Nurses’ Documentation Practice and Associated Factors in Eight Public Hospitals, Amhara Region, Ethiopia: A Cross-Sectional Study

Abstract

Background Nursing care documentation, which is the record of nursing care that is planned for and delivered to individual patients, can enhance patient outcomes while advancing the nursing profession. However, its practice and associated factors among Ethiopian nurses are not well investigated. Objective To assess the level of nursing care documentation practice and associated factors among nurses working at public hospitals in Ethiopia. Methods An institutional-based cross-sectional study was conducted from May 1 to 30, 2022. A total of 378 nurses and corresponding charts were randomly selected with a multistage sampling technique. Self-administered structured questionnaires and structured checklists were used to collect data about independent variables and nurses’ documentation practice, respectively. Epi Data 4.6 was used for data entry and SPSS version 25 for analysis. Descriptive statistics and binary logistic regression analysis have been employed. The STROBE checklist was used to report the study. Results In this study, 372 nurses participated, and 30.4% (95% confidence interval [CI]: 26%–35%) of them had good nursing care documentation practice. Adequate knowledge about nursing care documentation(adjusted odds ratio [AOR] = 4.16, 95% CI: [2.36–7.33]), favorable attitude toward nursing care documentation (AOR = 3.43, 95% CI: [1.85–6.36]), adequacy of documenting sheets (AOR = 2.02, 95% CI: [1.14–3.59]), adequacy of time (AOR = 3.85, 95% CI: [2.11–7.05]), nurse-to-patient ratio (AOR = 2.78, 95% CI: [1.13–6.84]), and caring patients who had no stress, anxiety, pain, and distress (AOR = 3.56, 95% CI: [1.69–7.52]) were significantly associated with proper nursing care documentation practices. Conclusion Nursing documentation practice was poor in this study compared to the health sector transformation in quality standards due to the identified factors. Improving nurses’ knowledge and attitude toward nursing care documentation and increasing access to documentation materials can contribute to improving documentation practice.