Documentation Practice and Associated Factors Among Nurses in Harari Regional State and Dire Dawa Administration Governmental Hospitals, Eastern Ethiopia

Figures & data

Figure 1 A conceptual framework of documentation practice and associated factors among nurses in Harari Region and Dire Dawa Administration Governmental Hospitals, Eastern Ethiopia 2019.

Notes: Adapted from Mihiretu K, Yesuf E, Desalegn TZ. Nursing care documentation practice: The unfinished task of nursing care in the University of Gondar Hospital. Informatics for Health and Social Care. 2017;42(3):290–302.¹

Table 1 Socio-Demographic Characteristics of Nurses in Governmental Hospitals of Harari Regional State and Dire Dawa Administration, Eastern Ethiopia, 2019 (n=430)

Variables		Frequency (n)	Percent (%)
Age group (in years)	21–25	93	21.6
	26–30	152	35.3
	31–35	96	22.3
	Above 35	89	20.8
Sex	Male	234	54.4
	Female	196	45.6
Educational level	College diploma	89	20.7
	BSc and above	341	79.3
Work experience (in years)	5 and less	224	52.1
	6–10	117	27.2
	11 and above	89	20.7
Working unit (current)	Medical ward	106	24.7
	Surgical ward	92	21.4
	Pediatrics ward	38	8.8
	OR	34	7.9
	ICU	39	9.1
	Emergency OPD	35	8.1
	Regular OPD	86	20

Abbreviations: OR, operation room; ICU, intensive care unit; OPD, outpatient department.

Table 2 Frequency and Percentage Distribution of Organizational Factors Among Nurses in Governmental Hospitals of Harari Regional State and Dire Dawa Administration, Eastern Ethiopia, 2019 (n=430)

Variables		Frequency	Percentage
Training attended	Yes	211	49.1
	No	219	50.9
Average No of patients cared for by a nurse per shift	5 and less	153	35.6
	6–10	161	37.4
	Above 10	116	27.0
Guideline availability	Yes	206	47.9
	No	224	52.1
Familiarity with standards	Familiar	284	66
	Not familiar	146	34
Documenting sheets	Adequate	257	59.8
	Inadequate	173	40.2
Motivation from supervisors	Available	228	53
	Not available	202	47
Time adequacy	Yes	296	68.8
	No	134	31.2

Table 3 Self-Reported Documentation Practice Among Nurses in Governmental Hospitals of Harari Regional State and Dire Dawa City Administration, Eastern Ethiopia, 2019 (n=430)

Item	Response
	Never		Sometimes		Always
	N	%	N	%	N	%
Do you document the assessments you have done for every patient?	36	8.4	172	40	222	51.6
Do you document problems you find (the nursing diagnosis) for every patient?	52	12.1	200	46.5	178	41.4
Do you document the intervention you have done for every patient?	60	14	184	42.8	186	43.2
Do you document the response to your intervention for every patient?	99	23	175	40.7	156	36.3
Do you document the fluid you administered for every patient?	91	21.2	165	38.3	174	40.5
Do you document the medication you administered for every patent?	46	10.7	106	24.7	278	64.6
Do you document the education or advice you have provided to a patient?	164	38.1	135	31.4	131	30.5
Do you document the fluid balance status of the patient?	100	23.3	189	44	141	32.7
Is all your documentation done immediately after care provided to the patient?	54	12.6	236	54.8	140	32.6

Table 4 Chart Review Documentation Practices Among Nurses in Governmental Hospitals of Harari Regional State and Dire Dawa City Administration, Eastern Ethiopia 2019 (n=421)

Item	Response
	Format Attachment Status				Record Completeness Status of Formats
	Yes		No		Not		Partially		Completely
	N	%	N	%	N	%	N	%	N	%
Is Vital sign sheet attached to patient chart?	387	91.9	34	8.1
Vital signs of the patient are completed and documented well (n=387)					17	4.4	132	34.1	238	61.5
Was medication ordered?	379	90	42	10
Is the medication administration sheet attached to the patient chart? (n=379)	223	58.8	156	41.2
Accurate nursing report about medication of the patient is documented well (n=223)					16	7.2	81	36.3	126	56.5
Was fluid ordered for the patient?	183	43.5	238	56.5
Is IV fluid administration record form attached to the patient chart? (n=183)	30	16.4	153	83.6
Accurate nursing report about administered intravenous fluid for the patient is documented well (n=30)					3	10	25	83	2	7
Is the fluid balance chart attached to the patient chart?	202	48	219	52
The fluid balance status of the patient is completed and documented well n=202					93	46	66	32.7	43	21.3
Is the nursing process format attached to the patient chart?	89	21.1	332	78.9
Nursing admission assessment was completed within 24 hours and attached to the Pt. chart (n=89)					27	30.3	30	33.7	32	36
The nursing diagnosis of a patient is complete and documented (n=89)					31	34.8	34	38.2	24	27
The nursing care plan is documented welland attached to the patient chart n=89)					44	49.4	37	41.6	8	9
Implementation of the care plan is complete and documented in the nursing patient progress report (n=89)					68	76.4	18	20.2	3	3.4
The progress report is documented at the end of each shift (n=89)					75	84.3	9	10.1	5	5.6
Timely evaluation of the implementation of care is completed and documented (n=89)					81	91	8	9	0	0
Is the record legible?					22	5.2	185	44	214	50.8

Table 5 Factors Associated with Documentation Practice Among Nurses in Governmental Hospitals of Harari Region and Dire Dawa Administration, Eastern Ethiopia, 2019 (n=430)

Variable		Documentation Practice		Bivariate Logistic Regression		Multivariate Logistic Regression
		Poor	Good	COR	p–v	AOR(95% CI)
		N	N
Age	21–25	67	31	1		1
	26–30	83	69	1.80	0.031	1.22(0.597, 2.491)
	31–35	39	36	1.99	0.029	1.18(0.448, 3108)
	Above 35	35	70	4.32	<0.0001	3.54(1.170, 10.8)*
Sex	Male	123	111	1
	Female	101	95	1.04	0.831
Education	Diploma	51	38	1
	≥MSc	173	168	1.30	0.270
Working unit	Outpatient	67	54	1		1
	MW	47	59	1.56	0.098	1.01(0.472, 2.145)
	SW	48	44	1.14	0.643	0.592(0.267, 1.315)
	Others	62	49	0.981	0.941	0.547(0.258, 1.163)
Service years	≤5	142	82	1		1
	6–10	52	65	2.165	0.001	1.60(0.783, 3.254)
	Above10	30	59	3.406	<0.0001	1.58(0.587, 4.242)
Guideline	No	141	83	1		1
	Yes	83	123	2.52	<0.0001	1.43(0.89, 2.395)
Familiarity with standard	Unfamiliar	104	42	1		1
	Familiar	120	164	3.384	<0.0001	1.98(1.137, 3.44)*
Documenting sheet	Inadequate	98	75	1		1
	Adequate	126	131	1.359	0.121	1.37(0.810, 2.315)
Motivation	No	148	54	1		1
	Yes	76	152	5.481	<0.0001	4.60(2.721, 7.76)***
Time adequacy	No	90	44	1		1
	Yes	134	162	2.473	<0.0001	1.69(0.951, 2.995)
Training	No	148	71	1		1
	Yes	76	135	3.703	<0.0001	2.53(1.477, 4.35)**
Nurse to patient ratio	Inadequate	150	105	1		1
	Adequate	74	101	1.950	0.001	2.24(1.24, 4.047)**
Attitude	Unfavorable	157	58	1		1
	Favorable	67	148	5.979	<0.0001	5.66(3.17, 10.11)***
Knowledge	Poor	128	80	1		1
	Good	96	126	2.100	<0.0001	0.747(0.420, 1.327)

Notes: *(p<0.05), ** (p<0.001), *** (p<0.0001), others: ICU, OR and Pediatrics ward.

Abbreviations: MW, medical ward; SW, surgical ward; COR, crude odds ratio; AOR, adjusted odds ratio; 95% CI, 95% confidence interval.

Mihiretu K, Yesuf E, Desalegn TZ. Nursing care documentation practice: the unfinished task of nursing care in the University of Gondar Hospital. Inform Health Soc Care. 2017;42(3):290–302. doi:10.1080/17538157.2016.1252766

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