Attitude Of Nurses And Midwives And Midwives Towards Documentation And Quality Record Keeping

Problem statement

Accurate patient information recording and use among the healthcare team is vital for quality of patient care, and in this way communication is effected through discussion, reports and recording accurate patient information, and additionally it is a valuable source for scientific research, quality of assurance and transparency of the care delivered (Zegers et al, 2011). However, the lack of appropriate nursing records raises various problems, such as difficulty in knowing what care has been provided, ethical and legal problems such as disciplinary action due to lack of evidence on sensitive issues, and difficulty in performing retrospective audits and research activities (Mamseri, 2012). Furthermore, poor documentation potentially negatively affects patients’ continuity of care, which leads to a poor decision-making process and patient outcomes and increased organisational risks (Blair & Smith, 2012).

Indeed, inadequate nurse’s knowledge and attitude on the benefits , and barriers related to the quality of patient record-keeping lead to poor record-keeping of quality, which might have different effects such as low priority given to records management, lack of awareness of the importance of good record-keeping, lack of information sharing between professional work units, tendency to treat records as personal rather than corporate assets, lack of coordination between paper and electronic information strategies, and the need to maintain confidentiality while legitimately freeing information (Ngao, 2015).

Personal observations have noted the lack of institutional policies regarding the quality of patient information record-keeping in public hospitals, particularly nursing progress notes, in Nigeria. Nursing practice in Nigeria has no standardised tool that can be used in the clinical setting by nurses and midwives  to timeously and accurately record and process patient information, and plan the care of the patient (Blair & Smith, 2012).

There is therefore limited information on the nurse’s knowledge and attitudes on the benefits of as well as barrier towards quality of patient record-keeping in hospitals in Nigeria. Hence this study was conducted to investigate the nurses and midwives  and midwives’s knowledge, attitudes, and barriers of quality of patient record-keeping in the public health hospitals of Nigeria.

Aim Of The Study

This study aim was to investigate the quality of patient record-keeping among nurses and midwives  in selected hospitals in Nigeria.

Study aim

This study aim was to investigate the Attitude of nurses and midwives  and midwives towards documentation and quality record keeping

Study objectives

The objectives of this study were:

1. To describe the knowledge of nurses and midwives  on the benefits of the quality of patient record-keeping in selected hospitals in Nigeria;

2. To describe the attitudes of nurses and midwives  on the benefits of the quality of patient record-keeping in selected hospitals in Nigeria;

3. To determine the association between sociodemographic characteristics and nurses and midwives ’ knowledge and attitudes about the benefits of the quality of record- keeping in selected hospitals; and

4. To identify barriers of the quality of patient record-keeping among nurses and midwives  in selected hospitals in Nigeria.

Significance of the study

The findings of the study has provided an understanding of the current nurse’s knowledge, attitudes as well as barriers on the benefits of the quality of patient record-keeping in the selected hospitals in Nigeria. It has provided relevant information about the knowledge and attitudes of nurses and midwives  on the benefits of the quality of patient record-keeping. The findings of the study can be used by relevant stakeholders, such as the management of the hospitals to provide a supporting structure that enhances the quality of patient record-keeping.

Definition of key terms

Nurse: A person who has completed a programme of basic nursing and general nursing education and is authorised by the appropriate regulatory authority to practice nursing in his/her country (Martin & McFerran, 2017). In this study nurses and midwives  referred to those who were working in hospitals with a State diploma or Medical Technical A2 (4 years nursing training completed, enrolled in the program after grade 10 completed), Auxiliary Nursing Diploma A3 (2 years nursing training completed, enrolled in the program after grade 10 completed), nurses and midwives  with Nursing Diploma A1 ((2 or 3 years training completed, enrolled in the program after grade 12 completed), and nurses and midwives  with a Bachelor of Science in Nursing (4 years training completed, enrolled in the program after grade 12 completed) during the data collection period.

Quality of patient records: The completeness, readability and adequacy of the information timeously and accurately recorded from the patient (Zegers et al., 2011). In this study quality of patient records referred to the accuracy, consistency and timeous nature of patient information recorded manually or electronically.

Patient information: Legal documents which must accurately and honestly reflect the nursing actions carried out for a particular patient, providing proof that nursing care was carried out (Van Niekerk, Mogothlane & Young, 2007). In this study patient information records referred to accurate patient information such as patient identification (name, address, age, etc.), patient case history, physical observations, medical records, and patient progress records (subjective, objective, assessment, planning) kept by nurses and midwives .

Record-keeping: Involves making and maintaining complete, accurate and reliable evidence of business transactions in the form of recorded information (Ngoepe, 2012). Record-keeping

referred to systems used by nurses and midwives  to keep information recorded on patients, whether manually or electronically.

Barrier: Something or a situation that makes it difficult or impossible to achieve a certain level of functioning (Ngao, 2015). In this study barrier referred to all personal, social, economic, environmental, technical, political and other barriers that prevent nurses and midwives  from recording patient information.

Attitudes: Can be defined as acquired tendencies that determine a person’s behaviour towards a specific object, subject to the conditions prevailing in the environment (Babu, 2004). In this study attitudes refer to the views or feelings of nurses and midwives  on the benefits of recording and keeping patient information accurately and timeously.

Knowledge: Is defined as an organised structure of facts, relationships, experience, skills and insights that produce a capacity for action (Leidner & Fernandez, 2008). In this study knowledge refers to the degree to which nurses and midwives  understand the benefits of the quality of patient information record-keeping.

Outline of the thesis

Chapter 1: Presents the background to the study, which includes the problem statement, study purpose and objectives, significance of the study, and definition of key terms.

Chapter 2: Present the review of the literature related to nurses and midwives ’ knowledge, attitudes and barriers to record-keeping, record-keeping as an integral part of nursing process, approaches to record- keeping, computer-based methods of record-keeping as well as advantages and barriers associated with record keeping. It also discusses barriers associated with the quality of patient information record-keeping.

Chapter 3: This describes the methodology of the study, which includes study design, setting, and population in association with the data collection process. Validity, reliability and ethical considerations are also described.

Chapter 4: Presents the findings of the study

Chapter 5: Discussion of the findings of the study based to the literature, conclusions, implications, recommendations, and limitations of the study.