OJN  Vol.5 No.12 , December 2015
The Nursing Documentation Dilemma in Uganda: Neglected but Necessary. A Case Study at Mulago National Referral Hospital
Abstract: In Uganda, nursing documentation still remains a challenge, in most of the government hospitals and some private hospitals, it remains at a manual (non-technology driven) level and omissions have been observed. Nurses continue to capture standard elements in their documentation. A mixed methods intervention study was conducted to determine knowledge and attitudes of nurses towards documentation, including an evaluation of nurses’ response to a designed nursing documentation form. Forty participants were selected through convenience sampling from six wards of a Ugandan health institution. The study intervention involved teaching nurses the importance of documentation and using of the trial documentation tool. Pre- and post-testing and open-ended questionnaires were used in data collection. The results from the close-ended questions were presented in the previous publication; the responses from the open-ended questions would then be presented. The open-ended questions regarding comments about the nursing documentation process and suggestions about the process of implementing the nursing documentation system in the ward units were considered. All participants were provided the opportunity to provide personal comments, reflections, or stories of their experiences with documentation in patient care. A thematic analysis approach was used during data analysis. The results showed that the participants had positive attitude towards documentation of patient care, but they had constraints limiting them to document, they reflected issues concerning the perceived pressure from the administrations and support to document. The study findings have implication that there is need for organizational support and to have multisite studies and extension of the documentation tool.
Cite this paper: Nakate, G. , Dahl, D. , Petrucka, P. , B. Drake, K. and Dunlap, R. (2015) The Nursing Documentation Dilemma in Uganda: Neglected but Necessary. A Case Study at Mulago National Referral Hospital. Open Journal of Nursing, 5, 1063-1071. doi: 10.4236/ojn.2015.512113.

[1]   Higginbotham, E. and McCarthy, R. (2001) Elements of Nursing Negligence. In: O’Keefe, M.E., Ed., Nursing Practice and the Law: Avoiding Malpractice and Other Legal Risks, F.A. Davis Co., Philadelphia, 118-131.

[2]   College of Nurses Ontario (2005) Practice Standard: Documentation. College of Nurses Ontario, Toronto.

[3]   Nurses Board of South Australia (2006) Guiding Principles for Documentation. Nurses Board of Australia, Adelaide.

[4]   Mbabazi, P. and Cassimjee, R. (2006) The Quality of Nursing Documentation in a Hospital in Rwanda. Africa Journal of Nursing and Midwifery, 8, 31-42.

[5]   Ofi, B. and Sowunmi, O. (2012) Nursing Documentation: Experience of the Use of the Nursing Process Model in Selected Hospitals in Ibadan, Oyo State, Nigeria. International Journal of Nursing Practice, 18, 354-362.

[6]   Pearson, A. (2003) The Role of Documentation in Making Nursing Work Visible. International Journal of Nursing Practice, 9, 271.

[7]   Jordan, K.S. (2009) SBAR: A Communication Formula for Patient Safety.

[8]   College of Registered Nurses of British Columbia (CRNBC) (2007) Practice Support: Nursing Documentation. College of Registered Nurses of British Columbia, Vancouver.

[9]   Cheevakasemsook, A., Chapman, Y., Francis, K. and Davies, C. (2006) The Study of Nursing Documentation Complexities. International Journal of Nursing Practice, 12, 366-374.

[10]   Griffith, R. (2004) Putting the Record Straight: The Importance of Documentation. British Journal of Community Nursing, 9, 122-125.

[11]   International Council of Nurses (2012) The ICN Code of Ethics for Nurses.

[12]   Jefferies, D., Johnson, M. and Griffiths, R. (2010) A Meta-Study of the Essentials of Quality Nursing Documentation. International Journal of Nursing Practice, 16, 112-124.

[13]   Hearthfield, M. (1996) Nursing Documentation and Nursing Practice: A Discourse Analysis. Journal of Advanced Nursing, 24, 98-103.

[14]   Hoban, V. (2003) How to Improve Your Record Keeping. Nursing Times, 99, 78-79.

[15]   Moody, L. and Snyder, P.E. (1995) Hospital Provider Satisfaction with a New Documentation System. Nursing Economics, 13, 24-31.

[16]   Gugerty, B., Maranda, M.J., Beachley, M., Navarro, V.B., Newbold, S., Hawk, W., et al. (2007) Challenges and Opportunities in Documentation of the Nursing Care of Patients: A Report of the Maryland Nursing Workforce Commission, Documentation Work Group. Maryland Nursing Workforce Commission, Baltimore.

[17]   Blair, W. and Smith, B. (2012) Nursing Documentation: Frameworks and Barriers. Contemporary Nurse, 41, 160-168.

[18]   Kärkkäinen, O. and Eriksson, K. (2005) Recording the Content of the Caring Process. Journal of Nursing Management, 13, 202-208.

[19]   Bakken, S. (2007) Building Standard-Based Nursing Information Systems. Pan American Health Organization, Washington DC.

[20]   Owen, K. (2005) Documentation in Nursing Practice. Nursing Standard, 19, 48-49.

[21]   Taylor, M. (2005) Clinical Record Keeping Guidelines. Primary Care Trust, South Worcestershire.

[22]   Papathanassiou, I., Kotrotsiou, S. and Bletsa, V. (2007) Nursing Documentation and Recording Systems of Nursing Care. ICUS and Nursing Web Journal, 16, 30-31.

[23]   Pelletier, D., Duffield, C. and Donoghue, J. (2005) Documentation and the Transfer of Clinical Information in Two Aged Care Settings. Australian Journal of Advanced Nursing, 22, 40-45.

[24]   Wood, C. (2003) The Importance of Good Record-Keeping for Nurses. Nursing Times, 99, 26-27.

[25]   Ehrenberg, A. and Birgersson, C. (2003) Nursing Documentation of Leg Ulcers: Adherence to Clinical Guidelines in a Swedish Primary Health Care District. Scandinavian Journal of Caring Sciences, 17, 278-284.

[26]   Darmer, M.R., Ankerson, L., Nielsen, B.G., Landberger, G., Lippert, E. and Egerod, I. (2006) Nursing Documentation Audit—The Effect of a VIPS Implementation Programme in Denmark. Journal of Clinical Nursing, 15, 525-534.

[27]   Pan American Health Organization (1999) Nursing in the Region of the Americas. Washington DC.

[28]   Braa, J., Hanseth, O., Mohammed, W., Heywood, A. and Shaw, V. (2007) Developing Health Information Systems in Developing Countries: The Flexible Standards Strategy. MIS Quarterly, 31, 1-22.

[29]   Heeks, R. (2002) Information Systems and Developing Countries: Failure, Success, and Local Improvisations. The Information Society, 18, 101-112.

[30]   Kossi, E.K., Sæbø, J.I., Braa, J., Jalloh, M.M. and Manya, A. (2012) Developing Decentralised Health Information Systems in Developing Countries—Cases from Sierra Leone and Kenya. The Journal of Community Informatics, 9.

[31]   Moahi, K.H. (2009) ICT and Health Information in Botswana: Towards the Millennium Development Goals. Information Development, 25, 198-206.

[32]   WHO-SEARO Coding Workshop (2007) Guidelines for Medical Records and Clinical Documentation.

[33]   World Health Organization (2006) Framework and Standards for the Development of Country Health Information Systems. Health Metrics Network, Geneva.

[34]   Nakate, M.G., Dahl, D., Drake, K.B. and Petrucka, P. (2015) Knowledge and Attitudes of Select Ugandan Nurses towards Documentation of Patient Care. African Journal of Nursing and Midwifery, 2, 57-65.

[35]   Alhojailan, M.I. (2012) Thematic Analysis: A Critical Review of its Process and Evaluation. West East Journal of Social Sciences, 1, 39-47.

[36]   Braun, V. and Clarke, V. (2006) Using Thematic Analysis in Psychology. Qualitative Research in Psychology, 3, 77-101.

[37]   Potter, P.A., Perry, A.G., Astle, B. and Duggleby, W. (2014) Canadian Fundamentals of Nursing. 5th Edition, Mosby, Toron-to.

[38]   BjoRvell, C., Wredling, R. and Thorell-Ekstrand, I. (2003) Improving Documentation Using a Nursing Model. Journal of Advanced Nursing, 43, 402-410.

[39]   Edelstein, A. (1990) A Study of Nursing Documentation with a Focus to Improve Both Knowledge and Attitude. Journal of Clinical Nursing, 8, 345-352.

[40]   Werner, P. (2004) Reasoned Action and Planned Behavior. In: Peterson, S.J. and Bredow, T., Eds., Middle Range Theories: Application to Nursing Research, Lippincott Williams & Wilkins, Philadelphia, 125-147.

[41]   Martin, A., Hinds, C. and Felix, M. (1999) Documentation Practices of Nurses in Long-Term Care. Journal of Clinical Nursing, 8, 345-352.

[42]   Darmer, M.R., Ankersen, L. and Nielsen, B.G. (2004) The Effect of a VIPS Implementation Programme on Nurses’ Knowledge and Attitudes towards Documentation. Scandinavian Journal of Caring Sciences, 18, 325-332.