Attitude Towards Documentation and Its Associated Factors Among Nurses Working in Public Hospitals of Hawassa City Administration, Southern Ethiopia.

BACKGROUND: Nursing documentation is the record of nursing care that has been planned and delivered to individual clients by qualified nurses or under the direction of qualified nurses. Various studies have shown that documentation is still a critical issue in both high- and low-income countries, especially in Sub-Saharan Africa like Ethiopia. However, there is a paucity of data in Ethiopia, the attitude of nurses towards nursing care documentation, particularly in the study setting. Therefore, this study aimed to assess the nurse's attitude towards documentation and associated factors in Hawassa City administration public hospitals, Southern Ethiopia.
METHODS: Institutional based cross-sectional study was conducted among 422 nurses from March 01 to 30, 2020. A simple random sampling technique was applied to select the study participants. Data were collected using a self-administered questionnaire. Statistical package of social science (SPSS) version 20.0 software was used for analysis. The association between the attitude of nurses towards documentation and predictors was determined using multivariable logistic regression analysis. The level of statistical significance was determined at a p-value of less than 0.05. RESULT: Among 413 nurses who participated in the study, 58.8% [95% CI of 54.5% to 63.7%] of them had a favorable attitude towards documentation. Work setting [AOR = 1.94 (95% CI: 1.23-3.05)] and Knowledge [AOR = 3.28 (95% CI: 2.08-5.16)], were significantly associated factors with nurses' attitude towards documentation.Conclusion and Recommendations: More than half of the study participants had a favorable attitude towards documentation. Working unit and knowledge were factors associated with nurse's attitude toward nursing care documentation. Therefore, increasing nurse's knowledge about documentation and managing working units effectively are recommended to increase the nurses' attitude toward documentation.

Documentation is the primary source of evidence used to continuously measure performance outcomes against predetermined standards, of individual nurses, health care team members, groups of health care providers, and organizations (American Nursing Association [ANA], 2010). Documentation is part of a legal record that specifies the care and progress of the patient. It is also used for research activity, reimbursement, quality assurance, and auditing clinical service (Aghdam et al., 2012; Avoka Asamani, 2014). It is keeping evidence to have an account of what happened and when it happened (Hana, 2017). It is written or electronically produced data to ensure continuity and planning of care (Kebede, 2017; Nakate, 2015).

Even though documentation is sometimes viewed as burdensome and even as a distraction from patient care, it is critical for effective communication with each other and with other disciplines (ANA, 2010). A survey by the world health organization (WHO) shows that poor communication between health care professionals is one factor for medical errors (Ente et al., 2010). It is estimated that nurses spend approximately 25% to 50% of each shift documenting patient care (Petkovšek & Skela-Savič, 2015; Salameh, 2019).

Nurses' attitude about documentation has an impact on the health care of patients, the nursing profession, the medico-legal suits, and the health care providers themselves (Aghdam et al., 2012; Avoka Asamani, 2014; Collins, 2013; Hana, 2017). Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice (ANA, 2010). Nurses' attitude towards documentation impacts the quality of how and what they document (Ehrenberg, 2001). Nurses' poor attitude about principles of nursing documentation usually results in unfinished and low-quality records (Alkouri, 2016; Salameh, 2019).

Although keeping a patient record is part of a professional obligation, many studies identified deficiencies in the attitude toward documentation among nurses across the globe (Broderick & Coffey, 2013; Lindo, 2016; Okaisu, 2014). Studies in various settings found that while nurses reflect documentation as important for the nursing profession, they consider it a burdensome secondary task that takes nurses away from direct patient care (Smith, 2012). Other studies indicated that most of the nurse's actions are either not documented or inappropriately documented. Also, it lacks accuracy due to the poor attitude of nurses, which creates a problem when it comes to the evaluation of client care (Jasemi, 2012; Mohammed, 2017; Paans, 2010; Petkovšek & Skela-Savič, 2015).

In Ethiopia, nearly all the nursing documentation is conducted through paper-based records (Kebede, 2017; Tasew, 2019). The Ethiopian Federal Ministry of Health (FMOH) Nursing care standards and communication in nursing, section 6 module 4, and Ethiopian Hospitals Reform Implementation Guideline (EHRIG) outlines that quality of patient care depends on the caregiver's ability to have an accurate, timely, and effective exchange of oral or written information, ideas and feelings with patients and colleagues. It is the nurse's responsibility to ensure that a patient's medical record is complete, accurate, containing all the necessary forms in the proper sequence (FMOH, 2011, 2016). Despite this, the nursing care activities remain not documented, which results in nurses' attitude on nursing care documentation in question.

Despite this, there are few studies conducted on this issue in Ethiopia, and there are no studies conducted specifically in the study area. Therefore, this study was aimed to determine the attitude of nurses' towards documentation and to identify factors associated with nurses' attitude towards documentation among nurses in Hawassa city administration public hospitals.

Methods and Materials

Study Setting and Design

An institution-based quantitative cross-sectional study design was carried out among nurses in Hawassa City Administration from March 1-30/2020. Hawassa city is 275 km away from Addis Ababa, the capital city of Ethiopia to the south. The city administration has eight sub-cities, seven urban with 21 Kebeles and one rural with 12 Kebeles. It has a total population of 3,87,087 (Central Statistical Agency, 2017). There are two public hospitals (one Referral hospital and one General Hospital) and ten public health centers found in the city. The Referral hospital, namely Hawassa University comprehensive specialized Hospital (HUCSH) is expected to serve 10 to 18 million people found in the southern region and the surrounding Oromia zones with 406 nurses (HUCSH, 2019). The General Hospital, namely Adare General Hospital (AGH) has been serving about 1,26,458 people with 195 nurses in the hospital (AGH, 2019). Thus, there were 601 nurses in these two governmental hospitals working in different departments.

Population

All employed nurses working in Hawassa City Administration Governmental hospitals were the source population, and sampled nurses during the data collection period in Hawassa City Administration Governmental hospitals were the study population.

Eligibility Criteria

All nurses working in governmental hospitals of Hawassa city administration during the study period were included and nurses who were unable to give responses due to different reasons were excluded.

Sample Size Determination

The sample size was calculated by using the single population proportion formula by considering the following assumptions; the proportion of favorable attitude was taken as 50% from a previous study done in the west Gojjam zone (Andualem A, 2018), with a 95% confidence level and 5% marginal error and by adding 10% non-response rate to increase power, the total sample size was 384 + 38 = 422.

Sampling Procedure

There are two governmental hospitals in Hawassa city administration. Based on the number of nurses the calculated sample size was proportionally allocated for each hospital, HUCSH (285) and AGH (137). The number of nurses in each hospital was selected by using a simple random sampling technique using the prepared sampling frame (lists of nurses with serial numbers) from the human resource department of each hospital.

Data Collection Tools and Quality

Data were collected through a structured, pre-tested, and self-administered questionnaire adopted from reviewing different pieces of literature (Aghdam et al., 2012; Andualem A, 2018; Mohammed, 2017; Petkovšek & Skela-Savič, 2015). The questionnaire includes questions regarding the socio-demographic characteristics of the nurses, organizational factors, nurses' related factors, and nurse's documentation attitude. One day of training was given to data collectors and supervisors about the instrument and the data collection process. The questionnaire was pretested on 5% of the sample size out of the study area in Dilla university referral hospital before the actual data collection period to assess the reliability, clarity, sequence, and consistency of the questionnaire. There were six data collectors (diploma nurses) and two supervisors (BSc nurses) who were not employees of the study hospitals. The completeness of data was checked by the principal investigator and supervisors.

Operational Definitions

Attitude Towards Documentation

The attitude of study participants towards nursing documentation was assessed using a 5-point Likert scale ranging from Strongly disagree to Strongly agree (1= Strongly disagree, 2= Disagree, 3= neutral, 4= Agree, 5= Strongly agree) with 12 measuring items. The total score for attitude questions was dichotomized into favorable and unfavorable attitude by mean score cut off point.

Favorable Attitude

Those respondents who scored greater than or equal to the mean score of attitude questions (Andualem, 2018).

Knowledge

Knowledge of study participants about documentation was measured by using 10 multiple options and multiple-choice type questions where the scoring was based on the type of responses. One was the score for the response of correct options and zero was the score for incorrect options. The total score for knowledge was dichotomized into good and poor knowledge by using 55% as a cut-off point.

Good Knowledge

Those respondents who scored more than or equal to 55% of knowledge questions (Andualem A, 2018).

Nurse to Patient Ratio

The number of patients that an individual nurse serves per shift.

Adequate Nurse to Patient Ratio

When a nurse serves ≤ 2 patients in ICU or ≤ 6 patients in other than Intensive Care Unit (FMOH, 2012).

Data Processing and Analysis

The collected data was checked for completion and cleaned manually. Then data were coded and entered into Epi-data version 3.1 and exported to SPSS version 22.0 for analysis. Descriptive statistics were used to organize and summarize the variables. Binary logistic regression was done to see the crude significant relation of each independent variable with dependent variables. Variables with a P-value <0.25 at 95% confidence interval during the bivariable analysis were entered into multivariable logistic regression analysis. Adjusted Odd ratio with 95% CI was performed on variables to determine the strength of association of variables. A P-value less than or equal to 0.05 was declared to be significant. A Multi-collinearity test was checked to see if there was any linear correlation among independent variables. The model fitness was checked using the Hosmer–Lemeshow model fitness.

Ethics Approval

Ethical clearance was obtained from the Haramaya University, College of Health and Medical Sciences, Institutional Health Research Ethics Review Committee (HU-IHRERC) from which an official letter was offered to acquire permission from administrations of the selected hospitals. Approvals were obtained from the participating hospitals.

Informed Consent

Written informed consent was taken from all the study participants after an explanation about the aims, objectives, benefits, and harms of the study were done. Confidentiality was ensured as well through anonyms of the questionnaire and safe storage of the filled questionnaire.

Results

Socio-Demographic Characteristics of the Respondents

Out of the total 422 sampled nurses, 413 nurses enrolled in the study giving a response rate of 96.56%.

The mean age of the study respondents was 30 years with ±4.4 standard deviation and a range of 21 to 53 years. Most of the respondents 289 (70.0%) fell within the range of 21–30 years age group. More than half 216 (52.3%) of the respondents were females, and 352 (85.2%) of the respondents were BSC degree nurses in their educational status. Two hundred forty (58.1%) of the respondents were working in the in-patient departments. Two hundred thirty-three (56.4%) of the respondents had 6–10 years of work experience as a nursing professional (Table 1).

Table 1.

Socio-Demographic Characteristics of Nurses in Hawassa City Administration Governmental Hospitals, Southern Ethiopia, 2020 (n = 413).

Variables	Category	Frequency	Percentage
Age in years	21–30 years	289	70.0
	31–40 years	108	26.2
	≥ 41 years	16	3.9
Sex	Male	197	47.7
	Female	216	52.3
Level of education	Diploma nurses	46	11.1
	Degree nurses	341	82.6
	MSC nurses	26	6.3
Work experience	≤5 years	132	32.0
	6–10 years	239	57.9
	≥11 years	42	10.2

Organizational Factors

Out of four hundred thirty participants, 261 (63.2%) of them had an operational standard for nursing care documentation in their hospital. One hundred ninety-one (46.2%) participated in in-service training about the nursing standard, of those, 46.9% received the training two or fewer years ago. Two hundred twenty-eight (55.2%) of the respondents provided nursing care for five or fewer patients per day, and 321 (77.7%) of the respondents said there was a shortage of time to provide standard nursing care (Table 2).

Table 2.

Frequency and Percentage Distribution of Organizational Factors of Nurses in Hawassa City Administration Governmental Hospitals, Southern Ethiopia, 2020 (n = 413).

Variables	Categories			Frequency	Percent (%)
Availability of operational standard for nursing care documentation	Yes			261	63.2
	No			152	36.8
Took in-service training about nursing standard	Yes			191	46.2
	No			222	53.8
When did you receive the training (n = 192)	≤2 years ago			117	60.9
	≥3 years ago			75	39.1
The average number of patients cared for by one nurse per shift (nurse to patient ratio)	ICU		≤2	24	5.8
			>2	21	5.1
	Other than ICU		<6	286	69.2
			>6	82	19.9
Shortage of time to provide the standard nursing care	Yes			321	77.7
	No			92	22.3
Current working unit	Out-patient departments	Emergency OPD		108	26.2
		Other OPDs		65	15.7
	Inpatient departments	Medical ward		39	9.4
		Surgical ward		39	9.4
		Pediatric ward		55	13.3
		ICU		45	10.9
		Operating room		62	15.0

Knowledge of Respondents Towards Nursing Care Documentation

Out of 413 respondents, 177 (43%) of them had good knowledge of nursing care documentation. Out of the total respondents who participated in the study, more than half of 243 (59%) knew that nursing care should be documented according to the guideline. Two hundred eighty (67.8%) of the respondents said completeness of the document is one of the principles needed to follow while documenting, and 317 (76.8%) of the respondents said documentation improves the quality of care. Two hundred seventy (65.4%) of the respondents answered that patient assessment data is one of the nursing activities to be documented, and 236 (57.1%) of the respondents answered poor documentation results in poor development of the nursing profession. Two-hundred forty-three (58.8%) respondents answered that the health care provider himself should document the provided nursing care (Table 3).

Table 3.

Knowledge of Documentation Among Nurses in Selected Public Hospitals of Hawassa City Administration, Southern Ethiopia, 2020 (n = 413).

Variables	Categories	Frequency	Percentage
know that nursing care should be documented according to guidelines	Yes	244	59.1
	No	169	40.9
The principles needed to be followed while documenting. (more than one answer is possible)	Error-free	216	52.3
	Complete	280	67.8
	Easily readable	192	46.8
	Chronological	140	33.9
The advantages of patient care documentation (more than one answer is possible)	To improve the quality of care	317	76.8
	For better communication with staffs	271	65.6
	For education and research	168	40.7
	For legal protection	195	47.2
	For Health planning	164	39.7
The main nursing activities that you are expected to document. (more than one answer is possible)	Assessment data	270	65.4
	Progress of patients	242	58.6
	Transfer and discharge of Patients	220	53.3
	Care provided and evaluation	177	42.9
The potential consequences of inadequate documentation. (more than one answer is possible).	Possible imprisonment	207	50.7
	Loss of salary increment (demotion)	128	30.8
	Poor development of the nursing profession	236	57.1
The effects of using non-standard abbreviations while documenting patient care. (more than one answer is possible)	Leads to errors	251	60.8
	Wastes time	160	38.7
	Causes confusion	287	69.5
Actions of documentation that protects you from legal suit. (more than one answer is possible)	Documenting the date and time of care	307	74.3
	Recording only what you saw or did	238	57.6
	Recording in a chronological order	194	47.1
	Make any corrections clearly	205	49.6
The components of documenting medication administration. (more than one answer is possible)	Name of medications	362	87.7
	Date and time of medications	361	87.4
	Routes and dosage of medications	315	76.3
	Nurses name and signature	304	73.6
Responsible person to document the care provided to a patient.	An individual who has observed the care.	5	1.2
	A colleague who has assisted the care.	4	1
	The same individual who provided the care.	243	58.8

The Attitude of Respondents Towards Nursing Care Documentation

The mean score for attitude questions was 46.6 (S.D ± 9.9); the minimum score was 13 and the maximum 60. From the 413 respondents who participated in the study, 243(58.8%) [95% CI of 54.5% to 63.7%] had a favorable attitude on nursing care documentation.

Among all respondents, 227 (55%), 212 (51.3%), and 205 (49.6%) of them strongly agreed that nursing documentation has a positive impact on patient safety; it is as equally important as any other patient documentation; and it ensures continuity of care, respectively. forty-six (11.1%), 44 (10.7%), and 41 (9.9%) of the respondents strongly disagree that documentation makes nurses’ work visible; documentation shows workload and tasks performed by nurses; and benefits can be gain from the use of nursing documentation, respectively (Table 4).

Table 4.

Attitude of Documentation Among Nurses in Selected Public Hospitals of Hawassa City Administration, Southern Ethiopia, 2020.

Variables	Strongly disagree		Disagree		Neutral		Agree		Strongly agree
	N	%	N	%	N	%	N	%	N	%
Nursing documentation of patient care is equally important as any other patient documentation.	22	5.3	31	7.5	29	7.0	119	28.8	212	51.3
Documentation of nursing activities ensures the continuity of care.	19	4.6	26	6.3	42	10.2	121	29.3	205	49.6
Documentation may be of importance to other health care providers.	29	7.0	56	13.6	68	16.5	141	34.1	119	28.8
Nursing documentation enhances the exchange of information between nurses during their change of shift.	21	5.1	26	6.3	30	7.3	148	35.8	188	45.5
Nursing documentation improves the interaction between medical team members.	35	8.5	41	9.9	44	10.7	104	25.2	189	45.8
Documentation serves to show the workload and tasks performed by nurses	44	10.7	118	28.6	48	11.6	101	24.5	102	24.7
Nursing documentation has a positive impact on patient safety.	18	4.4	28	6.8	41	9.9	99	24.0	227	55.0
A well-written report can replace an oral shift report.	14	3.4	44	10.7	29	7.0	130	31.5	196	47.5
Documentation makes nurses’ work visible.	46	11.1	83	20.1	52	12.6	117	28.3	115	27.8
Nursing documentation helps nurses gain sufficient knowledge about patients.	20	4.8	34	8.2	31	7.5	147	35.6	181	43.8
Nursing documentation makes patients' hospital discharge go smoothly.	23	5.6	40	9.7	41	9.9	151	36.6	158	38.3
Many benefits can be derived from the use of documentation in the everyday work of nurses.	41	9.9	43	10.4	30	7.3	140	33.9	159	38.5

Factors Associated With the Nurse’s Attitude Towards Documentation

For analysis of the data, bivariate and multivariable binary logistic regression was done. Crude and Adjusted odds ratio with a 95% confidence interval was calculated to determine the strength of association and statistical significance between documentation attitude and each independent variable.

Based on findings from the multivariable binary logistic regression, the odds of favorable attitude were 1.94 times higher among nurses who were working in the outpatient department than those who were working in the inpatient department [AOR = 1.94 (95% CI: 1.23–3.05)]. Similarly, the odds of favorable attitude were 3.28 times higher among nurses who had good knowledge about documentation than those who had poor knowledge [AOR = 3.28 (95% CI: 2.08–5.16)] (Table 5).

Table 5.

Multivariable Logistic Regression Analysis on the Study of Documentation Attitude and Associated Factors Among Nurses Working in Hawassa City Administration Governmental Hospitals, Southern Ethiopia, 2020 (n = 413).

Variables	Categories	Nurses attitude towards documentation		Crude odds ratio (95% CI)	AOR (95% CI)	p value
		Favorable N (%)	Unfavorable N (%)
Working Unit	Outpatient department	124 (71.7%)	49 (28.3%)	2.57 (1.69–3.90)	1.94 (1.23–3.05)**	.004
	Inpatient department	119 (49.6%)	121 (50.4%)	1	1
Nurse to patient ratio	Adequate	170 (54.8%)	140 (45.2%)	2.00 (1.24–3.24)	0.73 (0.43–1.24)	.248
	Inadequate	73 (70.9%)	30 (29.1%)	1	1
Year of working experience	≤5 years	66 (50.0%)	66 (50.0%)	1	1
	6–10 years	148 (61.9%)	91 (38.1%)	2.23 (1.06–4.66)	1.50 (0.94–2.38)	.083
	≥ 11 years	29 (69.0%)	13 (31.0%)	1.62 (1.05–2.49)	1.80 (0.81–3.97)	.144
Knowledge level	Good knowledge	136 (56.0%)	41 (24.1%)	3.99 (2.59–6.16)	3.28 (2.08–5.16)**	.000
	Poor knowledge	107 (44.0%)	129 (75.9%)	1	1

**Variables having a p-value ≤.05 statistically significant in multivariable analysis.

Discussion

This study assesses nurses' attitude towards documentation and its associated factors in governmental hospitals of Hawassa city administration, Southern Ethiopia. Accordingly, the results of this study indicated that 243 (58.8%) of nurses, [95% CI of 54.5% to 63.7%] had a favorable attitude towards documentation. This finding was in line with other studies conducted in Zambia 54% (Kalengo, 2015), Uganda 54% (Nakate, 2015), Addis Ababa 55.7% (Hana, 2017), and Amhara region 50% (Andualem A, 2018).

On the other hand, this finding is higher than the findings from European Hospitals like Slovenia 44.4% (Petkovšek & Skela-Savič, 2015) and Norway 46% (Bjerkan & Olsen, 2017). This discrepancy could be related to differences in the size of the study samples and the number of hospitals included in the studies. Our study was based on all wards from two hospitals. Moreover, this finding was lower than the study conducted in Indonesia 83.3% (Mote, 2016), Iran 85.8% (Aghdam et al., 2012), India 98.8% (Juliet & Sudha, 2013), South Africa 71.7% (Olivier, 2010), and Gondar 60.7% (Kebede, 2017). This discrepancy might be due to nurses' lack of attention to nursing documentation as professional duties and responsibilities. It might be due to the high workload since the country has a low nurse-to-patient ratio. Also, it might be a lack of in-service training about documentation.

On component-wise attitude, 205 (49.6%) of respondents said documentation ensures continuity of care which was lower than the finding of a study done in Nigeria 98.8% (Taiye, 2015). This difference might be due to the knowledge difference of respondents about documentation. Only 55.0% of respondents said documentation had a positive impact on patient safety which is in line with the study done in European hospital Slovenia (Petkovšek & Skela-Savič, 2015). In this study, only 49.6% of the respondents liked documentation because it ensures continuity of care. This finding was inconsistent with the findings of a study conducted in Nigeria which was 100% (Taiye, 2015). The inconsistency might be due to the knowledge difference among study participants about documentation and other organizational differences.

Regarding the factors associated with nurses’ attitude towards documentation, knowledge of nurses about documentation and their working unit were independently associated with nurses’ attitude towards documentation.

Knowledge may influence one’s action, the findings of this study indicated that nurse’s knowledge about documentation was a significant factor for nurses’ attitude towards documentation. The odds of favorable attitude were 3.28 times higher among nurses who had good knowledge about documentation than those who had poor knowledge. This result was reflected by findings of studies in Slovenia (Petkovšek & Skela-Savič, 2015), Indonesia (Mote, 2016), Uganda (Nakate, 2015), and South Africa (Olivier, 2010). The possible explanation might be nurses with good knowledge understand the importance of nursing care documentation and the impact of poor documentation.

This study revealed that work setting had a significant association with nurses' attitude towards nursing care documentation by which the odds of favorable attitude were 1.94 times higher among nurses who were working in the outpatient department than those who were working in the inpatient department. This finding was supported by studies in Norway (Bjerkan & Olsen, 2017) and Iran (Aghdam et al., 2012). The possible explanation might be there is more than one nurse in the inpatient department who is involved in nursing care documentation which may result in language ambiguities and misunderstandings. Moreover, it might be due to the presence of a high workload and advanced procedures in the inpatient department results in a shortage of time for documentation.

Limitation of the Study

Since this was a cross-sectional study design the cause-effect relationship for all significant associations may not be established. We included only public health facilities in the study setting. This may not be representative of nurses who are working at private facilities.

Conclusions

Overall, more than half of nurses in Hawassa city administration public hospital have a favorable attitude towards documentation. Work unit and knowledge on nursing care documentation were factors significantly associated with the attitude towards documentation. The researchers recommend to the health facilities and the hospital manager that it is necessary to realize that documentation is not an isolated event, and efforts to improve documentation require consideration of the context, the nurse’s knowledge, and the working unit. Therefore, health facilities should emphasize enhancing nurse's knowledge toward documentation through different mechanisms like training, short-term course, and experience sharing. The hospital managers should also focus on improving the working environment by increasing the number of nurses in the hospital and managing the workload.