67-4.44)]. Conclusion: The level of documentation practice is a little improved from the previous report but still needs strong work. Age, working unit, good knowledge, attitude, familiarity, and adequate time were the determinant factors in documentation practice. Better to increase awareness, familiarity, and adequate times have been improving the documentation practices.