Factors Affecting Effective Documentation by Nurses and Midwives in Five Maternities of Buea Health District
Department: Nursing
No of Pages: 50
Project Code: NS8
References: Yes
Cost: 5,000XAF
Cameroonian
: $15 for International students
ABSTRACT
Ideally,
through documentation, nurses/midwives track changes in a patient’s condition,
make decisions about needs and ensure continuity of care. However, midwifery
documentation has often not met these objectives. In Buea health district,
there is a huge gap between the care implemented and the care documented.
This
study was carried out to assess the different factors affecting the effective
documentation of care by nurses and midwives working in five maternities in the
Buea Health District. A cross sectional hospital based descriptive study was
used for this study. A total of 40 participants were enrolled for this study
and a purposive sampling method was used.
Data
collection was done through a well structured questionnaire that was
administered to the health personnel. Statistical Package for the Social
Sciences (SPSS), version 21.0 was used for a statistical descriptive data
analysis. The results showed that the greatest factors affecting documentation
is the lack of a good monitoring system (94.4%), followed by no system of
appraisal and punishment by the institution (75%), the workload that is the
nursing to patient ratio (25%) and the length of shift or lack of time (25%).
Conclusions
The health workers had a good knowledge on documentation of practice. Most of
the participants’ practice of documentation was neither influenced by length of
shift (75%) nor workload (75%). In order to increase the documentation skills
of staff, there must be a monitoring system on documentation and a system of
praises and punishment on the staff pertaining to their documentation practice.
CHAPTER ONE
INTRODUCTION
1.1 Background
Since
the beginning of nursing, documentation has always been an essential part of
the profession. From the time of Florence nightingale in the late 1800s, nurses
have viewed documentation as a very important aspect of their profession
practice.
Nightingale
described the need to document use of air, light, warmth, cleanliness and
proper selection of diet with an aim of collecting and retrieving data to aid
in proper patient management Virginia Henderson, a nurse theorist, promoted the
use of documentation when she introduced the idea of using the nursing care
plans to communicate nursing care during the 1930s but the nursing
documentation was discarded at the patient’s discharge.
As
the profession has evolved with time different tools have been invented to ease
documentation like the nursing care plan came upon by Ellen L. Buell in the
1930s-40s and was implemented in the 1960s-70s in USA and later on spread worldwide.
In addition, the nursing process discovered by Ida Jean Orlando in 1958
contributed to the facilitation of the documentation process.
It
creates a certain framework or route to nursing care and ease the process of documentation;
it is made up of assessment, diagnosis, expected outcome, planning,
implementation, rationale, evaluation. In midwifery, all these tools are being
used for the proper management of the patient and the partogragh is used in the
labor and delivery room for the proper monitoring of the progress of
intrapartum and postpartum.
The
partograph was first introduced by Friedman, graphically depicting the
dilatation of the cervix during labor. Philpott and Castle in 1972 developed
Friedman’s concept into a tool for monitoring labour by adding action and alert
lines. Documentation is the key to continuity of midwifery care. In the medical
profession, the practice of documentation is essential for the survival of the
patient.
This
is because good skills and proper practice without documenting is null and
void, it is considered not done. Midwives are professionally and legally
accountable and responsible for the standard of practice to which they
contribute and this includes record keeping. In the profession of midwifery,
documentation helps to understand the when? why?, and how things occur as it
occur from the antenatal visit to the labor room thereby covering the whole
period of pregnancy.
Midwifery
documentation refers to any and all forms of records done by the midwife in a
professional capacity in relation to the provision of midwifery care (6). The
quality of midwifery care depends on one’s ability of accurate documentation
entered into the patient’s record. Documentation serves multipurpose including
communication, education, research, auditing and monitoring [7, 9-11].
Documentation
and record keeping are essential to record the provision of safe and effective
care for women and their babies and are an integral part of midwifery practice
[12]. A high standard of record keeping is fundamental to the delivery of safe
and professional care (9).
Professional
record keeping includes all forms of recorded communication that supports the
midwifery care provide in partnership with all women – all written ad
electronic health care records, audio and text, emails, laboratory reports,
photos, videos, health talks, group discussions or any other form of
communication pertaining to a woman’s care (13).
There
are basically three (03) forms of record keeping which are: Hand-written
records, Computer based systems electronic) and a combination of both (14).
Hospital records can be broadly classified into four categories based on the
areas of usage. They are: Patients clinical record, individual staff records,
ward records, administrative records with educational value like government
reports NGOs reports etc. (15)
Components
of a patient’s report keeping include: medical records, nurses admission
assessments, nursing records/ progress notes, medication charts, laboratory
orders and reports, vital signs observation charts, hand over sheets and
admission, discharge and transfer checklists/ letters, patient’s assessment
forms (14).
Although
midwifery documentation is a valuable tool for communicating patient’s
information to nurses and other health professionals, it is often difficult for
busy clinicians to see the benefits. Communication, whether written or orals,
has been identified as contributing to approximately 50% of all adverse events
for patients (16). Looking at the actual work documentation gives, it is quite
difficult to practice it properly.
In
the Buea health district, written records are mostly used and the patient’s
medical file has the following section to be filled by the midwife: Nurses
admission assessments, Progress notes, Medication charts, Laboratory orders and
reports, Vital signs observation charts, Discharge and transfer letters,
Partograph, and a Consent form. In addition, there is an end of shift report,
as well as government and NGOs reports to be filled by midwives.
1.2 Statement of the
problem
Though
sometimes neglected due to several reasons, documentation is the backbone of
effective midwifery practice (7). Communication, whether written or orals, has
been identified as contributing to approximately 50% of all adverse events for
patients (16). Inaccurate documentation slows the progress of nursing/midwifery
profession by rendering research difficult and safe patient care is compromised
due to midwife’s incomplete/inaccurate clinical chart (17).
It
is often difficult for busy clinicians to see the benefits (16). Studies have
pointed out that 45.8% of nursing care given was not recorded and 63% of
nursing notes were not written after the first day (18). Umezileke et al.
evaluated the use of the partograph in a Nigeria teaching hospital where only
24% midwives stated that they used the partograph routinely.
This
was found to be attributed to the high maternal mortality in that hospitals, as
up to the 76% of the personnel were not using the partograph (19). An
evaluation of the use of a partograph in two hospitals in Kenya by Rotich et
al. revealed to the finding that each of the 234 reviewed partographs were
either incomplete or incorrectly filled (20).
However, although its significance has been discussed in numerous articles, midwifery documentation remains problematic. Thus, a need to understand the different factors, that may hinder effective documentation in the labor room of our health setting.
1.4 Objectives
1.4.1 General objective
- To identify factors that affect effective documentation among midwives in the maternities of Buea health district.
1.4.2 Specific objectives
This
study seeks to
- Assess midwives’ knowledge of documentation in midwifery practice
- Assess the relationship between workload and quality of documentation
- Assess the relationship between length of shift and effective documentation
- Identify factors that affect effective documentation by midwives in the maternities of Buea health district
