A Study to Assess the Knowledge and Practice of Nursing Documentation In Hospital Among Staff nurses of Selected Hospitals of Aravalli District"

Vatsal Upadhyay

Assistant Professor Mahavir College of Nursing, Vatrak Ta- Bayad, Dist- Arvalli (Gujarat)

*Corresponding Author E-mail: vatsalu96@gmail.com

ABSTRACT:

Background- Documentation ensures safety, quality and continuity of care of the patient. It is to improve, the time management, to avoid the numbers of error in the records, for the need of legal accountability, to make the nursing work visible and for the necessity of making nursing notes understandable to other disciplines. Staff nurses are educated through inservice education and computerized self study modules about complete and accurate documentation. The goal is to implement and evaluate standardized nursing record, positive perceptions of nursing documentation for further development to a nursing documentation including a holistic view of the patient. Aims and Objectives-1. To assess the knowledge of staff nurses regarding Nursing Documentation. 2. To assess the practice of staff nurses regarding Nursing Documentation. 3. To find the association between knowledge and practice with selected demographic variables. Material and Method- A non experimental descriptive design was used in the study. The data was collected from 30 subjects in SFGG hospital and 30 Subjects in Sarvajanik Hospital, through convenient sampling technique. Data was collected using structured questionnaire and observation checklist. Result- The overall analysis of level of knowledge of staff nurses regarding Nursing Documentation showed that mean knowledge score obtained by the subjects was 9.32 (46.6%) with standard deviation of 3.744 and the obtained practice score was 10.68 (71.2%) with standard deviation 2.877.

KEYWORDS: Nursing Documentation, Knowledge, Practice, Staff nurses.

INTRODUCTION:

A document is original or official representing information. The word document is derived from a Latin word – ‘documentum’. Documentation is a very important tool in patient safety and quality of care. Documentation and record keeping systems are to facilitate information flow that supports the continuity of care of the patient. Documentation serves multiple purposes. Eg; legal requirement, accreditation, accountability, financial billing and others. It is a requirement of Joint commission¹

There is currently considerable interest throughout the world within the health care sector to increase the quality of nursing documentation and nursing terminology. This is being accomplished through creating new systems, re-evaluating old systems and analyzing reasons for poor compliance with legislation stipulating registered nurses’ (RNs’) obligation to document. One reason for the emphasis on nursing documentation may be the increasing need for secure and accurate transfer of patientrelated information between different caregivers. The patient record is a principal source of information in which the nursing documentation of patient care is an essential component²

NEED FOR STUDY:

Staff nurses are educated through in-service education and computerized self study modules about complete and accurate documentation. The goal is to implement and evaluate standardized nursing record, positive perceptions of nursing documentation for further development to a nursing documentation including a holistic view of the patient.³

The RN has a paramount responsibility to foreword information about the patient’s needs and treatment to other health care professionals. Traditionally, this has been done verbally. However, today the information on the patient’s condition, care and treatment has become more complex and the amount of individuals in need of this information has increased. Information technology has made its entrance into the health care system whereby verbal transfer of information is becoming obsolete.⁴

The main benefit of documentation is improvement of the structured communication between healthcare professionals to ensure the continuity of individually planned patient care. Without an individualized care plan that is closely followed, nursing care tends to become fragmentary, being based predominantly on institutional routine and schedules. The care plan defines the focus of nursing care not only to the nursing staff but also to the patients and their relatives. By documenting the agreement between patients and RNs, an opportunity is provided for the patients to participate in the decision-making process of their own care. Moreover, the documentation of expert nursing provides an important source of knowledge to the novice RN and a potential motivating force for the further development of nursing theory. The care plan yields criteria for reviewing and evaluating care, as well as financial reimbursement and staffing^5.

In an investigation of dimensions of nursing practice, 137 RNs were asked to rate 28 items describing nursing actions on a four-point scale ranging from essential to slightly important. Results showed that the action of ‘Designing care plans in collaboration with the patient’ received a mean score of 3.25, which ranked as the ninth most important nursing action. The action ‘Use the nursing process as a basis for interventions’ received a mean score of 3.24, which ranked eleventh^6.

A study stated about “Advancing nursing documentation” in Department of Social and Welfare studies, Campus Norrkoping, Sweden. This was a prospective, stratified and randomized intervention study with one intervention group and one control group. A standardized nursing wound care record was designed and implemented in the intervention group for a period of 3 months. Pre-and post 4 intervention audits for nursing record [n = 102 and n = 92, respectively] were carried out and 126 district nurses answered questionnaires. As a result, the standardized nursing wound care record led to more informative, comprehensive and knowledge intensive documentation according to audit and district nurses’ opinion⁷.

OBJECTIVES:

1. To assess the knowledge of staff nurses regarding Nursing Documentation.

2. To assess the practice of staff nurses regarding Nursing Documentation.

3. To find the association between knowledge and practice with selected demographic variables.

MATERIAL AND METHOD:

A non experimental descriptive design was used in the study. The data was collected from 60 subjects from this 30 subjects from SFGG hospital and 30 Subjects from Sarvajanik Hospital, through convenient sampling technique. Data was collected using structured questionnaire and observation checklist. The data was analysed by using Descriptive and Inferential statistics.

RESULT AND DISCUSSION:

Table –I: Frequancy and Percentage vice distribution of the demographic variables [N=60]

Sr No.	Variables		Frequancy (f)	Per (%)
1	Age (In Yrs)	21-30	17	28.3
		31-40	20	33.3
		41-50	16	26.7
		51-58	7	11.7
2	Gender	Male	18	30
2	Gender	Female	42	70
3	Educational Qualification	GNM	60	100
		B.Sc(N)	0	0
		P.B.B.Sc(N)	0	0
4	Years of Experiences	0-5 YR	35	58.33
		6-10 YR	5	8.33
		11-15 YR	16	26.67
		Above 16 YRS	4	6.67
5	Attended In Service or Training	Yes	0	0
5	Attended In Service or Training	No	60	100

Table II: knowledge level of the Staff nurses regarding Nursing Documentation. [N=60]

Knowledge Level	Frequancy (f)	Per (%)
Poor Knowledge	31	51.7
Moderate knowledge	28	46.7
Good Knowledge	01	1.7
Total	60	100

Table-III-Practice level of the staff nurses regarding Nursing Documentation. [N=60]

Practice Level	Frequancy (f)	Per (%)
Poor Practice	26	43.3
Moderate Practice	34	56.7
Good Practice	00	0.0
Total	60	100

Table-IV- Mean, Median and SD of Knowledge and Practice Score staff nurses regarding Nursing Documentation [N=60]

Score	Mean	Mean %	Median	Standard Deviation (SD)
Knowledge Score	9.32	46.6	10	3.74
Practice Score	10.68	71.2	10	2.87

Table-V-Association of knowledge score of staff nurses with the demographic variables. [N=60]

Sr. No	Demographic Variables	< Median	>Median	χ²		Df	Significance
				χ² value	Table value
1	Age			24.67	7.82	3	S
	21-30 year	05	12
	31-40 Year	18	02
	41-50 Year 51-58 Year	02 03	14 04
2	Gender			0.388	3.84	1	NS
	Male	07	11
	Female	20	22
3	Educational Qualification GNM	28	32	-	-	-	NS
4	Years of Experience			6.88	7.82	3	NS
	0-5 yr	30	05
	6-10 yr	02	03
	11-15 yr Above 16 yr	10 03	06 01
5	Attended any program			-	-	-	NS
	No	25	35

Table-V-Association of practice score of staff nurses with the demographic variables. [N=60]

Sr. No	Demographic Variables	< Median	>Median	χ²		Df	Significance
				χ² value	Table value
1	Age			19.70	7.82	3	S
	21-30 year	06	11
	31-40 Year	03	17
	41-50 Year 51-58 Year	14 03	02 04
2	Gender			2.86	3.84	1	NS
	Male	06	12
	Female	24	18
3	Educational Qualification GNM	30	30	-	-	-	NS
4	Years of Experience			1.89	7.82	3	NS
	0-5 yr	18	17
	6-10 yr	02	03
	11-15 yr Above 16 yr	05 02	11 02
5	Attended any program			-	-	-	NS
	No	30	30

CONCLUSION:

The focus of this study was to assess the knowledge and practice of Staff nurses regarding documentation technique at the SFGG Hospital, Vatrak and Sarvajanik Hospital, Modasa. A non experimental descriptive design was used in the study. The data was collected from 60 samples through convenient sampling technique. The data collected was subjected to analysis using descriptive statistics in terms of frequencies, percentage and inferential statistics like ‘t’ test and chi square test to find the association.

REFERANCE:

1. Joint Commission on the Accreditation of Healthcare Organizations. 2003 standards for home health, personal care, and supportive services. Oakbrook Terrace, IL : Joint Commission Resources ; 2003.

2. Socialstyrelsen. The amount of administrative tasks in health care. Internet Publication. 2000.

3. Joint Commission on the Accreditation of Healthcare Organizations. 2005 hospital accreditation standards. Oakbrook Terrace, IL ; Joint Commission Resources ; 2005.

4. Admsen L, Tewis M. Discrepancy between patient’s perspectives, staff documentation and reflections on basic nursing care. Scandinavian J Caring Sciences 2000; 14 (2): 120-9.

5. Kramer M. Nursing care plans. Power to the point. J Nursing Administration 1972 Sep; 29-34.

6. Bradley J. Nurses attitude towards dimensions of nursing practice. J Nursing Research 1982; 32(2):110-4.

7. Tornvall E, Wahren LK, Wilhelmsson S. Advancing nursing documentation, Int. J. Med Inform. 2009 Sep ; 78 (9) : 605 – 17.

Received on 19.12.2022 Modified on 17.01.2023

Int. J. Nur. Edu. and Research. 2023; 11(2):165-167.

DOI: 10.52711/2454-2660.2023.00037