| dc.description.abstract | Quality care nursing practice requires quality nursing documentation and reporting to enhance efficient individualized client care. However, studies indicate that documentation of nursing interventions is insufficient.
The study assessed the factors influencing documentation of nursing interventions among qualified nurses working in Kabale regional referral hospital.
A descriptive cross sectional study design was employed to assess 60 qualified nurses working in Kabale Regional Referral hospital selected by simple random sampling using a self administered questionnaire and examination of 35 in patient files for completeness of nursing documentation. Data was analyzed by SPSS.
The study established that the commonest nursing intervention usually documented was administered drugs 35(100%), although all the documentation was incomplete.
The major factors influencing documentation of nursing intervention was work overload 42(70%), under staffing 41(68.3%), lack of hospital policy 35(58.3%), lack of knowledge and skills on how to make care plans 39(65%). Organization of CMEs and staff meetings on documentation 38(63.3%) and development of documentation guidelines 35(58.3%), were the major strategies suggested as ways of improving documentation of nursing interventions.
The study concluded that the level of documentation of nursing interventions was insufficient since nurses documented only drugs administered yet they do much more than this for patients, mainly as a result of work overload, under staffing, lack of hospital policy and lack of knowledge and skills on how to make care plans.
In view of the above findings, the study recommends that the hospital should use student nurses to improve on documentation of nursing interventions, creation of documentation guidelines coupled with support supervision and making continuous professional development regarding documentation
compulsory for all nurses in order to improve their knowledge and skills. | en_US |
