Factors that Contribute to Poor Documentation of Nursing Care in Surgical Units of Lilongwe Central Hospital, Malawi
Kamuzu University of Health Sciences
The researcher's experience through working in different hospitals of Malawi, showed that nurses do not like to document their interventions or nursing care done on the patient. This descriptive quantitative study was designed to discern the factors that contributed to poor documentation of nursing care in surgical units of Lilongwe Central Hospital, Malawi. The study focused mainly on documentation and the nursing process. Literature revealed that this area of nursing practice was not researched on extensively in Malawi and other countries. In the study, Fischbach's model of documentation was used, comprised of three major concepts, namely, Communication skills, Nursing process skills and Documentation standard skills. A convenience sample of twenty Enrolled and Ten State Registered Nurse midwives from ward IA, 4A, 4B and Children's ward was utilised. This was done to meet the proposed sample size. A pilot study was conducted to ensure validity and reliability of the structured questionnaire and checklist developed by the researcher. The main study was conducted from 6th to 18th December 1999. The subjects were requested to answer and fill the structured questionnaire with open and close-ended questions after gaining their consent Furthermore, a checklist was used to find more on the documentation practices in the files of January and February 1999. Data analysis was done manually and using the Statistical Package for Social Sciences to validate the findings. Open-ended questions were analysed by content analysis by Waltz et al (1991) and then categorised in themes to gain insight of the meaning of the findings. Descriptive statistics were used to describe the findings. Results are presented in frequency tables, descriptions, percentages and ratios. The results revealed that some nurses documented their nursing interventions effectively. The majority did not because of shortage of staff and stationery. This report is written to disseminate the findings of the study.