Abstract:
Background: Nursing documentation is an essential component of nursing practice that has a
potential to improve patient care outcome. Poor documentation of nursing care activities among
nurses has been shown to have negative impacts on the health care quality. However, little has
been explored about nursing documentation practice in the study area.
Objective: The aim of this study was to assess documentation practice and associated factors
among nurses working in Jimma university medical center.
Method: Institutional based cross sectional study design was employed. The study was
conducted from March l3 to April 6/2018 among 391 nurses. Data was collected using a
structured self- administered questionnaire. Simple random sampling was used to select the
study participants. Pre-taste was done among 39 (10%) of sampled nurses working in shenen
gibe Hospital and Cronbach’s alpha was calculated. Nursing care standard checklist was used
to review documents from major wards. Data was entered into Epidata version 3.1 and then
exported to SPSS version 21for analysis. Descriptive statistics, Binary logistic regression and
multivariate logistic regression was used to describe, identify candidate variable for multivariate
logistic regression and identify factors associated with documentation practice. P-value of less
than0.05 was used to declare statistical significance in multivariate logistic regression.
Result: Among the participants good nursing documentation was practiced by 48.6%. Adequacy
of documenting formats, motivation from supervisors, in-service training and familiarity with
operational standard of nursing documentation were significantly associated with practice of
nursing care documentation [AOR=0.357, AOR =4.237, AOR =0.462,AOR=2.165, respectively.
Conclusion: Nursing documentation practice was poor among nurses under the study.
Adequacy of documenting formats, availability of motivation, familiarity with operational
standard of nursing documentation and in-service training were significantly associated with
practice of nursing care documentation.
Recommendation: Nursing leaders should motivate the employees to enhance the practice of
documentation, avail the necessary documenting materials besides adequate staffing which may
be related to time shortage. Researchers also need to carry out large scale studies in order to
address the problem.
