View metadata, citation and similar papers at core.ac.

uk brought to you by CORE

provided by Stellenbosch University SUNScholar Repository

DOCUMENTATION OF NURSING CARE

CURRENT PRACTICES AND PERCEPTIONS OF NURSES IN
A TEACHING HOSPITAL IN SAUDI ARABIA

Aaron Mtsha

Assignment presented in partial fulfilment of the requirements for the degree of

Master of Nursing at Stellenbosch University

Supervisor: Dr EL Stellenberg March 2009

 i

DECLARATION

By submitting this assignment electronically, I declare that the entirety of the work
contained therein is my own original work, that I am the owner of the copyright
thereof (unless to the extent explicitly otherwise stated) and that I have not
previously in its entirety or in part submitted it for obtaining any qualification.

Date……………………
Signature…………………………

COPYRIGHT © 2008 STELLENBOSCH UNIVERSITY

ALL RIGHTS RESERVED

 ii

ABSTRACT

Nursing documentation is the written evidence of nursing practice and reflects the
accountability of nurses to patients. Accurate documentation is an important
prerequisite for individual and safe nursing care. It is a severe threat for the
individuality and safety of patient care if important aspects of nursing care remain
undocumented. Nursing staff cannot rely on information that is not documented.
Every patient is important and unique hence every patient’s care is individualised
and different according to his/her needs. This is why important aspects of his/her
care need to be documented. Ultimately, the documentation practices reflect the
values of the nursing personnel (Isola, Muurinen and Voutilainen, 2004:79-80).

The goal of this study was to investigate documentation of nursing care with
reference to current practices and perceptions of nurses in a teaching hospital in
Saudi Arabia

Specific objectives of the study were:

 to identify whether the hospital policies are being carried out

 to identify whether the procedures regarding current documentation are being carried
out and
 to explore the perceptions of the nurses regarding the current documentation
practices.

Research Methodology

For the purpose of this study, a non-experimental descriptive design with a

quantitative approach was used. The study was carried out at King Faisal
Specialist Hospital in Jeddah in Saudi Arabia. The total population of 90
registered nurses were used in this study. Questionnaires were distributed to the
participants and they were answered with no identities written on the
questionnaires. After the questionnaires were completed, it was posted in a box
and was collected by the researcher. The questions are straightforward, easily
understood, unambiguous, non-leading, objectively set and aimed at obtaining
views, experiences and perceptions of documentation of nursing care. .
Involvement of participants was voluntary and non-coercive.
 iii

Data analysis were carried out with the support of a statistician, expressed in
tables, frequencies and statistical associations were done between various
variables based on a 95% confidence interval.

The study revealed that:

 Hospital policies are being carried out N=76 (95%)

 Procedures pertaining to documentation of nursing care are being carried out
N=67(83,7%).
 Nurses N=45(56,3%) indicated that paper documentation included a lot of paperwork.
 The Cerner (computer system) is regarded as the best system ever used for
documentation of nursing care N=44(55%)
 The Mycare system (medication ordering system) is regarded as the most reliable,
user-friendly system and nurses are happy with it N=68(85%)

Recommendations are:

 Nurses still need to be taught about the hospital policies

 Nurses should be taught the correct procedure on documenting the patient data
 Nurse clinicians and managers should check the Cerner for compliance with regard to
documentation of physical assessment when conducting audits
 Use of paper for nursing documentation should be minimized by shifting some of the
nursing documentation procedures from paperwork to electronic version
 Continuous updating, in-service training and monitoring to keep nurses abreast with
the dynamic nature of computer usage
 Reviewing of the system, troubleshooting and suggestions from users need to be
attended to on a continuous basis
 It is recommended that a backup system (generator) is in place to ensure continuity
of documentation
 iv

SAMEVATTING

Die dokumentering van verpleegsorg is die skriftelike bewys van die

verpleegpraktyk en weerspieël die toerekenbaarheid van verpleegsters teenoor
pasiënte. Noukeurige dokumentering is ’n belangrike voorvereiste vir individuele
en veilige verpleegsorg. Dit is ’n ernstige bedreiging vir die individualiteit en
veiligheid van pasiënte-sorg, indien belangrike aspekte van verpleegsorg nie
gedokumenteer word nie. ’n Mens kan nie inligting vertrou wat nie gedokumenteer
is nie. Die versorging van elke pasiënt is belangrik en uniek. Dit is waarom
belangrike aspekte aangaande haar/sy versorging gedokumenteer behoort te
word. Uiteindelik weerspieël die dokumenteringspraktyke, die waardes van die
verpleegpersoneel (Isola, Muurinen en Voutilainen, 2004: 79-80).

Die doel van die studie was om dokumentasie van verpleegsorg met verwysing
na huidige praktyke en persepsies van verpleegkundiges in ‘n opleidingshospitaal
in Saudi Arabia te ondersopek.

Spesifieke doelwitte was

 om vas te stel of die hospitaal se beleidsrigtings toegepas word

 om vas te stel of die prosedure t.o.v die huidige dokumentering uitgevoer is
 en’n ondersoek na die persepsies van verpleegsters aangaande die huidige
dokumenteringspraktyke

Vir die doel van hierdie studie is ’n nie-eksperimentele beskrywingsontwerp met ’n

kwantitatiewe benadering gevolg. Hierdie studie was in King Faisal Specialist
Hospital in Jeddah, in Saudia Arabia gedoen. ’n Totale bevolking van 90
geregistreerde verpleegsters was betrokke. Vraelyste was versprei na die
deelnemers en is naamloos beantwoord, sonder dat hulle identiteite op die
vraelys aangebring is. Na voltooiing van die vraelyste, is dit in ’n houer geplaas en
deur die navorser afgehaal. Die vrae is direk, eenvoudig, maklik verstaanbaar,
ondubbelsinnig, nie-afleibaar, objektief opgestel en is daarop gemik om
gesigspunte, ervaringe en persepsies oor dokumentering van verpleegsters te
verkry.

Betrokkenheid van deelnemers was vrywillig en nie afdwingbaar nie.

 v

Data is getabuleer en in histogramme en frekwensies voorgestel. Deur die Chi-

square- toets te gebruik, is statisties betekenisvolle assosiasies tussen
veranderlikes bepaal.

Bevindinge sluit die volgende in:

 Die hospitaalbeleid word toegepas N= 76(95%)

 Prosedure t.o.v. dokumentering aangaande verpleegsorg word uitgedra
N=67(83,7%)
 Verpleegsters het aangedui dat dokumentering op papier, baie papierwerk behels
N=45(56,3%)
 Die Cerner (rekenaarstelsel) word beskou as die beste stelsel ooit in gebruik vir die
dokumentering van verpleegsorg N==44(55%)
 Die Mycare stelsel (medisyne bestellingstelsel) word beskou as betroubaar en
gebruikersvriendelik, en een waarmee verpleegsters gelukkig is N=68(85%).

Aanbevelings is gemaak, gebaseer op die volgende bevindinge:

 Dit is steeds nodig dat verpleegsters die hospitaal se beleidsrigtinge geleer moet
word
 Verpleegsters moet die korrekte prosedure aangaande die dokumentering van die
pasiënt se data geleer word
 Verpleegklinici en bestuurders moet die Cerner nagaan ter voldoening van die
dokumentering van fisiese waardebepalinge tydens ouditeringe
 Die gebruik van papier vir verpleegdokumentering behoort afgeskaal te word deur
van die praktyk van papierwerk na elektroniese dokumentering te skuif
 Voortdurende bywerking van data, indiensopleiding en monitering van verpleegsters
om hulle op die hoogte te hou van die dinamiese aard van rekenaargebruik
 Hersiening van die stelsel, foutspeurdery en voorstelle van gebruikers moet op ’n
voortdurende basis aandag geniet.
 vi

ACKNOWLEDGEMENTS

I would like to thank GOD the almighty for the strength he gave me to be able to
move a step forward in my career, through easy and difficult times he has been
with me.

My sincere gratitude goes to my supervisor Dr E.L. Stellenberg for her undying

support and guidance.

I thank the staff of Stellenbosch University for assisting me with technical work of
my study.

I thank Prof Kidd for his statistical assistance.

My sincere gratitude goes to Ms S. Varachia for her sisterly advice and support in
my study.

I am grateful as well to Ms Olga Seng, King Faisal Hospital’s librarian for her
willingness to always help.

I thank the Chief of Nursing (King Faisal Hospital) Mrs S Lovering for her
assistance in my study.

I thank the Institutional Research Board of King Faisal Hospital for approving my
study, Dr Bin Saddiq for statistical assistance.

I thank my wife Mrs S Mtsha-Nkwintyi for her support, as well as my family and
friends.

Aaron Mtsha March 2009

 vii

TABLE OF CONTENTS

DECLARATION ............................................................................................................................................... i
ABSTRACT ...................................................................................................................................................... ii
SAMEVATTING ............................................................................................................................................ iv
ACKNOWLEDGEMENTS ....................................................................................................................... vi
LIST OF TABLES ........................................................................................................................................ xi
CHAPTER 1 SCIENTIFIC FOUNDATION OF THE STUDY .................................................... 1

 1.1 Introduction....................................................................................................................... 1

1.1.1 Rationale.............................................................................................................. 1
1.1.2 Practice .............................................................................................................. 10
1.1.3 Legislation with reference to Documentation in South Africa ............................ 11

1.1.3.1 Nursing care plan........................................................................................................................... 11

 1.2 Problem statement .......................................................................................................12

 1.3 Research Question ......................................................................................................12
 1.4 Goal ..................................................................................................................................12
 1.5 Objectives .......................................................................................................................12
 1.6 Research methodology...............................................................................................12

1.6.1 Research Design ............................................................................................... 12

1.6.2 Population and sampling ................................................................................... 13
1.6.3 Instrumentation .................................................................................................. 13
1.6.4 Data collection ................................................................................................... 13

 1.7 Data analysis and interpretation ..............................................................................13

 1.8 Reliability and Validity .................................................................................................14
 1.9 Pilot Study ......................................................................................................................14
 1.10Ethical consideration .................................................................................................14
 1.11Study layout .................................................................................................................14
 1.12Conclusion ....................................................................................................................15

1.13 Operational definitions........................................................................................13

CHAPTER 2 LITERATURE REVIEW ............................................................................................... 16

 2.1 Introduction.....................................................................................................................16
 viii

 2.2 Theoretical Perspective ..............................................................................................17

 2.3 Discourse Analysis Of Nursing Documentation ..................................................17

2.3.1 Patients as objects............................................................................................. 17

2.3.2 Patients as subjects ........................................................................................... 18
2.3.3 Holism ................................................................................................................ 19
2.4 Power Relations................................................................................................. 19

 2.4 Documentation Of Nursing Care .............................................................................20

 2.5 Different Nursing Documentation Systems ..........................................................26
 2.6 Nursing Documentation Guidelines ........................................................................28

2.6.1 Accuracy ............................................................................................................ 28

2.6.2 Pitfalls of countersigning .................................................................................... 28
2.6.3 Handling late entries .......................................................................................... 28
2.6.4 How to correct a mistake ................................................................................... 29
2.6.5 Fill in the blank spaces ...................................................................................... 29
2.6.6 Do not throw away your defence ....................................................................... 29
2.6.7 Timing is everything ........................................................................................... 29

 2.7 Exclusion and inclusion criteria for charting .........................................................29

 2.8 Conclusion ......................................................................................................................30

CHAPTER 3 RESEARCH METHODOLOGY ............................................................................... 31

 3.1 Introduction.....................................................................................................................31
 3.2 Research question .......................................................................................................31
 3.3 Goal ..................................................................................................................................31
 3.4 The objectives ...............................................................................................................31
 3.5 Research design...........................................................................................................31
 3.6 Population and sampling ............................................................................................32
 3.7 Instrumentation .............................................................................................................32

3.7.1 The questionnaire .............................................................................................. 33

3.7.2 The design of the questionnaire ........................................................................ 33
3.7.3 Types of questions............................................................................................. 33

 3.7.4...................................................................................... Data collection method

34
 3.8 Ethical consideration ...................................................................................................34
 ix

 3.9 Pilot study .......................................................................................................................34

 3.10Data analysis and interpretation ............................................................................35
 3.11Conclusion ....................................................................................................................35

CHAPTER 4 DATA ANALYSIS AND INTERPRETATION .................................................... 36

 4.1 Introduction.....................................................................................................................36
 4.2 Data Analysis and Interpretation .............................................................................36

4.2.1 Section A: Biographical data.............................................................................. 36

4.2.2 Section B ........................................................................................................... 39

 4.3 Discussions ....................................................................................................................58

 4.4 Conclusion ......................................................................................................................63

CHAPTER 5 CONCLUSIONS AND RECOMMENDATIONS ............................................... 65

 5.1 Introduction.....................................................................................................................65
 5.2 Recommendations .......................................................................................................65

5.2.1 Hospital policies on patients' vital signs ............................................................. 65

5.2.2 Documentation of patient data on the Cerner .................................................... 65
5.2.3 Electronic documentation of the physical assessment of a patient ................... 66
5.2.4 Personal feelings and experiences regarding current documentation: paper
system ........................................................................................................ 66
5.2.5 Personal feelings and experiences regarding current documentation: Cerner. . 66
5.2.6 Personal feelings and experiences regarding current documentation: Mycare
system ........................................................................................................ 66
5.2.7 The use of electronic documentation ................................................................. 67

 5.3 Final conclusion ............................................................................................................67

REFERENCES ............................................................................................................................................. 69
ANNEXURES ............................................................................................................................................... 72

 Annexure A: Questionnaire..............................................................................................72
 Annexure B: Consent letter to the participant ............................................................82
 Annexure C: Letter of approval.......................................................................................83
 Annexure D: Letter of approval from the university ..................................................84
x
 xi

LIST OF TABLES

Table 4.1: Ages of Respondents ............................................................................................37

Table 4.2: Gender ..................................................................................................................37
Table 4.3: Duration of employment at the Hospital of Research............................................38
Table 4.4: Type of ward speciality..........................................................................................38
Table 4.5: Policies pertaining to documentation.....................................................................39
Table 4.6: Hospital policy on patients’ vital signs ...................................................................39
Table 4.7: Patient data that can be recorded in the Cerner ...................................................40
Table 4.8: Electronic Documentation of Physical Assessment ..............................................40
Table 4.9: Problems experienced with manual documentation..............................................42
Table 4.10: Problems experienced with electronic documentation ........................................43
Table 4.11: The advantages of traditional documentation ( writing on paper) .......................43
Table 4.12: Disadvantages of paper documentation?............................................................44
Table 4.13: Advantages of electronic documentation ............................................................44
Table 4.14: Disadvantages of electronic documentation........................................................45
Table 4.15: Interventions used for when computers are down...............................................47
Table 4.16: Security measure to ensure that nobody else can erase or modify an entry
without being identified...........................................................................................................47
Table 4.17: Paper System......................................................................................................48
Table 4.18: Cerner .................................................................................................................48
Table 4.19: Mycare.................................................................................................................49
Table 4.20: Advantages of entering some of the nursing procedures in the electronic system
instead of paperwork ..............................................................................................................50
Table 4.21: Specific practices and procedures documented electronically ............................50
Table 4.22: Electronic nursing action / intervention entries indicating that procedures were
viewed or what must be done such as blood in progress.......................................................51
Table 4.23: Year in which electronic system was introduced.................................................51
Table 4.24: In the immediate post operative phase what must be covered in a nurse's
documentation about the patient ............................................................................................52
Table 4.25: Documentation of a dressing...............................................................................52
Table 4.26: Documentation of disputes in the patient's file ....................................................54
Table 4.27: Relevancy of documentation about a paediatric patient......................................54
Table 4.28: Patient involvement in planning of his or her nursing care..................................55
Table 4.29: Good nursing documentation ..............................................................................55
Table 4.30: Legibility in documentation ..................................................................................56
Table 4.31: Nursing documentation in a patient's file.............................................................56
Table 4.32: Access to the patient's nursing documentation and rationale .............................57
 1

CHAPTER 1
SCIENTIFIC FOUNDATION OF THE STUDY

1.1 INTRODUCTION

Recording is essential for nursing practice and it is an attempt to reflect the

nursing process and to underpin the decision-making process. Systematic and
purposeful documentation itself produces evidence. Thus, as a result of nursing
care documentation, valid and reliable evidence of caring is produced on a daily
basis. It is not however, self evident what kind of documentation and what
documented items can be considered as proof or evidence (Erickson and
Karkkainen 2003:199).

According to Ehnfors and Ehrenberg (2001:303), the patient record is naturally a

vital parameter in health care. The record is used as a basis for care delivery, for
communication between practitioners and institutions and as a document to
ensure continuity of care. The care-givers need access to reliable information and
an appropriate care plan for the patient. In addition, there are increasing demands
for aggregated data from the records to serve other purposes, such as allocation
of resources, assessment of the quality of care, research and health policy
decisions.

This study is about the documentation of nursing care practices and procedures
as well as the nurses’ perceptions regarding documentation practices in use.
Documentation of nursing care is a very important aspect of every nurse’s job as
the old saying goes “if it is not documented it is not done”. What is documented
provides evidence of what has been done and also gives an idea to an interested
person concerning the medical condition of the patient.

1.1.1 Rationale

All nurses are aware of the importance of recording their plans of action and the
actual implementation of care. This was traditionally done as part of an extensive
paper-driven system. To improve efficiency and quality of patient care, hospitals
worldwide are increasingly relying on computer technology to improve not only
efficiency but also accuracy in various fields of health care, including
documentation systems. Electronic-documentation provides real time access to
the patient records, thus the health care worker can constantly and immediately
be aware of the condition, needs and problems as they arise. There are clearly
 2

illustrated clinical alerts of various changes in the patient's condition that can be
noted immediately. Decisions made at the end-point of care provide the most
current patient information and contribute to high quality of care. Another
advantage is that information is entered only once, and if the data-base is
correctly structured, and the same information is needed elsewhere in the record,
it will immediately provide a link to that page. Other advantages mentioned in the
literature, are that it prevents mistakes due to unclear handwriting, signatures not
legible and other variances in the format nurses use when documenting care
(Aydin, Eusebio-Angeja, Gregory, and Korst, 2003:26). It can thus be said that
there are definite advantages to electronic documentation versus traditional
paper-driven documentation systems.

There are different views pertaining to the attitude of nurses towards the use of
computers, which cannot be generalized as being positive or negative. Some of
the researchers decided to assess nurses' attitudes both pre and post
implementation of computer systems. Among variables examined, were factors
influencing computer acceptance, such as users exposed to computers before
and users who were not exposed to computers. According to Krugman, Oman,
Smith and Smith (2005:133), positive attitudes among the nurses were associated
with prior experience with the use of computers. However, researchers also
stated that pre and post computer implementation studies showed contradictory
findings because some of the studies they looked at showed a more positive
attitude than others. Furthermore, they identified an improvement in
documentation of care although this was demonstrated over time with repeated
measures.

It is generally believed that improved accuracy and quality of documentation,

efficiency in communications and better accessibility to and retrieval of data are
benefits of clinical information systems. Aydin, Eusebio-Angeja, Gregory and
Korst's study (2003:28), also agreed that, to improve efficiency and quality of
patient care the hospitals are increasingly relying on computer technology. In their
study they focussed solely on the maternity section's labour and delivery in which
the system was used to continuously monitor uterine contractions and foetal heart
rate. It allowed the user to chart the progress of labour, including interventions at
the bedside computer or at any computer on the unit that is part of the system.

Many of the users initially expressed concerns that the new computerised method
of charting would be more time consuming and would detract from patient
 3

care. This study was done during the transition from paper to computer charting,
during a time when the nurses were still charting both by paper and computer.
They found that less time was spent charting electronically with the use of the
computer than by paper. The use of the system was enhanced further by the
actual physical position of the computers. Computer workstations had been
deliberately placed at the bedside to encourage nurses to stay with the patients in
labour. The nurses therefore could not complain that the computers kept them
away from the patients. They found that switching to a computerised
documentation system enabled nurses to spend less time on documentation and
more time on direct patient care. Nurses could also update care plans easily
(Aydin, Eusebio-Angeja, Gregory and Korst, 2003:28-29). It can thus be said that
there are definite advantages to electronic documentation versus traditional
paper-driven documentation systems.

In Sweden documentation of nursing care is a legal issue. For the purpose of

supporting documentation, clinical decisions and evaluation of care, an electronic
patient care records system was introduced into primary health care. In a study
carried out by Tornvall, Wahren and Wilhelmson (2004:310), the Swedish
government initiated a Swedish Patient Record Act which regulates that the
reason for giving care, the judgements made, interventions administered and the
outcome of care should be documented for the safety of the patient and the
possibility of evaluating the care. Nursing care is legally equivalent to medical
care.

In this particular study of Tornval, Wahren and Wilhemson (2004:310), the

implementation of the electronic patient record involved new knowledge of the
nursing process documentation and new technology about the use of a computer.
The emphasis was on the nurses' experiences, the nursing process and the use
of the keywords they documented. From the results they (Tornval et al. 2005:315)
supported their findings with the following reasons:

 Firstly the introduction of the electronic patient record involved three new
areas to learn and understand simultaneously – the nursing process, the
structural form of documentation and how to use a computer. The feeling of
satisfaction could be derived from the sense of mastering the skill, that is,
being able to control the new technology and document more
comprehensively than before. It is possible that the skill of documenting
 4

nursing care had, however been pushed into the background by the nurses
due to the emphasis on having to learn how to handle a computer instead of
having the possibility of concentrating on and developing the nursing record.

 Secondly the electronic patient record used in the area did not give the general
view desirable from a nursing aspect, the medical diagnosis and treatment dominated
instead. Perhaps the documentation under the keywords nursing history and nursing
status was incomplete.
 Thirdly the role of the Swedish nurse in primary health care could both facilitate
and inhibit nursing documentation. The district nurse makes independent judgements
regarding treatment. However, the attribute of the district nurse's role as a coordinator
with a comprehensive view of the patient's life situation should encourage her/him to
describe the patient's situation as she/he perceives it.
 Fourthly, resistance to the district nurse's documentation from the general
practitioners, who found the nursing documentation too extensive and difficult to
obtain information from, could influence the documentation of nursing care negatively.
But if one reflects over the saying "if it was not documented, it was not done" a great
part of the district nurse's work therefore may not exist. The district nurses in this
study found several advantages in structured documentation.

There is a need for support and education of nurses to strengthen their nursing
identity and make them aware of the value of a wider use of documentation. This
could on the other hand lead to a predominance of documentation of nursing facts
instead of medical care.

According to Turpin (n.d:61-62), since the advent of computers in health care,

nurses have explored the capability of automating the documentation of care. In
the early years according to Turpin there was an effort to take the forms that were
used in the manual process and "import" these into the computers.

Be it electronically or manually the fact remains that documentation of nursing

care has to be meaningful, clear, tangible and unambiguous. As a communication
strategy documentation has to have an ability to send a clear message across to
the next person reading what is written. A nurse has to always bear in mind that it
is the same documentation of nursing care that will be referred to months or years
later, should there be a need to testify and review the same documentation that
she or he has written. However nurses' documentation serves not only to
communicate information to others, but also has a political function as a
 5

presentation of what is important and ethically "right" to report (Buttler, Irving,

Hyde, Macneela, Scott and Treacy, 2006:151).

According to Erickson and Karkkainen (2005:203), nursing care needs a clearly

formulated theoretical basis which is based on consistent recorded caring as
scientific knowledge. Without a clear vision of what problem is experienced by the
patients and in what way knowledge that accumulates about care is passed on,
there is the risk that the documentation of patient care serves other interests and
demands than those of caring and nursing. There is also some danger that the
classified recording of care will focus too much on administration and technology,
and that the reality that should be documented is forgotten.

Erickson and Karkkainen (2005:203) further state that documentation is of central

importance for the results of patient care and for showing the content of nursing. If
written notes are not made of the nursing care, it is also impossible to verify on
what grounds decisions and actions related to nursing care have been based. The
assumption has been that what the nurses have not recorded, they have not done
either. According to studies evaluating nursing care documentation the nurses
record more matters connected with the patients' medical treatment and
admission assessment as well as nursing interventions than caring of the
patients. In spite of attempts, no agreement has been reached on how nursing
care could be made visible in documentation.

The human being is an entity of body, soul and spirit. Therefore it is of utmost
importance that the human being is cared for as a whole entity and that the care
is documented from the point of view of the patient's holistic situation. The main
goal is health, even if in different stages of the process of caring several such
aims may be set down which are indirectly related to health. The aim of caring is
to help the patient to attain as much good health as possible. Health does not
mean absence of illness, for health and suffering or illness is part of life. Caring
and nursing originate in the desire to alleviate this suffering (Karkainnen and
Erickson, 2004:268).

From an ethical point Erickson and Karkkainen (2005:203), further elaborate that
documentation of nursing care is to form a basis for the patients' inviolability and
for the respect and preservation of their dignity. The way in which the care is
recorded reveals the values of the recorder and her view of human beings. When
the nurses genuinely say that they respect the patients and their decisions, they
 6

simultaneously confirm the patient's dignity as a human being. By recording the

patient's wishes and needs regarding how they want to be cared for, the patient's
views are made visible. Thus also the things that the patient regards as important
will be revealed. The patient's or the significant other's view and experience of the
care will be revealed by using straight citations of their own expressions.

Bailey and Howse (1992:372), in their research study on resistance to

documentation stated their concern as being based on a common view that
quality and continuity of patient care can be threatened if essential facts about
patients are blocked. Faced with a chronic communication problem, hospital
managers have implemented corrective measures to resolve it, but with limited
success. Breakdown of communication is of particular concern to nursing
management since much of the duty for clinical communication is assured by
nursing staff and because they (the nurses) are the only professional group that
maintain continuous service for patients over the 24 hour period. Further they
assume responsibility for a large amount of documentation or charting as they
attend to all aspects of patient care. Indeed nurses spend 38% of their day in
activities that involve transmitting information through nursing care plans and
nursing notes. Given this demand for charting and the constant rotation of staff,
one-to-one communication is not feasible. Therefore, critical information must be
written down and permanently stored. It is imperative then, that there be
commitment and compliance among nurses if effective communication is to occur.
Charting is often seen as taking priority over "hands-on care" that nurses regard
as purposeful use of their time and while most nurses will acknowledge the merits
of documentation, few will see the task as rewarding or completely performed.

Involvement of patients in their nursing care is critically important. In the study

carried out by Bondas, Erickson and Karkkainen (2005:128), it has been identified
that the patients and their views were seldom referred to in the documentation of
nursing. The reason for that was not necessarily nurses' lack of knowledge or
their unwillingness to record from a patient-centred point of view, but might have
been because nurses chose to record matters connected with medical treatment
rather than with caring. Recording patient care was reduced to parts of the body
and to physical functions. The nurses did not always seem to be aware of the
patients' need for care. Nurses also preferred recording positive rather than
negative matters. On the other hand, they did not always record all the knowledge
they had of patients. If the patients did not participate in the planning of their care,
 7

any problems specified with regard to patients or nursing diagnosis did not
necessarily define patients' state. Rather they defined the nurses' perception of
patient state or a need chosen from a classification. There is a tendency within a
nursing profession to move away from the traditional focus on basic nursing care
towards more instrumental and technological nursing.

Bondas et al. (2005:128) therefore suggest that, by documenting nursing care in a

patient-centred way, together with the patient whenever this is feasible, it will be
possible to reveal the substance of patient care and to obtain an accurate record
of what nurses do. Documentation may also be obstructed by the fact that nursing
care has not yet created a distinctive image for itself as a scientific area with clear
principles based on its own knowledge base. Bondas et al. caution if nursing is
centred around values foreign to it, this could cause confusion and even
opposition among nurses, which may also result in reluctance to documenting
nursing care.

According to Teytelman (2002:122), the purpose of documentation is to promote

communication among health care providers and to promote good care.
Documentation informs other staff about the patient's health status and care
provided. Moreover documentation is used by the system's risk management
department and quality assurance committees to evaluate patient care and to
determine whether improvements should occur. Documentation is also used by
third party payers to determine if and when they will pay providers for the care of
the patient. It is also used by researchers in health care and for initial and
continuing of licensing grants by health care administrative agencies.
Documentation serves to meet legal and professional standards.

Teytelman further explains that if the nurse has not met these standards, this can
result in harm to the patient because important information regarding statements
and valuable observations can be overlooked. Consequently this may result in
poor documentation being used by a patient's attorney in a lawsuit. Secondly a
nurse-expert witness for the patient may use poorly kept nurses' notes as support
for the conclusion that the patient was poorly monitored by the nursing staff.
Lastly a jury may correlate a sloppy, disorganised record with sloppy,
disorganised care. Some studies indicate that one in four malpractice lawsuits are
decided by information in the patient's record.
 8

Therefore a lack of documentation can be as grave for both the nurse and the
patient as inaccurate or confusing documentation. Nursing is not complete until
the care has been properly documented and the old saying "if it was not
documented, it was not done" applies with strong force today. While incomplete or
inaccurate documentation can be used by a patient's attorney in a lawsuit,
accurate, complete and legible documentation can be a nurse's best defence in a
potential lawsuit (Teytelman, 2002:123).

Tapp (1990:234) in her study on inhibitors and facilitators to documentation of

nursing care practice found that the majority of subjects described a dilemma
between documentation and caring for the patients. Most believed that
documentation is done at the expense of patient care time. Many participants
stated that they created time for documentation by omitting meal breaks, staying
over after the shift or omitting the psychosocial nursing assessments and
interventions. To grapple with the lack of the time issue, one subject described his
charting a "reader's digest note''. He further explained that a "reader's digest note"
is merely words on paper without supporting evidence for reporting stability or
instability of patient condition.

Tapp's study concerning facilitators doing documentation mentioned a theoretical

framework. The nurses were enthusiastic in praise for the efficiency that the
structure of a theoretical nursing framework brought to documentation. They
reported that the use of a discreet vocabulary describing patient problems
amenable to nursing simplified and coordinated care and documentation. Positive
reinforcement from another facilitator could be illustrated when a nursing
supervisor gives praise and positive comments concerning the documentation.
Interesting or gossipy information also facilitated documentation. If a patient is
noncompliant, uncooperative or refuses therapy, it is often recorded. One subject
commented that the only time a nurse charts care is when a patient has refused
something or is being difficult.

Generally in Tapp's study nurses agree that documentation is important legal

evidence that nursing care provides and that without a written record, nursing is
legally indefensible. However, redundancy of forms, repetitive data records and
imprecise language contributed to a lack of accurate documentation. Nurses who
work with a theoretical model of nursing practice express enthusiasm for the
specific terminology and structure it provides. A theoretical model describes a
patient's nursing needs and problems more clearly, therefore, documentation is
 9

more organised and less difficult. Documentation of nursing practice is necessary

to define practice and to provide evidence that nursing care occurs. Effective and
accurate written communication is the link from clinical practice to research and
education.

Involvement of the patient in his or her nursing care as evidenced by nursing care
documentation cannot be emphasised enough. Erickson and Karkkainen
(2004:272), suggest that the best way to document the patient's conceptions of a
situation is to use the patient's own words. Including the patient's viewpoint in the
documentation yields important evidence for caring and nursing care, so that the
visibility of caring will be assured in the future as well. Examining the
documentation of caring and nursing on the practical level, it is important that the
nurses have a common theoretical basis. When the concepts used originate from
a common theoretical foundation, the creation of a consistent structure of nursing
care documentation is possible. Without a clearly expressed theoretical basis,
caring science cannot purport to be an independent domain with its clearly
defined and expressed basis for its activities.

Erickson and Karkkainen (2004:229), in another study on documentation on the

basis of the process model stated that the advantage of the process model from
the standpoint of the documentation of nursing care, is that it provides a logical
structure for recording, which guides the nurse to document systematically and
purposefully. The nursing process is also for its part regarded as creating a basis
for professional nursing. The ongoing computerisation of nursing care
documentation makes the discussion of the nursing process particularly topical,
because it has been regarded as the most suitable for the computerised
structuring and classification of documentation of nursing care. Depending on the
nursing science frame of reference, the nursing care process and its
documentation can be understood in many ways. It can for example, be seen as a
description of the tasks of the nurses, as a method of solving problems and
making decisions and as a theoretical or philosophical model of thinking,
describing caring as a whole.

The documentation of nursing care is always linked to the nurse's internalised

values, which are the nurse's conscious conception of human beings and their
human status. This is why the documentation of care, in accordance with ethical
principles, should be based on the inviolability of the patient's human dignity and
its preservation. Respecting the patients and their opinions imply that the nurse
 10

also records such matters which the patients consider important, even if the nurse
disagrees. The documentation should not reveal the nurse's own viewpoints, but
should reflect the patients' hopes and needs with respect to the way in which they
wish to be cared for. Nursing care documentation should consist of information
about the patient on admission, final evaluation, the discharge plan and nursing
referral based on evaluation (Erickson and Karkkainen, 2003:201).

There are acts or procedures that serve as guidelines and are mandatory for a
South African registered nurse to comply with. Among those acts is
documentation of nursing care whereby a nurse is expected to document her care
given to the patient. It is advised that a registered nurse in his or her daily
professional practice remembers her scope of practice to be able to perform his or
her duties legally and efficiently, The registered nurse must have had sufficient
training and supervision to be able to do any procedure or act that is out of the
scope of practice, especially given the fact that some of the health practice
institutions may expect nurses to be able to do functions that may not be covered
in their scope of practice. (South African Nursing Council regulation R2598 of
1982, Chapter 2).

In chapter 2 of the South African Nursing Council's regulation R387 of 1985, there
are acts or omissions set out in respect of which the Nursing Council can take
disciplinary steps against a registered nurse.

1.1.2 Practice

Wilful or negligent omissions to carry out such acts in respect of diagnosing,

treating, caring, prescribing, collaborating, referring, coordinating and patient
advocacy as the scope of practice of the registered nurse permits, could lead to
disciplinary steps.

Wilful or negligent omission to maintain the health status of the patient under his
care or charge, and to protect the name, person and possessions of such a
patient through:

correct patient identification

determining the health status of the patient and the physiological responses of the
body to disease, condition, trauma and stress
correct administration of treatment, medication and care
the prevention of accidents, injury or other trauma
 11

the prevention of the spread of infection

the checking of all forms of diagnostic and therapeutic interventions of the individual
specific care and treatment of the very ill, the disturbed, the confused, the aged,
infants and children, the unconscious patient, the patient with communication
problems, the vulnerable and high risk patient as well as the monitoring of all the vital
signs of the patient concerned
to keep clear and accurate records of all actions which he performs in connection
with patient
purporting to perform the acts of a person registered in terms of the Medical, Dental
and Supplementary Health Services Professions Act, 1974 and Pharmacy Act 1974,
unless the nurse is also registered in such a capacity.

1.1.3 Legislation with reference to Documentation in South Africa

1.1.3.1 Nursing care plan

"Immediately the patient is delivered into the nurses’ care the registered nurse (not
enrolled personnel) must prepare a nursing care plan based on correct identification,
meticulous history taking, careful physical examination, consideration of the medical
diagnosis and treatment and medical judgement. A clearly defined plan for intervention,
evaluation and recording is essential. The practitioner must ensure that all findings,
actions, observations, reactions, interactions, decisions and any untoward occurrences
are meticulously recorded. All care must be planned according to individual needs. The
practitioner must practise her independent professional judgement with care and where
necessary, must adapt (and not disregard) institutional policy, nursing routines,
procedures, psychological approaches and standing guidelines to the needs of the
patient. Where necessary she must make environmental changes to meet the needs of
the patient and where improvisation is necessary, she must ensure safe methods and
materials. Co-ordination of care given to the patient by other health professionals must
be effected meticulously”, Searle (2004:200).

The importance of record keeping cannot be over emphasized, Pera and van
Tonder (2004:51) caution that legal claims can be instituted against a nurse
months or years later, a nurse must at all times document accurately and
completely because inaccurate and incomplete records are evidence of a nurse
who is negligent. According to the South African Nursing Council Act 33 of 2005 a
nurse may be disciplined if found negligent for not recording his or her nursing
care.
 12

1.2 PROBLEM STATEMENT

The literature reveals definite advantages and disadvantages of changing the

documentation system to the electronic format (Krugman, Oman, Smith & Smith,
2005:135). The use of electronic documentation systems in a specialist hospital in
Jeddah, Saudi Arabia, has been initiated since the opening of the Hospital. It is a
known fact that any new system takes time to be successfully implemented. A
phase in approach was applied resulting in a dual system for a period of time
specifically related to documentation. Currently part of patient information is still
being recorded on paper, while other information is directly electronically
recorded.

In the light of the above the researcher suspects that the nurse as end-user of
electronic documentation will experience problems with electronic documentation
and resistance to change with reference to documentation.

1.3 RESEARCH QUESTION

The researcher has therefore set the following questions as a point of departure
for the research.

Are the procedures and practices regarding electronic documentation in the

hospital being executed? How do nurses experience the electronic system?

1.4 GOAL

The goal of this study is to investigate documentation of nursing care with

reference to current practices and perceptions of nurses in a teaching hospital in
Saudi Arabia.

1.5 OBJECTIVES

To identify whether the hospital policies are being carried out

To identify whether procedures regarding current documentation are being carried
out
Explore the perceptions of the nurses regarding the current documentation practices.

1.6 RESEARCH METHODOLOGY

1.6.1 Research Design

A research design is a blue print for conducting a research study. It maximizes

control over factors that could interfere with the study’s desired outcome. The type
 13

of design directs the selection of a population, sampling procedure, methods of

measurement and a plan for data collection (Burns and Grove, 2001:47).

A non-experimental descriptive design with a quantitative approach will be used.

The study will be carried out in King Faisal Specialist Hospital in Jeddah in Saudi
Arabia.

1.6.2 Population and sampling

There are 10 wards available in the hospital with a. total population of ninety (90)
registered nurses working in these wards. For the purpose of this project the
registered nurses working in these wards will form the target population and all
the registered nurses will be included in the sample.

1.6.3 Instrumentation

A structured questionnaire will be used to collect data. The questionnaire will

enable the researcher to determine whether the hospital policies and procedures
are carried out, to identify problems and whether the nurses are experiencing
electronic recording of nursing care positively.

The questionnaire will consist of both closed and open ended questions. The
questionnaire will be divided into sections.

1.6.4 Data collection

Data will be collected through the use of a questionnaire. Participants will only be
registered professional nurses. The collection will take two weeks to be
completed. The researcher will collect data personally.

1.7 DATA ANALYSIS AND INTERPRETATION

A statistician will be used to assist with the data analysis with the use of a
computerized statistical programme. The researcher will also determine
associations between variables using the chi square tests.

Quantitative information will be presented as percentages and numeric data in

table format. Qualitative information will be analysed by identifying core themes
and sub-themes and then quantifying it.
 14

1.8 RELIABILITY AND VALIDITY

The reliability and validity will be supported by a pilot study, the use of experts in
the fields of nursing, statistics and research methodology. The pre-tested
questionnaire will be checked for inaccuracies and ambiguity to ensure that it
measures exactly what it is supposed to measure.

1.9 PILOT STUDY

A pilot study is commonly defined as a smaller version of a proposed study

conducted to refine the methodology. It is developed much like the proposed
study, using similar subjects, the same setting, the same treatment and the same
data collection and analysis. Burns and Grove (2001:49-50)

The pilot study will be done prior to the collection of data itself under the same
circumstances as the actual study. The questionnaire will be tested for
inaccuracies and ambiguity. 10% (9) registered nurses will be used in the pilot
study. These nurses will not form part of the actual study.

1.10 ETHICAL CONSIDERATION

According to Basson and Uys (1991:96) nursing research must not only be able to
guarantee or refine knowledge, but the development and implementation of such
research should also be ethically acceptable. The ethical acceptability of the
research should apply first of all to the people directly involved in it, but also to the
people involved in carrying out the research.

For the purpose of this project consent will be requested from the Chief of Nursing
Affairs at King Faisal Specialist Hospital in Jeddah in Saudi Arabia and the
Committee for Human Research at the University of Stellenbosch.

Informed written consent will be obtained from each participant. Participation will
be voluntarily and without any coercion (Annexure A). The aim and the reason for
the study will be explained to the participants. Anonymity and confidentiality will
be ensured.

1.11 STUDY LAYOUT

In chapter 1 the rationale, research questions, objectives and aspects related to

the research methodology will be described. Furthermore the general layout of the
study will be covered in this chapter.
 15

In chapter 2 an overview of the literature study will be described.

In chapter 3 the research methodology is described which includes the research

design, research questions, instrumentation, data collection, ethical
considerations, pilot study and data analysis.

In chapter 4 data analysis and interpretation of the data will be described.

In chapter 5 results and recommendations based on the findings of the study will
be described.

1.12 CONCLUSION

This chapter provides the motivation and the scientific foundation for the research
study. The background to the study of the documentation of nursing care, current
practices and perceptions of nurses are addressed. The objectives and the
problem statement are highlighted followed by the format of the five chapters. The
following chapter provides an in-depth theoretical framework for the secondary
data.

1.13 OPERATIONAL DEFINITIONS

ADLS – activities of daily living.

CNS – central nervous system.

CERNER – computer system used to document patients’ vital signs.

FACT SYSTEM – factual accurate completeness and timely.

GIT – gastro intestinal tract.

MYCARE SYSTEM – electronic medication ordering system.

OVR – occurrence variance report .

VIPS – wellbeing integrity prevention and safety.

 16

CHAPTER 2
LITERATURE REVIEW

2.1 INTRODUCTION

Documentation is a professional and legal issue which has been adopted by all
nurse training institutions throughout the world. It is a fundamental concept which
already starts in the foundation phase of the profession and is emphasised
continuously throughout the student nurse’s training and beyond.

Some of the articles in the literature have discussed such concepts as

prerequisites, facilitators and consequences of sound professional nursing
documentation. Different researchers have portrayed different points of
arguments when it comes to nursing documentation. Some of those perspectives
have been grounded on concepts like institutional policies, legal connotations,
perceptions and attitudes of nursing staff and quality of nursing documentation.

Regardless of a researcher's point of argument it has been noted that a large

percentage of reviewed articles show that most research participants perceived
nursing documentation as a good, mandatory, important aspect of patient safety,
is beneficial, facilitates nursing care and is a very good mode of communication
not only among professional nurses, but with other members of the
multidisciplinary fraternity as well.

In this chapter the benefits of nursing documentation, advantages, attitudes

toward nursing documentation, some theoretical perspectives and different forms
of nursing documentation will be discussed. Shortcomings, guidelines or
suggestions on nursing documentation are some of the concepts which a current
researcher has reviewed in some of the research articles. Both negatives and
positives covered in different reviewed articles should therefore act as a strategy
to educate nurses regarding documentation covered by this research as a whole.

When documentation is accurate, individual, pertinent, non-judgemental and up to

date, it promotes consistency, understanding and effective communication
between health care providers. Nursing documentation is an essential element of
professional practice, the role of which is to ensure the quality of nursing care
rendered. For instance a nursing care plan — illustrates the patient's present chief
complaint then follows other complaints, nursing history and assessments. All of
these aspects form the basis from which a patient's hospital stay will be focused
 17

on from a nursing perspective. The primary purpose of documentation of nursing

care is to ensure individuality and continuity of care.

2.2 THEORETICAL PERSPECTIVE

Karkkainen (2004:268) did a theoretical study on documentation of care in which

she started off by stating that the attitude of caring depends on the approach to
the basic questions of existence or ontology. The ontological underpinning of her
theory are ethics that are based on a conscious ethical view of caring reality, with
regards to minor matters and complex or major matters. It is of central importance
that human beings are cared for as body, soul and spirit and not just with respect
to some part. When a human being is cared for as a whole, the essence of the
caring is that there is respect for dignity, which is founded on the quality and
integrity of each person. Human dignity is also based on letting each human being
make individual choices and protect him or herself from infringement. Ethical care
thus means accepting other human beings or patients as they are.

Information recorded in this way will be patient centred instead of having the main
interest focused on to what the nurses do. The intermediaries of the substance of
caring will thus be the concepts and words which describe the various dimensions
of caring. The concepts used will reflect the recorders' ethical principles and their
conception of human beings and the world.

Heartfield (1996:100) in her discourse analysis of nursing documentation states

that, the discursive properties of the texts were: emphasis on bodies, body parts,
bodily functions, health and self "deficits" writing for particular audiences, patient
observation, nursing outcomes, dominance of the voices of the doctors, with a
coinciding absence of the patient's or family's voices and objective language that
filters subjective information or shared understanding of the hospital experience of
the patient. They are read as discourse of nursing documentation that frames
nursing in particular ways.

2.3 DISCOURSE ANALYSIS OF NURSING DOCUMENTATION

2.3.1 Patients as objects

The hospital and more especially the patient record becomes the surface of
emergences for the object of patient. The person enters the hospital as an
individual, through the process of being written about, the person loses the
encumbrance and complex of his or her life and is transformed to patient. This
 18

object status given to the patient makes it manifest, nameable and describable.
The individual is highly visible and able to be categorized, identified and
compared to others. A ‘65 year old alert female admitted for worsening muscular
dystrophy', is by the end of the first page of her admission notes categorised as
mobile, with pain control and a safety concern (Heartfield, 1996:101).

There is a focus on body parts within nurses’ writing. Many entries in the patient
record reveal a systematic non-acknowledgement of the patient as more than an
object. This objective language creates the focus on the parts of the person. The
patient is composed of potential problems deficits, functions and symptoms.
According to Heartfield (1996:101) the patient is constructed as both object and
subject of documentation. The separate parts and problems form the object of
judgement, observation and measurement. It is this objectification and
categorisation that makes the individuals subject to the knowledge that others
have developed. The patient is constituted as more than these parts.

2.3.2 Patients as subjects

Heartfield (1996:101) explained that following an admission the individual is

subjected to the rituals of examination and treatment. Part of becoming a patient
means that they lose their identity. They are rarely referred to by name but are
given descriptive labels such as "patient" or "59 year old man". Through this
process they become the silent recipient of the hospital regime. Patients have a
subjective role but it is the speaking subject that discourse is concerned with and
being discursively made silent, the patients become objects. Heartfield further
states that the patient concept is formed by discourse.

The discursive elements unite to construct patients as a passive collection of

systems, parts and functions, ADLS (activities of daily living), CNS (central
nervous system), GIT (gastro intestinal tract), the list goes endless. Despite the
choice of heading with which to classify the patient, the overall concept of the
patient does not change. The patient is constructed as a fragmented body. These
headings indicate different ways of ordering patients and their problems or deficits
but any selection from this list indicates a conceptual relationship between the
ways of describing the patient as an element of discourse.
 19

2.3.3 Holism

What is written by nurses in the patient records refers to the patient's body as
reduced to parts and functions. In writing about the patient's body, the nurse does
not simply write about the individual's body but it is the body in relation to the
hospital, the disease, the alteration from the norm, the body as it requires nursing
care / time / resource. A viewed concept of patient is presented through nursing
documentation. Of all the nursing observations and actions, only fragments are
documented. The fragments as body parts and functions are the body systems of
medical science (Heartfield 1996:101).

The nurse as person, carer or often decision maker is hidden behind dominant
rational forms of organisation that dictate documentation protocol. Nursing
documentation functions to communicate the performance of medical orders and
patient responses through very specific language. The dominant power of
institutional, scientific, medical knowledge and processes are clearly evident in
the way that nursing is mediated through the patient record (Heartfield 1996:101).

2.3.4 Power Relations

According to Heartfield (1996:102) the hospital is an examining mechanism,

particularly through the use of documentation. Nursing documentation functions
as a manifestation and ritual of power relations. Through the recording of nursing
activities the patient and nurses are examined but communication occurs through
a limited language. While the client as object becomes visible within the care-
notes the nurse disappears.

Other professionals write clearly about their judgements and examinations.

Heartfield's study revealed that the nurses write about observations and
responses in a manner that is passive. Such intentions leave the record devoid of
meaning as anything more than a record of information that assists the other
health care providers. There is no apparent knowledge base that underpins what
nurses are doing that differentiates from them assisting the doctor.

There have been quite a few articles on nursing documentation, some have been
based on certain models. However the literature serves as a guideline to
professional nurses when documenting, indicating what should be documented. It
is of utmost importance for a professional nurse to know what to write especially
when considering a sound professional nursing documentation.
 20

2.4 DOCUMENTATION OF NURSING CARE

The most important purpose of documentation is to communicate to other

members of the multidisciplinary team the patient's progress and general
condition. Documentation of nursing care is also used when looking at the quality
of care rendered to the client whilst he or she is in the capable hands of
professional health care workers. According to Jual and Moyet (2004:9), there are
other important reasons for having nursing documentation done in addition to
what has been mentioned above.

The reasons are to:

 differentiate the accountability of the nurse from that of other members of the health
care team
 provide the criteria for reviewing and evaluating care (quality improvement)
 define the nursing focus for the client or the group
 provide the criteria for client classification
 provide justification for reimbursement
 provide data for administrative and legal review
 comply with legal, accreditation and professional standard requirements
 provide data for research and educational purposes.

Karkkainen and Erickson (2003:199) suggested that recording is essential for

nursing practice and is an attempt to show what happens in the nursing process
and what decision making is based on. Systematic and purposeful documentation
itself produces evidence. Thus as a result of nursing care documentation, valid
and reliable evidence of caring is produced on a daily basis. It is not however, self
evident what kind of documentation and what documented items can be
considered as proof of evidence. The question of what can be regarded as
evidence has indeed given rise to lengthy international debates in recent years.
Knowledge and skills that cannot be measured are also needed, for example
professional clinical skills and the patient's own experience must be taken into
account. This kind of multidimensional understanding of nursing evidence gives
the concept of evidence a novel content which is more compatible with nursing
care.

Karkkainen and Erickson (2003:199) further acknowledged that a prerequisite for

using nursing documents in evidence based nursing care is ensuring the quality of
the documents. The quality of nursing care is evaluated retrospectively, assuming
 21

that what has been recorded has been performed and that good documentation
also indicates good care. Nursing care is evaluated by comparing the notes with
approved standards. In the study carried out by Karkkainen and Eriksson
(2003:199), they found that least attention was paid to nursing diagnosis and
discharge summaries. The final evaluation of the nursing care process was often
a copy of a note written by a physician. In the documents direct citations of
patients’ statements were very rare and only seldom were there any notes
referring to patients' families. The nursing documentation indicated poor planning
and evaluation of nursing care. There was no proof of nurses' ability to analyse
information and draw inferences from it. A comparison of the information on
nursing care provided by the nurses interviewed with the information recorded
showed that they did not always match. The researchers therefore concluded that
nursing care documents do not constitute a comprehensive source of information
about the care that the patient has received.

In Sweden Bjorvell, Thorell-Ekstrand and Wreddling (2003:206), carried out a

study using a VIPS model which is an acronym formed from the Swedish words
for Wellbeing, Integrity, Prevention and Safety. Most of the participants perceived
nursing documentation to be beneficial to them in their daily practice and to
increase patient safety. The use of the VIPS model facilitates documentation of
nursing care. The researchers were positive also that the inhibitors, facilitators
and consequences of nursing documentation identified should help both
registered nurses in practice and their leaders to be more attentive to the
prerequisites needed to achieve satisfactory nursing documentation in patient
records.

In this particular research it is said that the Swedish Board of Health and Welfare
passed a regulation that mandated the nurses to document their nursing care.
According to the regulation the documentation should describe the individual
needs of the patient planned and executed interventions, evaluation and
discharge notes – which comply with the nursing process. The VIPS applies both
to electronic documentation and paper based documentation. Apart from this
particular study there have been reports in other studies that registered nurses
were complaining that the notes that were written were neither valued, nor
accurate and that they were seldom read. Another argument was that the nursing
process is based on a model of a one-to-one nurse-patient relationship whilst
 22

nurses in most hospital situations have multiple patient assignments (Bjorvell et

al., 2003:207).

Some of the barriers revealed in different studies are a lack of knowledge of the
nursing process, negative attitude towards change, inability to see the benefits of
nursing documentation, lack of consistent record systems and routines, lack of
time, lack of support from supervisors and colleagues, organisational obstacles,
difficulties in writing, inappropriate forms and lack of continuity. One of the studies
however also described what registered nurses perceived as motives for
documentation, namely that it should be a working tool and that it should increase
both patient and staff safety.

The results of this particular study by Bjorvell, Thorell-Ekstrand and Wredling

(2003:208), revealed that most registered nurses believed that the nursing
documentation was useful for their work and also that well written nursing
documentation could replace oral shifts reports. A large number of nurses
believed that other professionals had an interest in nursing documentation and
department supervisors did support its implementation. If the nursing
documentation in patient records is asked for by other professionals and
supported by leaders, this may increase the feeling of meaningfulness of the
documentation, as it shows that the notes are also useful for others. On the other
hand there were some inhibitors identified to be contributing to ineffective, nursing
documentation such as – a place to sit when documenting, functional computer or
forms/charts, the opportunity to sit undisturbed when writing. Insufficient time
available for registered nurses to document nursing care in practice is a problem
that has frequently been expressed. However that there might have been
inhibitors found, most of the registered nurses had sufficient knowledge in
documentation and the VIPS model.

According to Isola, Muurinen and Voutilainen (2004:73), there is evidence

suggesting that a continuous performed audit of patient records combined with
discussions of improvement is one way to improve the quality of care and that a
good level of documentation correlates with high quality practise. Thus studies
focussing on nursing documentation also offer useful information on the quality of
nursing care. When the patients' individual needs are carefully assessed, goals
are set to respond to the patients' individual needs, interventions are chosen to
achieve the goals set and the plan is implemented. Furthermore if the goal
achievement is regularly evaluated the quality of nursing care is high.
 23

As much as the nurses have to write everything when they are documenting their
nursing care they also need to adhere to the nurses’ duties so as to fill up the gap
that might be present because for example, in the study carried out by Isola,
Muurinen and Voutilainen, they identified that even though the documentation of
nursing care increased, the medical treatment was, the most documented area.
The researchers pointed out that the documentation should communicate the
patient's situation and progress. The nursing staff should be able to use the
information in everyday nursing care activities. This requires the existence of a
well-structured and freely available basis for documentation.

Isola, Muurinen and Voutilainen (2004:73) identified in their study that evaluation
of nursing documentation performed regularly in order to gain information on the
quality of nursing care is rare in Finland. Although there is some evidence
available to suggest that a continuously performed audit of patient records
combined with discussions of improvement is one way to improve quality of care,
Isola et al (2004:73) suggest that there are serious limitations in using the patient
records as a data source for quality assessment and evaluation of care. However
if nursing documentation is not accurate and adequate, there is an obvious risk to
patient safety and well-being and to the continuity of care. Assessment of the
patient's cognition and documentation of the results of assessment is of major
importance when planning the care on a reliable, individual foundation.

Some previous studies according to Isola et al. (2004:78) do also miss the
cognitive impairment of patients by insufficient assessment of cognitive status.
Another area to which development activities should be targeted is the
documentation of clear and concrete means by which patients’ independent
functioning is supported. Also the nursing personnel should be encouraged to
document information of the patient's own resources. Building nursing care on an
individual basis means that the patient's functional capability and resources
should be carefully assessed and nursing care adjusted accordingly. Also,
documentation of patient care should emphasize the importance of these
activities. Furthermore they also found that almost half of the documents lacked
information on the specific times and frequencies of carrying out preventive or
therapeutic interventions. This is an important result to be taken into account
when considering the development activities. Evaluation is the area that warrants
most attention and development activities. Only every fourth record included
information on every change in the patient's functional capability. Insufficient and
 24

inaccurate evaluation follows from insufficient and inaccurate assessment of

patient needs. When assessment fails, the basis for planning nursing care is
fragile, implementation of the plan is problematic and evaluation of goal
achievement becomes difficult or even impossible.

It is of interest to learn more about to what extent patient records accurately

reflect the situation and the care of the patient. Ehnfors and Ehrenberg (2001:304)
suggest that the patient record should be an important basis for delivery of
nursing care and in the assessment of quality of care. In areas of care where the
patients have limited abilities to express themselves the demand for accurate
patient care records is great, both for everyday care and for retrospective audits.

They also stated that the Swedish Board of Health and Welfare emphasises that
the patient record should provide for the evaluation of the care of patients with
chronic diseases, multiple diseases and at the end of life. In the nursing home
environment in which they did their research they also stated that the patient
record as a data source in nursing home care is therefore of great interest.
Nurses have an essential role in managing and recording nursing as well as
medical care for residents in Swedish nursing homes.

Mental condition, nutritional and hydration status, oral status, status regarding
urinary incontinence, skin condition, physical activity, mobility, disturbed balance
and sleep are all of special importance in the care of elderly patients . These are
factors that influence the self care ability of the patient and are important
predictors of serious risks such as pressure sores and falls. Ehnfors and
Ehrenberg (2001:304) also stated that a great quantity of data is hidden in the
patient records but there are also serious flaws in these data. Nurses need to
make use of patient records for the care of individual patients as well as for other
purposes.

Aggregated record data have the potential to be an important source for

expanded knowledge and improved practice in health care. The findings of this
particular study, together with previous works indicated that at the present state, it
is not possible to rely solely on recorded data for nursing care delivery or for the
assessment of care quality. It is strongly recommended that before using
recorded data for research purposes, investigators should carefully examine the
accuracy of the data and consider the use of additional data sources. Structured
 25

and systematic formats of records seem to increase the accuracy of the data
(Ehnfors and Ehrenberg, 2001:309).

Ankersen, Darmer, Egerod, Landberger, Lipart and Nielsen (2006:532), undertook

a study on nursing documentation audit focusing on the VIPS implementation
programme in Denmark. Ankersen et al (2006:532) found that the study
demonstrated that the VIPS is intuitively easy to understand, which facilitates
implementation. The challenge in documenting the ongoing status of the patient
has been the degree of reuse of information across the patient trajectory. The
study showed that the care plans were motivated by the documented signs and
symptoms. The success of the study was due to the systematic structure of the
VIPS model and the simplification of the diagnostic statement. The majority of the
care plans were standardized, a fact which further obscure the estimated quality
in relation to the individual needs of the patient.

The study has shown that nurses formulate diagnoses regarding existing or
potential problems but none drew upon the patients' resources. One reason may
be that the project leaders and supervisors failed to focus on this aspect. Looking
at patients' resources in a broader perspective, the hospitals are now regarded as
primary targets for preventive strategies related to life style changes. Nurses have
an opportunity to discuss lifestyle changes while patients are hospitalised and
understand the gravity of their situation (Ankersen et al. 2006:532).

Ankersen et al. (2006:533) stated that training the entire staff simultaneously
rather than using key persons has shown promise as a learning method and
implementation strategy in relation to nursing documentation. Clinical supervision
and chart audits have proven to be a good learning experience for the supervisors
as well as the staff nurses. The support of the hospital management is an aspect
of the implementation process, which should not be overlooked. Managerial
nurses need to be proficient in theories of nursing as well as management, as
managers at the unit level should be able to evaluate and supervise nurses in
their effort to improve documentation.

Bondas, Erickson and Karkkainen (2005:124) stated that individual care means
that care is planned together with the patient and takes into consideration the
person's innermost world and his or her needs and wishes. Ethical care means a
desire to do good for the patients. Doing good is shown in ways nurses work and
in the things they do for the patients. Bondas et al. further indicated that the
 26

documentation of nursing care is always related to nurses' internalised values

which means nurses' conceptions of a human being and human existence and
their respect for human dignity. A human being's dignity, which is based on
equality and inviolability, implies a right for patients to make their own decisions
and the right to defend their integrity and therefore, also what is written about their
care. In the documentation of nursing care, Bondas et al. further explain that
respecting patients and their views means that nurses also record matters that in
patients' opinion are important. When the documentation is in accordance with the
ethical principle, its content reveals patients’ hopes and needs regarding how they
wish to be cared for and how they wish to appear in the documentation. Nursing
documentation cannot be based solely on formalistic problem solving, but must be
based on an individual assessment of a situation. One of the shortcomings of care
documentation is the small amount allotted to patients' wishes and needs. Nurses
should be made aware of the importance of documentation that pays attention to
patients' needs and their ability to analyse and express in writing knowledge
derived from nursing, should be improved.

2.5 DIFFERENT NURSING DOCUMENTATION SYSTEMS

Basically two types of nursing documentation systems in nursing care exist, firstly
manual or traditional documentation and secondly electronic nursing
documentation. Both systems have its merits in presenting information about the
patients. Both systems have advantages and disadvantages and consequently
the one is preferred above the other while many nursing professionals sometimes
prefer both.

According to Turpin (n.d:62) one of the important lessons learned about the move
from paper to computerised charting is that the process is not "automatic". The
capacity of computers to sort, rearrange and copy data expands the potential for
data management, however the computers must be programmed to perform the
functions as required. For instance, in a paper chart, a column is needed to write
a date and time for each entry. In a well-designed computer system, the date and
time are defined when the user makes an entry. No specific column is needed
although the programmer must know how the user wishes the data to be
presented. It can be emphasised that undoubtedly the primary concern of
electronic documentation is about communication between nurses, physicians,
inventory control staff and other health care providers in an institution in which the
main focus is the wellbeing of the patient.
 27

La Duke (2001:284) in her study on online nursing documentation found that

nurses were dissatisfied and complained about the length of the time it took them
to document. They felt they were charting information that no one was reviewing
or that was clinically irrelevant. Many of their complaints focussed on the way the
software worked as opposed to the way it has been individualised by the facility.
Physicians on the other hand were unhappy with the "new" nursing
documentation. They were more concerned about the quality of the content being
captured. Nursing staff perceived that their suggestions and requests for changes
to the system were being ignored. Ultimately re-engineering of the system was
conducted with the critical support for the change being from management,
administration and physicians.

In her recommendations La Duke had the following strategies in place:

 Use research based standardized languages for goals, diagnoses and

intervention dictionaries.
 Be sure that there's a value to moving a documentation process online. For
example ask yourself what patient specific data could be shared among disciplines
and what aggregated data could be of use to various departments for process
improvement. Plan hands-on classroom training for users in small bites to maximise
ability to retain and use information. Bring one nursing unit or one discipline online at
a time. Evaluate anxiety, disruption and resistance at each step.

Langowski (2005:124) found from the research she did online on nursing
documentation systems that nurses’ satisfaction increased by 20% because their
perception was that less time was available for direct patient care. There was
significant improvement in quality of nursing documentation. Online nursing
documentation offers prompts, alerts and a customised screen to obtain required
data. Information is documented in real time and health care decisions are made
with the entire patient information available.

According to Ammenwerth, Mansmann, Iller and Eischstadter (2003:70) user

acceptance is often seen as the crucial factor determining the success or failure
of the project. Functionality and usability of the documentation system, training
and support, previously paper-based documentation processes and other
differences in the environment can influence a user's acceptance of a new
computer-based system and thus its overall success. Obviously low acceptance
of computers may make the introduction of computer-based systems difficult.
 28

Another important issue is the acceptance of the nursing process which can be
supported by computer-based nursing documentation.

2.6 NURSING DOCUMENTATION GUIDELINES

Bergerson (1989:11) in his article titled "more about charting with the jury in mind"
had a lot of suggestions of what a nurse has to write about the patient in the chart
and what to leave out. He said that if you are ever involved in a malpractice
dispute, the patient's chart will be your best friend or your enemy. To avoid
making the chart and yourself vulnerable, use a set of charting guidelines called
the FACT system which ensures that each entry is factual, accurate, complete
and timely. Adhere to the facts – the chart should contain descriptive, objective
information: what you see, hear, smell, and feel not what you suppose, infer,
conclude or assume. The chart should contain subjective information too but only
when it is supported by documented facts. For example the entry is written as
"patient appears restless" what does that mean? Does it mean tossing in bed,
talking incessantly or pacing the floor? Bergeson cautions to be descriptive of
what you mean and not conclude and say the patient is restless.

2.6.1 Accuracy

This is a crucial element. Do not make the chart look inaccurate or unreliable for
example do not chart for somebody else or let them chart for you. If you are to
chart for somebody else for any uncontrollable circumstance, make an entry in a
way that implies that somebody else did the intervention.

2.6.2 Pitfalls of countersigning

Bergerson (1989:11) suggest that nurses should review the entry and ensure that
it clearly identifies whoever did the procedure.

What you do not chart can hurt you - when you are very busy, getting your work
done may seem more important than documenting every detail. But from a jury's
point of view an incomplete chart suggests incomplete nursing care. Learn to
anticipate litigation whenever you give patient care.

2.6.3 Handling late entries

Do not squeeze entry in the margins or between existing entries. It looks

unprofessional and may allow the jury to draw a "sloppy chart" of a sloppy nurse
inference. Instead add an entry at the first available space on the next day's chart.
 29

Then document the date and time the event occurred. Clearly identify your entry
as a late entry and be sure to cross reference the late entry with the page where it
should have appeared.

2.6.4 How to correct a mistake

Simply draw a single straight line through the mistake so it remains legible. Then
write "mistaken entry" or "disregard" above or beside it and sign your name. This
is important because falsification of records is evidence of what attorneys call a
consciousness of negligence. The inference is that someone was negligent, knew
it and tried to cover it up.

2.6.5 Fill in the blank spaces

Avoid leaving blank spaces in the chart. When you complete an entry draw a line
to the right and margin. Similarly do not leave a blank space between two entries.
Each new entry should be "snagged up" against the previous one.

2.6.6 Do not throw away your defence

This is illustrated for example, when you have spilled coffee on the page. Do not
throw away, copy it and put the damaged one in the file. Once something is
considered to be part of the official record, do not discard or destroy it.

2.6.7 Timing is everything

You might be very busy and forget to chart the right time of the interventions.
Routinely carry a notepad and keep personal working notes. Do not chart
anything in anticipation of doing it.

2.7 EXCLUSION AND INCLUSION CRITERIA FOR CHARTING

 Document the patient’s behaviour objectively, the chart must reflect nursing care at all
times.
 When documenting avoid unprofessional, derogatory references as these references
are likely to upset patients.
 Whenever possible use the patient’s own words.
 Incident reports are temporarily kept in the patients’ files and when patients are
discharged they are removed.
 It is unethical to document disputes among professionals in the patients’ files, only
nursing care must be documented in the patients’ files.
 Entries must be legible at all times.
 30

Teytelman (2002:123) suggested that any generalizations, nurses opinions or

criticisms of the patient should be left out. The documentation should contain:

 An assessment of the client's health status and situation.

 A care plan or health care plan reflecting the needs and goals of the client.
 Nursing actions and the patient's response to the intervention provided.
 Re-evaluation and needed adjustments to care.
 Information reported to a physician or any other health care provider and that
provider's response.

Teytelman further explains that the ethical principle of veracity serves as the
bedrock issue in documentation. Providing truthful information in the record is of
critical importance. Even if there are other mitigating circumstances, one piece of
falsified documentation casts doubt on the entire record and can easily render an
indefensible malpractice case. It can subject the nurse to not only civil (monetary)
but also criminal liability.

2.8 CONCLUSION

In summary, documentation by the nurse is the written evidence of nursing

practice. It is the communication about the patient's general condition and the
record of the patient's response to nursing, medical and allied professional
interventions. Legally, if what nurses do is not documented, it was not done.
Nursing clinicians, educators, administrators and researchers use accurate and
timely records to assist in the development of a knowledge base for nursing
practice (Tapp, 1990:229).

If the medical record is complete, accurate and reflects the documentation of high
quality, non-negligent care, it can be the nurse's "best defence" against
allegations of negligence. If, however, the documentation is incomplete, contains
gaps, is not consistently done pursuant to policies and is inaccurate, then the
record can and will be used to support the allegations of negligence in the
patient's complaint according to Brent (2001:81). Thus adherence to guidelines
for proper documentation is essential.
 31

CHAPTER 3
RESEARCH METHODOLOGY

3.1 INTRODUCTION

In this chapter the researcher describes the research methodology followed in this
research study.

3.2 RESEARCH QUESTION

For the purpose of this study the researcher set the following questions as a point
of departure for the research.

Are the procedures and practices regarding electronic documentation in the

hospital being executed? How do nurses experience the electronic system?

3.3 GOAL

The goal of this study was to investigate documentation of nursing care with
reference to current practices and perceptions of nurses in a teaching hospital in
Saudi Arabia.

3.4 THE OBJECTIVES

to identify whether the hospital policies are being carried out

to identify whether procedures regarding current documentation are being carried out
explore the perceptions of the nurses regarding the current documentation practices.

3.5 RESEARCH DESIGN

The research design flows directly from the particular research question or
hypothesis and from the specific purpose of the study. Simply stated, the research
design is the set of logical steps taken by the researcher to answer the research
question. It forms the ‘blue print’ of the study and determines the methodology
used by the researcher to obtain sources of information, such as subjects,
elements and units of analysis, to collect and analyze the data and to interpret the
results (Brink, 2006:92).

For the purpose of this study, a non-experimental descriptive design with a

quantitative approach was used. The study was carried out at King Faisal
Specialist Hospital in Jeddah in Saudi Arabia. Questionnaires were distributed to
the participants and they were answered anonymously with no identities written
 32

on the questionnaires. After the questionnaires were completed, they were posted
in a box and were collected by the researcher. The questions were
straightforward, easily understood, unambiguous, non-leading, objectively set and
the purpose was to attain views, experiences and perceptions of documentation
of nursing care.

Focus areas were (a) the contemporary shift to electronic documentation (b)
working in both traditional and electronic paradigms (c) perceptions with regard to
the impact on quality of care, patient outcome and patient safety. Involvement of
participants was voluntary and non-coercive.

3.6 POPULATION AND SAMPLING

According to Brink (2006:123) a population is the entire group of persons or

objects that is of interest to the researcher, in other words, that meets the criteria
which the researcher is interested in studying.

The total population were 90 registered nurses working in different wards of King
Faisal Specialist Hospital in Jeddah, Saudi Arabia. All of the 90 registered nurses
participated with 9 out of 90 making up the pilot study and 81 remaining for the
actual; study. The population was a limitation as all the nurses were included in
the study.

3.7 INSTRUMENTATION

Instrumentation is a component of measurement. It is the application of specific

rules to develop a measuring devise. The purpose of instrumentation is to
produce trustworthy evidence that can be used in evaluating the outcomes of
research (Burns and Grove, 2001:389).

A structured questionnaire with both open and close-ended questions were used
to collect data. The questionnaire enabled the researcher to determine whether
the hospital policies and procedures were carried out, identify problems and
whether the nurses experienced electronic recording of nursing care positively.
The questionnaire had two sections namely section A and section B. The total
number of questions was 33. There were 32 closed ended questions with
answers to choose from and 1 open-ended question, the last question number 33.
Section A concentrated on biographical data which consisted of gender, age,
ward speciality and duration of work in the hospital of research. Section B
concentrated on nursing documentation policies and procedures, various
 33

documentation systems, advantages and disadvantages of documentation

systems, as well as nurses’ perceptions about current documentation systems
used in the hospital of research.

Participants were all registered professional nurses working in different wards.

Data was collected by answering the question in a questionnaire and after the
respondents completed the questionnaires, the questionnaires were collected by
the researcher.

The questionnaire was based on literature study and the researcher’s clinical
experience in the hospital. It was validated by experts in nursing, the ethical
committee and the statistician.

3.7.1 The questionnaire

Burns and Grove (2001:426) define a questionnaire as a printed self-report form

designed to elicit information that can be obtained through the written response of
the subject.

3.7.2 The design of the questionnaire

A structured questionnaire was used with information about the research study. It
was easy, clear and had instructions on how to go about completing it. The nature
of the questions in the questionnaire ensured rapid computation and statistical
analysis of the data obtained.

The questionnaire had two sections, namely section A and section B. Section A
was basically demographic data and section B was about the policies and
procedures pertaining to nursing documentation performed in the wards and the
perceptions of the registered nurses regarding the types of documentation
systems.

3.7.3 Types of questions

The questionnaire consisted of 33 questions with 32 of the questions being

multiple- choice, close-ended questions with answers provided. The last question
number 33 was an open-ended question about the general nurses’ view with
regards to electronic documentation of nursing care in the chosen hospital.
 34

3.7.4 DATA COLLECTION

The target population of the registered nurses working at King Faisal Hospital in
Jeddah, Saudi Arabia was given a questionnaire by the researcher. The
respondents were requested to complete the questionnaire and the completed
questionnaires were collected by the researcher.

3.8 ETHICAL CONSIDERATION

Nursing research must not only be able to guarantee or refine knowledge, but the
development and implementation of such research should also be ethically
acceptable. The ethical acceptability of the research should apply first of all to the
people directly involved in it, but also to the people involved in carrying out the
research (Basson and Uys 1991:96).

For the purpose of this project consent was obtained from the Chief of Nursing
Affairs at King Faisal Hospital in Jeddah, Saudi Arabia and the Committee for
Human Research at the University of Stellenbosch in South Africa.

Informed written consent was obtained from each participant. Participation was
voluntary and without any coercion. The aim and the reason for the study were
explained to the respondents. All respondents were assured of anonymity and
confidentiality.

3.9 PILOT STUDY

According to Delport, de Vos, Fouche and Strydom (1998:211) a pilot study is the
process whereby the research design for a prospective survey is tested. A pilot
study can be regarded as a small-scale trial run of all the aspects planned for use
in the main enquiry. Burns and Grove (2001:49-50) on the other hand stated that
a pilot study is commonly defined as a smaller version of a proposed study
conducted to refine the methodology. It is developed much like the proposed
study, using similar subjects, the same setting, the same treatment and the same
data collection and analysis techniques. However, a pilot study could be
conducted to develop and refine a variety of the steps in the research process.
For example a pilot study could be conducted to refine a research treatment, a
data collection tool, or the data collection process. Thus a pilot study could be
used to develop a research plan (Burns Grove, 2001:49-50).
 35

A pilot study was done prior to the actual collection of the data to pre-test the
instrument for inaccuracies and ambiguity and the feasibility of the study. A total
number of 9 (10%) registered nurses were used in the pilot study. These nurses
did not form part of the actual study. Permission was obtained from the hospital's
Institutional Research Board and from the participants respectively. The pilot
study was conducted as the actual study. The pre-tested instrument was found to
be accurate and without any ambiguity.

None of the respondents reported any difficulty in answering the questionnaire,

and stated that they took 15-20 minutes to answer the questionnaires. The pilot
study showed understanding of the questionnaire and there was no need to
change the questionnaire.

3.10 DATA ANALYSIS AND INTERPRETATION

The data of the study was analysed by the researcher with the support of the
statistician. The SPSS computer programme was used to organise data from the
respondents. The data was presented in frequencies, tables and statistical
associations done between variables using the Chi square test on a 95%
confidence interval.

3.11 CONCLUSION

The various steps for research methodology adopted for this study were outlined.
The research design, target population and the research process were discussed.
The research objectives, research instrument, data analysis, pilot study and
ethical consideration for this study were highlighted. The next chapter presents
the summarized findings by descriptive analysis followed by the discussion of the
primary findings in keeping with the objectives.
 36

CHAPTER 4
DATA ANALYSIS AND INTERPRETATION

4.1 INTRODUCTION

In this chapter the data analysis and the findings of the collected data from the
research is presented. All the data from completed questionnaires were
transferred to the computer by the statistician working together with the
researcher. The data are presented, analyzed and interpreted in this chapter. All
the respondents were registered nurses. There were 81 questionnaires
distributed; only one was spoilt and the remaining 80 were returned completed.
No complaints of inability to understand the questionnaire or difficulty experienced
in answering questions were reported.

The data are presented in the form of frequency distribution tables. Bar charts
were created from the frequency distribution tables. A follow up confirmatory
analysis to test for equality of proportions across the levels of the variables was
carried out using the chi-squared test. The chi-squared test for independence was
also used to test for associations between demographic variables and the
responses to the various questions. The p-value is the measure reported from all
tests of statistical significance. It is defined as the probability that an effect at least
as extreme as that observed in a particular study could have occurred by chance
alone. If the p-value is greater than 0.05 by convention the chance cannot be
excluded as a likely explanation and the findings are stated as not statistically
significant at that level (Hennekens & Burning, 1987:108). Therefore the 95%
confidence interval was applied to determine whether there were any statistical
associations between variables.

4.2 DATA ANALYSIS AND INTERPRETATION

4.2.1 Section A: Biographical data

Question 1: Ages of Respondents

Table 4.2.1 shows that the majority of the respondents, N=40 (50%) are adult
registered nurses between the ages of 30-39 years, followed by age group 40-49
years, N=24 (30%).The table also shows that the hospital does not have many
older nurses in employment as shown in the age groups 50-59 years N=5 (6,3%)
above 60 years N=1 (1.5%)
 37

Table 4.2.1: Ages of Respondents

Age N %
≤21 yrs 0 0
≥22≤29 yrs 10 12.5
≥30≤39 yrs 40 50
≥40≤49 yrs 24 30
≥50≤59 yrs 5 6.2
≥60 yrs 1 1.3
TOTAL N 80 100

Question 2: Gender

Table 4.2.2 shows that the majority of the respondents were predominantly
females that is N= 69 (86.3%).

Table 4.2.2: Gender

Gender N %
Male 11 13.7
Female 69 86.3
TOTAL N 100

Question 3: How long have you been working at this hospital?

Table 4.2.3 shows that the majority of respondents have been working at the
hospital for more than 59 months N= 21(26.3 %), however there are numerous
variations between less than 12 months and 59 months as shown in table 4.3.
 38

Table 4.2.3: Duration of employment at the Hospital of Research

Duration N %
≤12mths 15 18.7
≥13≤24mths 14 17.5
≥25≤36mths 9 11.3
≥37≤49mths 13 16.3
≥50≤59mths 8 10
>59mths 21 26.2
TOTAL 80 100

Question 4: What type of ward speciality are you working in?

Table 4.2.4 shows that the respondents are widely distributed between all
speciality areas, with paediatric, ICU, oncology and neurology wards having the
largest percentages.

Table 4.2.4: Type of ward speciality

N %
Medical ward 9 11.2
Surgical ward 4 5
Paediatric ward 10 12.5
ICU 10 12.5
Cardiology ward 5 6.3
Oncology ward 10 12.5
Neurology ward 10 12.5
Operating room 7 8.8
Emergency room 6 7.5
Neonatal 9 11.2
TOTAL 80 100
 39

4.2.2 Section B

Question 5: Do you have policies pertaining to documentation of nursing

care in your nursing unit?

Table 4.2.5 shows that the majority of the wards N=75 (93.7%) have policies
relating to documentation of nursing care. N=4(5%) respondents stated that there
are no policies and N= 1(1,3%) respondent stated that she does not know.

Table 4.2.5: Policies pertaining to documentation

N %
Yes 75 93.7
No 4 5
Do not know 1 1.3
TOTAL 80 100

Question 6: what does the hospital policy state on documentation of

patients’ vital signs?

Table 4.2.6 shows that the majority of the respondents N=76(95%) are aware that
the patients’ vital signs must be recorded in the Cerner and the vital signs sheet
and the remaining N=4(5%) stated that it must be recorded in the Mycare system
and the physician’s order sheet. According to Ammenwerth, Eichstadter, Iller
and Mansmann (2003:70) nursing documentation is an important part of
clinical documentation, therefore it is expected that 100% would be aware
of the policies on documentation of nursing care. Thorough nursing
documentation is a precondition for good patient care and for efficient
communication and cooperation within the health care professional team.

Table 4.2.6: Hospital policy on patients’ vital signs

N %
It must be recorded in a Cerner (computer) and vital signs 76 95
sheet
It must be recorded in the Mycare system 2 2.5
It must be signed in a physician’s order sheet 2 2.5
 40

TOTAL 80 100

Question 7: Which of the following patient data can be recorded in the

Cerner?

Table 4.2.7 shows that the majority of respondents, N=67(83.7%) are aware of
the policy on vital signs that can be recorded in the Cerner. N=13(16.3%) are not
aware of the policy.

Table 4.2.7: Patient data that can be recorded in the Cerner

N %
Temperature, pulse rate, blood pressure, respiration rate, 67 83.7
oxygen saturation and pain
Muscle contractions and dilatations 2 2.5
Fluid intake and urinary output 11 13.8
TOTAL 100 100

Question 8: What does the hospital policy state about electronic

documentation of physical assessment?

Table 4.2.8 shows that the majority of respondents, N=76(95%) are aware of the
policy on electronic documentation of physical assessment and N=4(5%) are not
aware of such a policy. These results show, as described in the discussion of
table 4.2.7, that all nurses should be aware of the policies on documentation, a
deficit in knowledge may result in a deficit in accurate and complete
documentation about patient care.

Table 4.2.8: Electronic Documentation of Physical Assessment

N
%
It must be recorded once a month 2 2.5
It must be recorded twice a week 2 2.5
It must be recorded once at least within 2 hours of 76 95
commencing a shift per day
 41

TOTAL 80 100
 42

Question 9: What problems do you experience with manual documentation?

Table 4.2.9 shows that only N= 5(6.3%) responded that handwriting is illegible
and time consuming which was the most appropriate answer. Langowski
(2005:122) stated the following problems with manual documentation that it is
time consuming, one may miss important documentation requirements, may not
be aware of what someone else has documented and it could be viewed as
impersonal and expensive. N=59(73,7%) respondents stated that hand writing
may be illegible because of the individual’s hand writing. N=10(12,5%)
respondents stated that it is time consuming N=4(5%). Respondents stated that
the notes are written in clear understandable language. N=2(2,5%) respondents
stated that notes are written in the English language.

Table 4.2.9: Problems experienced with manual documentation

N %
Hand writing may be illegible because of the individual's hand 59 73.7
writing
Notes are written in a clear understandable language 4 5
Notes are written in the English language 2 2.5
It is time consuming 10 12.5
Illegibility of handwriting and time consuming 5 6.3
TOTAL 80 100

Question 10: What problems do you experience with the electronic

documentation system?

Table 4.2.10 shows that the majority of the respondents indicated that the worse
problem that could be experienced with electronic documentation is when the
computer systems are down, when they need to document nursing care
N=78(97,5%). N=2(2,5%) respondents stated that there is only one computer in
each ward. Time delays in documentation could lead to poor care or even failure
to document valuable and critical information.
 43

Table 4.2.10: Problems experienced with electronic documentation

N %
The computer system may be down by the time I want to do 78 97.5
documentation
Computer documentation system is not used in this hospital 0 0
There is only one computer in each ward 2 2.5
Computers have never been functional in this hospital in this 0 0
year
TOTAL 80 100

Question 11: According to your opinion what are the advantages of

traditional documentation (writing on paper)?

Table 4.2.11 shows that the majority of the respondents N=45(56.3%) can
express themselves on paper freely with no space constraints followed by
N=28(35%) respondents indicating that they do not have to depend on a
computer for documentation. N=6(7,5%) indicated that there was no need for
computers which could cause space constraints (mean=3,34;SD=0,83;SE=0,09).
A statistical association was identified between age and advantages of traditional
documentation (Mann Whitney p=0,06). Another statistical association with no
significance was identified between the duration of working in the hospital and
advantages of traditional documentation (Mann Whitney p=0,57).

Table 4.2.11: The advantages of traditional documentation (writing on paper)

N %
Do not depend on the computer to do documentation 28 35
Can express myself on paper freely with no space constraints 45 56.2
There is not enough paper to write on 1 1.3
No need for computers, no space constraints 6 7.5
TOTAL 80 100

Question 12: What are the disadvantages of paper documentation?

 44

Table 4.2.12 shows that the majority N=72(90%) indicated that handwriting on
paper is illegible and that a paper can be thrown away. As described in the
analysis of question 9 the literature support is applicable in this question as well.
N=6(7,5%) respondents stated that some of the hand writings are not easy to
read ;N=2(2,5%) stated that you can always refer to what you have written.
Illegibility of handwriting may pose threatening situations for patient care as
handwriting could be interpreted incorrectly resulting in care being seriously
compromised.

Table 4.2.12: Disadvantages of paper documentation?

N %
Some of the handwriting is not easy to read 6 7.5
You can always refer to what you have written 2 2.5
Illegible handwriting, paper can be thrown in a trash bin 72 90
TOTAL 80 100

Question 13: What are the advantages of electronic documentation?

Table 4.2.13 shows that the majority N=69(86.3%) agrees that the information is
safely kept and requires a username; N=7(8,7%) respondents stated that it is
safely kept in the computer; N=2(2,5%) respondents state that you require a
username and password to access the information in the computer. According to
Langowski (2005:122) in electronic documentation information is entered only
once. It provides fast, real time access to patient records. Decisions are made at
the point of care with the most current patient information. This in turn drives
higher quality of care.

Table 4.2.13: Advantages of electronic documentation

N %
It is safely kept in the computer 7 8.7
You require a username and password to access information on 2 2.5
the computer
You need a lot of computers to do it 2 2.5
Safely kept and username required 69 86.3
TOTAL 80 100
 45

Question 14: What are the disadvantages of electronic documentation?

Table 4.2.14 shows that the majority, N=50 (62.5%) of the respondents indicated
that the disadvantages of electronic documentation are when computers are down
and there are no computers; N=27(33,7%) respondents stated that when the
computer system is down you cannot complete the documentation; N=2(2,5%)
respondents stated that it is difficult to read other people’s notes because it is not
clear in the computer; N=1(1,3%) respondent stated that you cannot document
without using a computer.

Table 4.2.14: Disadvantages of electronic documentation

N %
When computer system is down you cannot complete the 27 33.7
documentation
It is difficult to read other people's notes because it is not clear 2 2.5
on the computer
You cannot document without using a computer 1 1.3
Computers down and absence of computers 50 62.5
TOTAL 80 100

Question 15: If computers are not working on a particular day, what are the
interventions used for nursing care procedures and practices?

Table 4.2.15 shows that the majority, N=44(55%) of respondents indicated the
most appropriate response according to policy that “down time forms” and
physician’s order sheets are to be used; N=30(37,5%) respondents stated that
down time forms may be used for ordered tests; N=6(7,5%) respondents stated
that physician’s order forms may be used for medication ordering if the Mycare
system is not working (mean=3,33;SD=0,82;SE=0,092). Statistical association
between age and interventions used during computer down time was identified
but with no significance (Kruskal Wallis p=0,19). However, a statistical
significance has been identified between duration of working in the hospital and
nursing interventions used during down time (Kruskal Wallis p=0,01). An
unacceptable number of respondents N=36(45%) indicated incorrectly the
measures which are applied for documentation when computers are down. It is
 46

critical that all nurses are aware of the measures in place when computers are
down as documentation of patient care may be delayed or not documented at all
which may influence patient care.
 47

Table 4.2.15: Interventions used for when computers are down

N %
Down time forms may be used for ordered tests 30 37.5
Physician 's order forms may be used for medication ordering if 6 7.5
my care system is not working
Down time forms and physician’s order sheets 44 55
TOTAL 80 100

Question 16: If a nurse has documented his/her nursing care in the system,
what is the security measure to ensure that nobody else can erase or
modify the entry without being identified?

Table 4.2.16 shows that the majority N=71(88.7%) indicated the most appropriate
response according to policy is that a username and password protect all
electronic entries. However it is a concern that N=9(11.3%) respondents do not
know what the policy is with reference to the security measures protecting
electronic entries. Failing to know the policies with reference to documentation
may result in inadequate documentation which may directly influence patient care.

Table 4.2.16: Security measure to ensure that nobody else can erase or modify an entry without
being identified

N %
Username and password 71 88.7
Identity document 2 2.5
Employee number 7 8.8
TOTAL 80 100

Question 17: What are your personal experiences and feelings regarding
current documentation systems?

Paper System

Table 4.2.17 shows that the majority N=45(56.3%) indicated that paper
documentation is a lot of paperwork and it is time consuming, followed by minimal
time and lots of paperwork N=23(28,7%) respondents; N=12(15%) respondents
state that because they have to do a lot of paperwork they have minimal time with
 48

their patients (mean=3,33;SD=0,82;SE=0,092). A statistical association has been

identified between age and personal experiences regarding current
documentation systems (the paper system) but with no significance (Kruskal
Wallis p=0,69). Another statistical association with no significance was identified
between duration of working in the hospital and personal experiences and
feelings regarding the paper documentation system (Kruskal Wallis p=0,84).

Table 4.2.17: Paper System

N %
A lot of papers to write on and it is time consuming 45 56.3
Because I have to do a lot of paperwork I have minimal time 12 15
with my patient
Minimal time and lots of paperwork 23 28.7
TOTAL 80 100

Question 18: What are your personal experiences and feelings regarding
Cerner documentation system?

Table 4.2.18 shows that the majority N=44(55%) indicated Cerner electronic
documentation is one of the best systems used for documentation, however,
N=18(22.5%) indicated negatively that there are not enough computers to use;
N=11(13,7%) respondents stated that there are frequent down times which has
an impact on their nursing care; N=7(8,8%) respondents stated that nobody reads
what they have written so why should they bother.
(mean=3,33;SD0,82;SE=0,092). Statistical association was done with no
significance between the age and experiences and feelings regarding the Cerner
system (Kruskal Wallis p=0,21). Statistical association has also been done
between duration of working in the hospital and personal experiences and
feelings regarding the Cerner system (Kruskal Wallis p=0,29), however no
significance has been found.

Table 4.2.18: Cerner

N %
Nobody reads what I have written so why should I bother 7 8.8
Not enough computers to use 18 22.5
 49

It is one of the best systems used for documentation 44 55

There are frequent down times which has an impact on my 11 13.7
nursing care
TOTAL 80 100

Question 19: What are your personal experiences and feelings regarding
current Mycare documentation system?

Table 4.19 shows that the majority N=68(85%) indicated the Mycare electronic
system is the best system, it is user friendly and they are happy with it.
N=12(15%) respondents stated that the Mycare system is not good at all, they
find it difficult to use and it is outdated. The discrepancy which exists between the
respondents who were positive about the Mycare electronic system and those
who found it to be outdated is a concern.

Table 4.2.19: Mycare

N %
It is a reliable system, it is user friendly therefore I am happy 68 85
with it
It is not good at all I find it difficult to use and it is outdated 12 15
TOTAL 80 100

Question 20: In your mind what do you think are the advantages of entering
some of the nursing procedures in the electronic system instead of
paperwork?

Table 4.2.20 shows that the majority N=46(57.5%) have indicated that nursing
procedures entered electronically are safely kept until needed; N=15(18,8%)
respondents stated that everybody has a different handwriting which is difficult to
read; N=11(13,7%) respondents stated that there is no need for date and time, it
is kept safely; N=8(10%) respondents stated that you do not need to write time
and date it is already there. The preservation of accurate records is important
especially in providing continuity of care and for legal enquiries.
 50

Table 4.2.20: Advantages of entering some of the nursing procedures in the electronic system
instead of paperwork

N %
When entered it is safely kept until when needed 46 57.5
You do not need to write time and date it is already there 8 10
Everybody has a different handwriting which is difficult to read 15 18.8
No need for date and time, it is kept safely 11 13.7
TOTAL 80 100

Question 21: Which specific practices and procedures are documented

electronically?

Table 4.2.21 shows that the majority N=56(70%) indicated that physical
assessment and vital signs are documented electronically. This is a correct
answer. However, N=24(30%) of the respondents are not accurate in knowing
what is the policy about specific practices and procedures. It is expected that all
staff will have the knowledge about documentation about specific practices and
procedures. A breakdown in the continuity of care could result if there is
insufficient knowledge about specific policies concerning practices and
procedures.

Table 4.2.21: Specific practices and procedures documented electronically

N %
Vital signs (blood pressure, temperature, pulse, respiration, 14 17.4
oxygen saturation and pain
Checking of narcotic medications 3 3.8
Physical assessment 7 8.8
Physical assessment and vital signs 56 70
TOTAL 80 100

Question 22: What nursing action / intervention does a nurse complete in

the Cerner that shows that he/she viewed procedures done or to be done for
instance blood in progress or radiological procedures?
 51

Table 4.2.22 shows that the majority N=78(97%) indicated correctly that an
electronic Cerner review should be done and N=2(2,5%) respondents stated that
oracle and hospital intranet systems respectively be reviewed.

Table 4.2.22: Electronic nursing action / intervention entries indicating that procedures were
viewed or what must be done such as blood in progress

N %
Nurses review in the Cerner 78 97.5
Nurses review of oracle system 1 1.3
Nurses review of hospital intranet system 1 1.2
TOTAL 80 100

Question 23: Which year was the electronic system introduced in this
hospital?

Table 4.2.23 shows that the majority N=42(52.5%) indicated the correct year
when the electronic system was introduced; N=31(38,7) respondents mentioned
2005 and N=2(2,5%) respondents stated that it was introduced in 2007.
(mean=3,33;SD=0.82;SE=0,092). A statistical association was done between age
and the year in which the electronic system was introduced in the hospital (Mann
Whitney p=0,36). Another statistical association was done between the duration
of working in the hospital and the year in which electronic system was introduced
in the hospital (Mann Whitney p=0,67).(mean=11,60;SD=1,87;SE=0,21). No
significance obtained.

Table 4.2.23 Year for introduction of electronic system

N %
2007 2 2.5
2005 31 38.7
2000 42 52.5
2006 5 6.3
TOTAL 80 100

Question 24: In the immediate post operative phase what must be covered
in a nurse's documentation about the patient?
 52

Table 4.2.24 shows that the majority N=75(93.8%) indicated the correct response.
However, N=5(6.3%) have indicated that there is “no need to bother about the
general condition as long as the procedure is done”. This is an unacceptable
response as a holistic approach is applied to patient care. It is not just the
procedure that matters. Furthermore, the quality of nursing care can be evaluated
retrospectively, assuming that what has been recorded has also been performed.
Good documentation may indicate good care. Secondly nursing care is evaluated
by comparing the notes with approved standards. A prerequisite for using nursing
documents in evidence-based nursing care is ensuring the quality of the
documents (Erickson and Karkkainen, 2003:199).

Table 4.2.24: In the immediate post operative phase what must be covered in a nurse's
documentation about the patient

N %
General condition of patient and post operative instructions 75 93.7
No need to bother about general condition as long as the 5 6.3
procedure has been done
The surgeon will do the documentation of nursing care no need 0 0
to worry about the condition of the patient
TOTAL 80 100

Question 25: When doing a dressing, what exactly do you as a nurse

document about the dressing?

Table 4.2.25 shows that the majority N=76(95%) indicated the general condition
of the wound should be documented after a wound dressing. This is a correct
answer; N=3(3,6%) respondents mentioned size and appearance only while
N=1(1,3%) stated that there is no need for documentation, the wound has been
there all along. These results show a deficiency in knowledge about
documentation of wound care which may have implications for the continuity of
wound care existing among the respondents.

Table 4.2.25: Documentation of a dressing

N %
General condition of the wound 76 95
 53

Size and appearance only 3 3.6

No need for documentation, the wound has been there all along 1 1.3
TOTAL 80 100
 54

Question 26: If there is a dispute between the nurse and the doctor for
example, should that be indicated in the patient's file?

Table 4.2.26 shows that the majority N=61(76.3%) indicated that disputes
between staff members for example should not be documented, while
N=19(23,7%) respondents are contrary to the idea of not documenting disputes
between staff in the patients’ files. A statistical significance has been identified
between the age an opinions regarding documentation of professional disputes in
the patients’ files (Mann Whitney p=0,02). A statistical association has also been
done between duration of working in the hospital and opinions regarding
documentation of professional disputes in the patients’ files (Mann Whitney
p=0,85) but found to have no significance.

Table 4.2.26: Documentation of disputes in the patient's file

N %
no 61 76.3
yes 19 23.7
TOTAL 80 100

Question 27: Is it relevant to do documentation about a paediatric patient

when you are nursing him or her?

Table 4.2.27 shows that the majority N=78(97.5%) indicated that documentation
of a paediatric patient is necessary but it is a concern that N=2(2.5%) indicated
that this was not a requirement.

Table 4.2.27: Relevancy of documentation about a paediatric patient

N %
No, he/she is only a child therefore there is no need to do 2 2.5
documentation about his or her care
Yes, it is my duty and responsibility to document my nursing 78 97.5
care about the paediatric patient I took care of
Only sometimes it will be required to document 0 0
TOTAL 80 100
 55

Question 28: Why should a patient be involved in the planning of his or her
nursing care?

Table 4.2.28 shows that the majority N=77(96.2%) indicated that the patient
should be involved in the planning of his/ her nursing care; N=2(2,5%)
respondents stated that the patients must be involved in their planning of care as
required by the institution, while N=1(1,3%) respondent stated that this can only
be done if the nurse is concerned that somebody will be checking on the nurse’s
work afterwards. Involving the patient in his/ her care is not only a right but also
promotes compliance of care.

Table 4.2.28: Patient involvement in planning of his or her nursing care

N %
As a patient's right, a health care provider should involve a 77 96.2
patient in a planning of his care
Involve the patient in his care plan as required by the institution 2 2.5
This can only be done if the nurse is concerned that somebody 1 1.3
will be checking on the nurse's work afterwards
TOTAL 80 100

Question 29: What does good nursing documentation entail?

Table 4.2.29 shows that the majority N=79(98.7%) indicated that good
documentation entails clear communication about the patient’s general condition;
N=1(1,3%) respondent stated that good nursing documentation entails writing
about the nurse’s personal feelings and preferences. A 100% response was
expected as documentation entails clear communication about the patient’s
general condition.

Table 4.2.29: Good nursing documentation

N %
Clear communication about the patient's general condition 79 98.7
Writing about the nurse's personal feelings and preferences 1 1.3
To show a nurse's beautiful handwriting when documenting 0 0
TOTAL 80 100
 56

Question 30: Why should a nurse's handwriting be legible in a

documentation that she/he has written?

Table 4.2.30 shows that the majority N=79(98.7%) of respondents indicated

legibility of documentation is important to show people who reads the
documentation that they understand it and N=1(1,3%) respondent stated that
legibility in documentation is to show how beautiful the nurse’s handwriting can
be. A 100% response was expected as documentation should enable people
reading it to understand what has been written.

Table 4.2.30: Legibility in documentation

N %
To enable people reading his/her documentation to understand 79 98.7
what has been written
To show how beautiful his/her handwriting can be 1 1.3
TOTAL 80 100

Question 31: Why should there be nursing documentation in a patient's file

in the first place?

Table 4.2.31 shows that all N=80(100%) of the respondents indicated that nursing
documentation should be reflected in the patients’ file.

Table 4.2.31: Nursing documentation in a patient's file

N %
As a professional obligation that nursing care was rendered and 80 100
to communicate to other staff members about the patient's
condition
Just for fun and the sake of doing it 0 0
To be done only if a nurse feels like doing it and has time for it 0 0
TOTAL 80 100
 57

Question 31: Who are the people that are supposed to have access to the
patient's nursing documentation and why should those people access the
patient's file?

Table 4.2.32 shows that all N=79(98.7%) of the respondents indicated that the
multidisciplinary team members taking care of the patient should have access to
the patient’s file while only N=1(1,3%) respondent stated that the family members
should have access to the patient’s file to make sure that the multidisciplinary
team members are providing adequate care to their relative.

Table 4.2.32: Access to the patient's nursing documentation and rationale

N %
Multidisciplinary team members taking care of the patient - to 79 98.7
communicate and monitor the patient's progress
Family members - to make sure that the multidisciplinary 1 1.3
members are providing adequate care to their relative
Patient's occupational colleagues - to read and correct 0 0
whatever has been written about the patient
TOTAL 80 100

Open question: What is your general view on electronic documentation of

nursing care?

The responses to this question were summarized as follows:

Advantages and preferences of the system

1. Best system.
2. Data can be retrieved.
3. System better off than paper system.
4. It is clear, brief, concise, understandable, accessible, convenient, easy to use
and the data is kept safe.
5. Documentation is standardized, illegibility avoided, saves space and time, it is
a comfortable and excellent method and not time consuming.
6. Less paperwork, good, accessed by username and password.
 58

7. Patient confidentiality maintained, perfect, user friendly, settles disputes

quickly.

Disadvantages and contributing factors to the (computer system) not being much
favorable:

1. Computers take a lot of time away from patients, meant for minimizing
paperwork but too much time spent on it.
2. It affects nursing care.
3. When the system breaks down one has to go back to the paper system.
4. There are not enough computers to be able to complete work in a timely
manner.
5. Hardware does not support staff.
6. If the system can be available to all staff members with an effective training
system it can be effective in nursing institutions.
7. It is time consuming; therefore it does not work well.
8. It can only be excellent if it can be next to each bedside.
9. It is robotic and not always accessible especially during down time.
10. The system is not user friendly.

4.3 DISCUSSIONS

The respondents who have the most experience, 50-59 months, at the hospital
under study are N=21(26,3%). Registered nurses who have least working
experience less than 12 months in this hospital are N=15(18,8%). The majority of
the nurses have more than 12 months of experience and this should be an
advantage about the knowledge of policies and procedures regarding
documentation.

Ward specialty does not have a major influence per se in the knowledge of
policies and procedures pertaining to documentation of nursing care because
documentation guidelines are generic. The only difference will be the unit guide
lines which will demonstrate what should be done in a specific unit with reference
to a certain routine of work or patient assignment for instance.

In question 5 which asked about the availability of policies pertaining to

documentation of nursing care, N=75(93,8%) answered yes meanwhile only a
mere N=4(5%) answered no. This large percentage is representative of registered
nurses who know the availability and implementation of policies in the hospital
 59

and also this percentage N=75(93,8%) is not unit or ward specific. It is a general
response from the respondents.

The majority of registered nurses in this hospital know where to document their
vital signs as evidenced by the N=76(95%) response who stated that it must be
documented both in the computer and the vital sign sheet. For the least
N=2(2,5%) said vital signs must be recorded in the Mycare system and N=2
(2,5%) who said it must be recorded in the physician's order sheet.

Vital signs to be recorded are temperature, blood pressure, pulse, respiration,

oxygen saturation and pain (in King Faisal hospital – Jeddah, Saudi Arabia). This
is the policy of the hospital. The majority of respondents answered correctly
N=67(83,8%0 however it is expected that all nurses will have adequate
knowledge of the policies and procedures.

King Faisal hospital – Jeddah has a clear policy which states that the vital signs
and physical assessment must be documented once at least within two hours of
having started the shift per day. The majority of respondents N=76 (95%)
indicated the correct answer. It is expected that all nurses will show adequate
knowledge with regard to the policies on patient documentation.

Illegibility of handwriting has been mentioned by the respondents as the problem

mostly experienced N=59(73,8%); followed by N=10(12,5%) respondents who
stated that manual documentation is time consuming and a further N=5(6,3%)
combining the possibility of illegible handwriting and time issues. These statistics
can be used in favor of electronic documentation especially when one considers
legibility of handwriting which is not a problem at all when dealing with electronic
documentation. Meanwhile the majority N=78(97,5%) indicated that the main
problem experienced with electronic documentation was the possibility of the
computer system being down especially when a nurse wants to check her orders
and procedures or have to document electronically.

There are still mixed feelings with regards to advantages and disadvantages of
writing on paper, and the use of the computer system; N=45(56.2%) of
respondents felt that they can express themselves freely with no space
constraints on paper and N=28(35%) stated that one does not depend on a
computer to do documentation. However, N=6(7,5%) stated that difficulty in
reading some of the handwritings and the fact that the paper on which one has
 60

documented may land in a thrash bin were the most convincing disadvantages of
the manual/paper documentation version.

On the other hand respondents N=69(86,3%) stated that information is safely kept
in a computer and also you need to have a username and a password to retrieve
information, but the majority of respondents N=77 (96,3%) stated that you cannot
do electronic documentation without using a computer and it is impossible to
document electronically when the computer system is down.

The majority of respondents N=74(92,5%) are familiar with the hospital policies
pertaining to documentation when computers are not working on a particular day,
that down time forms may be used for ordered tests and the physician's order
sheet may be used to order medication when the Mycare system which is the
medication ordering system is down. It is however expected that all nurses are
familiar with the policies.

For identification of a person who has accessed, modified or erased any

documented information about the patient in a computer, N=71(88,8%)
respondents stated that, such a person would be easily identified by their
username and password which is the security measure to ensure confidentiality to
the access of patients' computerized information. Personal experiences and
feelings regarding the current paper documentation in particular, are that the
respondents felt that there is a lot of paper to write on, it is time consuming and
there is minimal time to do all the paper work which in future might be deemed
outdated because of the negative image it (paper documentation) has from the
registered nurses point of view in which case electronic documentation might be
the more acceptable form.

The Cerner (computer) on the other hand is said to be one of the best systems
supported by N=44(55%) of the respondents. The negative experiences
mentioned N=11(13,8%) about frequent downtimes may influence nursing care
adversely. Inadequate computers N=18(22,5%) might delay the nurses in doing
their documentation and checking procedures done or to be done. Some of the
respondents N=7(8,8%) indicated that there is nobody reading what they have
documented in the computer system so why should they bother doing it. This may
create some problems with the continuity of care.

Personal experiences with regards to the Mycare system which is the system for
medication ordering from the pharmacy using computers, N=68(85%) of the
 61

respondents said it is a reliable system, it is user friendly and they are quite happy
with it, while only N=12(15%) found it not to be good at all, difficult to use and
outdated. This could be attributed to the fact that it was only introduced in April
2006 in King Faisal hospital – Jeddah.

On stating advantages of entering some of the nursing procedures in the

electronic system instead of paper documentation, N=61(81,3%) said that when
information is entered into the computer system it is safely kept until needed, you
do not need to write date and time since it is already there. Registered nurses
stated that some practices and procedures are documented electronically, for
instance temperature, blood pressure, respiration, oxygen saturation and pain.
This is an indication that the hospital policies and procedures are being carried
out by the nurses.

To have determined whether the registered nurses were carrying out the hospital
policies and procedures a question was asked about specific nursing
interventions carried out by nurses to ensure that he/she reviewed procedures
done or to be done for instance blood is in progress; N=78(97,5%) answered that
the correct intervention is the nurses’ review in the Cerner (computer system).
This demonstrated that the registered nurses were carrying out the hospital
policies and procedures as were expected.

Immediate post operative care of the patient following a procedure that was done
in the operating theatre entails documentation about the patient's general
condition on arrival from the operating theatre and following post operative
medical orders; N=76(95%) of the respondents responded correctly.

When the respondents were asked about what to write when a nurse has done a
wound dressing N=76(95%) said that there must be documentation about the
general condition of the wound, which will provide continuity in care. Thus, as a
result of nursing care documentation valid and reliable evidence of caring is
produced on a daily basis according to Karkainnen and Erickson (2003:199).

The majority of respondents N=61(76,3%) indicated that the patients’ records

should not be used for disputes between a nurse and a doctor. It is unfortunate
that N=19(23,7%) indicated the contrary. Bergerson (1989:11) in his guidelines
about documentation of nursing care pointed out clearly that the patient's chart
should not be used to settle disputes or assign blame. Bergerson further stated
that finger pointing and accusations have no place in the patient's official chart
 62

whatsoever. Currently at King Faisal hospital in Jeddah in Saudi Arabia there is

an OVR (occurrence variance report) which might be referred to as an incident
report. In other hospitals it is used to describe what happened during the patient's
care that is essential and this OVR must not be kept in a patient's file. For the
respondents who felt that disputes can be written about in a patient's file an OVR
can perfectly replace that beyond any possible doubt.

When nursing a pediatric patient N=78(97,5%) of the respondents stated that you
have to document your nursing care about that pediatric patient, whereas
N=2(2,5%) felt that there is no need to document because she/he is only a child.
Professionally and legally a nurse is obliged to document nursing care of every
patient regardless of age. This is in full support of the legal statement for the
nurse that if it was not documented it was not done.

A total of N=77(96,2%) answered that as a patient's right a health care provider

should involve a patient in a patient plan of care with N=2(2,5%) stating that a
patient is only involved if that is an institutional requirement and then N=1(1,3%)
stated that the involvement of a patient in his or her plan of care can only be done
if a nurse is concerned that somebody will be checking on the nurse's work
afterwards. Involvement of a patient in the plan of care not only enhances
participation and compliance but it can also give the patient a clear picture of how
the health care system works. Karkkainen (2004:269) states that respect for
human rights and human dignity is part of the nurse's responsibility for those in
his or her care. This means that in nursing care, human beings are genuinely
helped to make use of their freedom and right to decide on their own affairs. In
order to make this possible, Karkkainen further explains that the nurse should
give the patients sufficient comprehensive information for them (patients) to be
able to make the best decisions.

When the respondents were asked about what exactly a good nursing care
documentation entails, N=79(98,8%) stated that it is about a clear communication
with regard to a patient's general condition. This is so true because when a nurse
documents a patient's condition the nurse explains what has been done by
him/her (the nurse) and the other multidisciplinary team members, the nurse also
explains what is to be done in future in relation to the patient. The nurse also
writes about the changes, improvements, deterioration of the patient's general
condition and the nurse covers aspects such as response to treatment given,
wound condition, state of consciousness, psychological status, social status which
 63

covers important aspects like family visiting, concerns of the family about the
patient's progress and any planned medical management issues.

Some of the problems experienced by the nurses in manual documentation of

nursing care was legibility of handwriting. This is also the indication from the
respondents N=79(98,8%) who said that the nurse's handwriting must be legible
so that people reading the nurse's notes would be able to understand what has
been written. When the respondents were asked why should there be
documentation in the patient's file in the first place 100% stated that it indicated
that nursing care as a professional obligation was rendered and to communicate
to other staff members the patient's general condition.

In answering the question asking about the people who are supposed to have
access to the patient's file, N=79(98,8%) responded that it is the multidisciplinary
team members taking care of the patient and the reason for that response is to
communicate and monitor the patient's progress. Taking ethical principles into
account one can be much convinced that, with such a good response this ensures
that the principle of confidentiality is maintained at all times which will without any
doubt enhance a trusting relationship between the clients/patients with their
concerned relatives and the multidisciplinary members.

4.4 CONCLUSION

This chapter presented the findings, analysis and discussions of the collected
data. The sections focused on the findings on documentation of nursing care,
policies and procedures and perceptions of registered nurses with regard to
current documentation systems used in the hospital of research. The findings in
this study answered the research question “are the procedures and practices
regarding electronic documentation in the hospital being executed”? N=76(95%)
of the respondents stated that electronic documentation must be recorded within
2 hours of commencing a shift per day and N=67(83,7%) stated that temperature,
pulse rate, blood pressure, respiration rate, oxygen saturation and pain are the
patient data documented electronically. The goal of this study was to investigate
documentation of nursing care with reference to current practices and perceptions
of nurses in a teaching hospital in Saudi Arabia. The nurses document manually
and electronically but have the following perceptions about current practices,
namely that manual documentation involves a lot of paper to write on and it is
time consuming. N=45(56,3%0 indicated that the Cerner system which is an
 64

electronic documentation system is the best system used for documentation

N=44(55%).

The following objectives were reached to:

 identify whether the hospital policies are being carried out, N=76(95%)
respondents stated that patients’ vital signs are recorded in the Cerner and a
vital sign sheet which has to be recorded within two hours of having
commenced the shift for the day.

 identify whether procedures regarding current documentation system are carried out,
N=67(83,7%) stated that pulse, temperature, respiration rate, blood pressure, oxygen
saturation and pain are documented and
 explore the perceptions of nurses regarding current documentation systems, N=45(
56,3%) stated that there are a lot of paper to write on and it is time consuming. The
Cerner system on the other hand is regarded as the best used for documentation
N=44(55%).

Chapter 5 presents the conclusions and recommendations emanating from this study.
 65

CHAPTER 5
CONCLUSIONS AND RECOMMENDATIONS

5.1 INTRODUCTION

The preceding chapter contains discussions, analyses and interpretation of the

research findings. This chapter presents the summaries of the primary findings of
the research study presented in chapter 4. The findings are concluded to
determine if the objectives and research questions of the study were achieved.
From these presentations, conclusions and recommendations are offered.

5.2 RECOMMENDATIONS

From the conclusions of the primary findings, the following recommendations are
offered to reinforce the execution of procedures and practices regarding nursing
documentation and the nurses' perceptions regarding current documentation
systems.

5.2.1 Hospital policies on patients' vital signs

The response given by the respondents showed that the respondents are aware
of the hospital policies on patient’s vital signs. N=75(93,7%) respondents stated
that there are policies on vital signs. Despite the fact that the majority of
registered nurses are aware of the policies it is recommended that the registered
nurses should still be taught about hospital policies for the good functioning of the
hospital. It is expected that all nurses are aware of the policies on documentation.
A deficiency in knowledge about documentation may result in poor and inaccurate
documentation about patient care which may result in a breakdown in the
continuity of care.

5.2.2 Documentation of patient data on the Cerner

N=76(95%) respondents stated that the patient data must be recorded in a Cerner
and vital sign sheet. Majority of respondents are aware of the documentation of
patient data, it is recommended that the registered nurses should be taught the
correct procedure on documenting the patient data. According to Ammenwerth,
Eichstadter, Iller and Mansmann (2003:70) nursing documentation is an important
part of clinical documentation.
 66

5.2.3 Electronic documentation of the physical assessment of a patient

The policy of King Faisal Hospital clearly states that physical assessment must be
documented on the Cerner (computer) at least within two hours of having
commenced each shift. It is recommended that nurse clinicians and nurse
managers when doing their audits should check the Cerner and see if there is
compliance with regards to documentation of physical assessment (skin
appearance from head to toe and integrity, breathing rate and sounds, heart rate
etc.) in the Cerner.

5.2.4 Personal feelings and experiences regarding current documentation:

paper system

N=45(56,3%) of the respondents complained that there are lots of paper to write
on and it is time consuming. According to Langowski (2005:122) manual
documentation is time consuming. One may miss important documentation
requirements, may not be aware of what someone else is documenting or has
documented. It is therefore recommended that the use of paper be minimized by
shifting some of the nursing documentation procedures from paperwork to an
electronic version especially given the dynamic nature of technology.

5.2.5 Cerner.

Contemporary documentation by electronic means is preferred by some

respondents as the best system N=44(55%). According to Langowski (2005:124)
computer documentation is timely and health care decisions are made with the
entire patient information available. Computer documentation offers patient
centred care allowing all disciplines to make improved decisions in a timely
manner based on all of the patient information. It is recommended that continuous
updating, in service training and monitoring be done to encourage nurses to keep
up with the dynamic nature of computer usage.

5.2.6 Mycare electronic system

Despite the fact that the Mycare system has been preferred by the majority of the
respondents N=68(85%), reviewing of the system, troubleshooting and
suggestions from users need to be attended to on a continuous basis. This is to
ensure that the system is well understood and that any problem arising is dealt
with. The Mycare system is the new system introduced in the hospital, meaning
that there might still be resistance to its installation and some problems might be
experienced in some instances.
 67

The research questions “Are the procedures and practices regarding

electronic documentation in the hospital being executed? And how do nurses
experience the electronic system?” have been answered. Based on the
conclusions drawn from the data, hospital policies and practices regarding
documentation of nursing care are being carried out.

The goal of this study was to investigate documentation of nursing care with
reference to current practices and perceptions of nurses in a teaching hospital in
Saudi Arabia.

The following objectives were set to:

 identify whether the hospital policies are being carried out

 identify whether procedures regarding current documentation are being carried out
and
 explore the perceptions of the nurses regarding the current documentation practices.

The goal and objectives set for this study have been reached. The respondents
have given different opinions regarding an electronic documentation system,
giving some positive and negative feelings according to the way they view it.

5.2.7 The use of electronic documentation

Despite the fact that various advantages exist in the use of electronic
documentation as identified in this study the majority N=50(62.5%) of the
respondents indicated that the disadvantages of electronic documentation are
when computers are down and there are no computers, N=27(33,7%) of the
respondents stated that when the computer system is down you cannot complete
the documentation. It is recommended that a back-up system (generator) is in
place to ensure the continuity of documentation.

5.3 FINAL CONCLUSION

In an attempt to conduct a study on documentation of nursing care, current

practices and perceptions of nurses, a research assignment was undertaken to
gain scientific knowledge on various aspects of nursing documentation. This
includes various types of nursing documentation, policies and procedures,
documentation guidelines and theoretical bases.
 68

A scientific research plan was formulated to validate the study from which the
researcher drew answers to research questions to satisfy the objectives of this
study. The collected data was statistically analysed, interpreted and the findings
were discussed.

It was found that the nurses are aware of the hospital policies pertaining to
documentation of nursing care and the nurses do carry out these hospital policies.

Furthermore it was found that procedures regarding current documentation are

being carried out as well.

Perceptions of nurses regarding the current documentation practices are that:

paper documentation is time consuming and there are lots of paper to write on and
the Cerner system is the best system to be applied.
Documentation of nursing care whether it is done manually or electronically is very
important and it is a legal document. It should be effectively and efficiently done.

Recommendations were made based on the findings. This study can possibly be
used as a foundational study to conduct further research.
 69

REFERENCES

Alligood, M.R., Tommey, A.M. (2002). Nursing Theorists And Their Work. St. Louis,
Mosby.

Ammenwerth, E., Eichstadter, R., Iller, C., Mansmann, U. (2003). Factors Affecting And
Affected By User Acceptance Of Computer-based Nursing Documentation: Results of
a Two–year Study. JAMIA . 10, 69-84.

Ankersen, L., Darmer, M.R., Egerod, I., Landberger, G., Lippert, E., Nielsen, B. G. (2006).
Nursing Documentation Audit – the effect of a VIPS implementation programme in
Denmark. Journal Of Clinical Nursing.15, 525-534.

Aydin, C.E., Eusebio-Angeja, A.C., Gregory, K.D. and Korst, L.M. (2003). Nursing
Documentation Time During Implementation Of An Electronic Medical Record. JONA.
33(1) January, pp.24-30.

Bailey, J. and Howse, E. (1992). Resistance To Documentation – A Nursing Research Issue.

International Journal of Nursing Study. 29(4) November, pp.371-380.

Basson, A.A., Uys, H.H.M. (1991). Research Methodology In Nursing. 2nd Edition.
CapeTown: Kagiso Tertiary

Beck, C.T., Polit, D.F., (2008). Nursing Research : Generating and Assessing Evidence
For Nursing Practice. 8th Edition. Philadelphia, Lippincot Williams & Wilkins.

Beck, C.T., Polit D.F. (2006). Essentials of Nursing Research: Methods, Appraisal And
Utilization. 6th Edition Philadelphia, Lippincot Williams & Wilkins

Bergerson, S. (1991). More About Charting With A Jury In Mind. Nursing Institute C.E Test
Hand Book . Volume 4,11-17.

Bjorvell, C., Thorell-Ekstrand, I., Wredling, R. (2003). Prerequisites And Consequences Of

Patient Records As Perceived By A Group Of Registered Nurses. Journal Of
Clinical Nursing . 12,206-214.

Bondas, T., Eriksson, K., and Karkkainen, O. (2005). Documentation Of Individualised Care
Patient: A Qualitative Metasynthesis. Nursing Ethics. 12(2), pp.124-132.

Brent, N.J. (2001). Nurses And The Law. A Guide To Principles Applications. 2nd Edition
Philadelphia, W.B. Saunders.
 70

Brink, H. (2006). Fundamentals of Research Methodology for Health Care Professionals. 2nd
Edition Cape Town: Juta.

Burns, N. and Grove, K. S. (2001). The Practice Of Nursing Research. 4th Edition.
Philadelphia, W.B. Saunders.

Butler, M., Hyde, A., Irving, K., Macneela, P., Scott, A. and Treacy, M. (2006). Discursive
Practices In The Documentation of Patient Assessments. Journal of Advanced
Nursing. 53(2) May, pp.151-159.

Carpenito-Moyet L.J. (2004). Nursing Care Plans And Documentation . 4th Edition
Philadelphia, Lippincot.

Coyle, G.A., Hamilton, A.V. and Heinen, M.G. (2004). E-documentation, Electronic Options
Keep Staff Informed And Patients Updated. Nursing Management. 35(9)
September, pp.44-47.

Delport, C.S.L., De Vos, A.S., Fouche, C.B., Strydom, H, (1998). Research At Grass Roots
: For The Social Sciences and Human Service Professions. Paarl: Van Schaik
Publishers.

Ehnfors, M., Ehrenberg, A. (2001). The Accuracy Of Patient Records In Swedish Nursing
Home : Congruence Of Record Content And Nurses' And Patients' Description.
Nordic College Of Caring Sciences. 15,303-310.

Erickson, K., Karkkainen O., (2005). Recording The Content Of The Caring Process. Journal
Of Nursing Management.13(1) January, pp.202-208.

Erickson, K., KarkkainenO., (2004). A Theoretical Approach To Documentation Of Care.

Nursing Science Quarterly.17(3) July, pp.268-272.

Erickson, K., KarkainnenO., (2004). Structuring The Documentation Of Nursing Care On The
Basis Of A Theoretical Process Model. Nordic College Of Caring Sciences. 18,
March, pp.229-236.

Erickson, K., Karkkainen, O., (2003). Evaluation Of Patient Records As Part Of Developing A
Nursing Classification. Journal Of Clinical Nursing. 12, August, pp.198-205.

Heartfield, M., (1996). Nursing Documentation And Nursing Practice: A Discourse Analysis.
Journal Of Advanced Nursing. 24,98-103.
 71

Isola, A., Muurinen, S., Voutilainen, P. (2004). Nursing Documentation In Nursing Homes –
State-Of –The-Art And Implications For Quality Improvement. Nordic College Of
Caring Sciences . 18,72-81.

Krugman, M., Oman, K., Smith, K. and Smith, V. (2005). Evaluating The Impact Of
Computerised Clinical Documentation. JONA. 23(3) June, pp.132-138.

La Duke, S. (2001). Online Nursing Documentation , Finding A Middle Ground. JONA.

312(6),283-286.

Langowski, C. (2005). The Times They Are A Changing: Effects Of Online Nursing
Documentation System. JONA. 14(2), pp.121-125.

Pera S. A., van Tonder, S. ed. (2004). Ethics In Nursing Practice. Cape Town: Juta
Academic.

Searle, C. (2004). Professional Practice: A Southern African Nursing Perspective. 4th

Edition. Pietermaritzburg: Heinemann.

South African Nursing Council: Nursing Act 2005 (Chapter 3) Pretoria, Government
Gazette.

South African Nursing Council Regulations: Acts Or Omissions 1985 (Chapter 2) Pretoria,
Government Gazette.

South African Nursing Council Regulations: Scope Of Practice 1984 (Chapter 2) Pretoria,
Government Gazette.

Tapp, A., (1990). Inhibitors And Facilitators To Documentation Of Nursing Practice. Western
Journal Of Nursing Research. 12(2) April, pp.229-240.

Tornvall E., Wahren L.K. and Whilhemsson S., (2004). Electronic Nursing Documentation in
Primary Health Care. Nordic College of Caring Sciences. 18March, pp.310-317.

Teytelman, Y., (2002). Effective Nursing Documentation. Seminars In Oncology

Nursing.18(2) May, pp.121-127.

Turpin, P.G. (n.d). Transition From Paper To Computerised Documentation.

Gastroenterology Nursing Page. 61-62.
 72

ANNEXURES

ANNESURE A: QUESTIONNAIRE

Dear participant, I am Aaron Mtsha. I am doing a mini research

project as one of my study programme requirements. I would like to request your
voluntary participation by answering the following questions. Please do not write
your name anywhere on the questionnaire. If there is anything at any stage that you
are unsure about or it is not clear please do not hesitate to contact me. My contact
details are 0508157344 or extension 5810/5811/5812.

INSTRUCTIONS
Please mark your answer with an X next to the correct answer or write your answer
in the space provided.

SECTION A: BIOGRAPHICAL DATA

QUESTION 1: How old are you?

Age
1 ≤21 yrs
2 ≥22≤29 yrs
3 ≥30≤39 yrs
4 ≥40≤49 yrs
5 ≥50≤59 yrs
6 ≥60 yrs

QUESTION 2: What is your gender?

7 Male
8 Female
 73

QUESTION 3: How long have you been working at this hospital?

9 ≤12mths
10 ≥13≤24mths
11 ≥25≤36mths
12 ≥37≤49mths
13 ≥50≤59mths
14 >59mths

QUESTION 4: What type of ward speciality are you working in?

15 Medical ward
16 Surgical ward
17 Paediatric ward
18 ICU
19 Cardiology ward
20 Oncology ward
21 Neurology ward
22 Operating room
23 Emergency room
24 Labour and delivery room
25 Neonatal

SECTION B

QUESTION 5: Do you have policies pertaining to documentation of nursing

care in your nursing unit?

26 Yes
27 No
28 Do not know
 74

QUESTION 6: What does your hospital policy state on documenting patients'

vital signs?

29 It must be recorded in a Cerner(computer) and vital signs sheet

30 It must be recorded in the Mycare system
31 It must be signed in a physicians order sheet

QUESTION 7: Which of the following patient data can be recorded in the Cerner?

32 Temperature, pulse rate, blood pressure, respiration rate,

oxygen saturation and pain
33 Muscle contractions and dilatations
34 Fluid intake and urinary output

QUESTION 8: What does the hospital policy state about electronic

documentation of physical assessment?

35 It must be recorded once a month

36 It must be recorded twice a week
37 It must be recorded once at least within 2 hours of
commencing a shift per day

QUESTION 9: What problems do you experience with manual documentation?

38 Handwriting may be illegible because of the individual's

handwriting
39 Notes are written in a clear understandable language
40 Notes are written in the English language
41 It is time consuming
 75

QUESTION10: What problems do you experience with electronic documentation

system?

42 The computer system may be down by the time I want to do

documentation
43 Computer documentation system is not used in this hospital
44 There is only one computer in each ward
45 Computers have never been functional in this hospital this
year

QUESTION 11: According to your opinion what are the advantages of

traditional documentation (that means writing on paper)?

46 Do not depend on the computer to do documentation

47 Can express myself on paper freely with no space constraints
48 There is not enough paper to write on

QUESTION 12: What are the disadvantages of paper documentation?

49 Some of the handwritings are not easy to read

50 You can always refer to what you have written
51 A written paper can be torn apart and thrown in a trash bin
52 It is not a requirement for nursing care procedures

QUESTION 13: What are the advantages of electronic documentation?

53 It is safely kept in the computer

54 You require a username and password to access information
from the computer
55 You need a lot of computers to do it
56 Information is safely kept, username is required
 76

QUESTION 14: What are the disadvantages of electronic documentation?

57 When the computer system is down you cannot complete the

documentation
58 It is difficult to read other people's notes because it is not
clear on the computer
59 You cannot document without using a computer

QUESTION 15: If computers are not working on a particular day, what are the
interventions used for nursing care procedures and practices?

60 Down time forms may be used for ordered tests

61 Physician 's order forms may be used for medication ordering
if Mycare system is not working
62 Down time forms and physicians’ order sheets

QUESTION 16: If a nurse has documented his/her nursing care in the system ,
what is the security measure to ensure that nobody else can erase or modify
the entry without being identified?

63 Username and password

64 Identity document
65 Blood group type
66 Employee number
 77

QUESTION 17: What are your personal experiences and feelings regarding
current documentation systems?
Paper System

67 A lot of paper to write on and it is time consuming

68 Because I have to do a lot of paperwork I have minimal time
with my patient
69 Minimal time and lots of paperwork
70 Nobody reads what I have written so why should I bother

QUESTION 18: What are your personal experiences and feelings regarding
current documentation systems?
Cerner

71 Nobody reads what I have written so why should I bother

72 There are not enough computers to use
73 It is one of the best systems used for documentation
74 There are frequent down times which has an impact on my
nursing care

QUESTION 19: What are your personal experiences and feelings regarding
current documentation systems?
Mycare

75 It is a reliable system, which is user friendly and I am happy

with it
76 It is not good at all I find it difficult to use and it is outdated
 78

QUESTION 20: In your mind what do you think are the advantages of entering
some of the nursing procedures in the electronic system instead of
paperwork?

77 When entered it is safely kept until when needed

78 You do not need to write time and date it is already there
79 Everybody has a different handwriting which could be difficult
to read

QUESTION 21: What specific practices and procedures are documented

electronically?

80 Vital signs (blood pressure, temperature, pulse, respiration,

oxygen saturation and pain
81 Physical assessment and vital signs
82 Checking of narcotic medications
83 Physical assessment

QUESTION 22: What nursing action / intervention does a nurse complete in the
Cerner that shows that he/she viewed procedures done or to be done for
instance blood in progress or radiological procedures?

84 Nurses review in the Cerner

85 Nurses review of oracle system
86 Nurses review of hospital intranet system

QUESTION 23: Which year was the electronic system introduced in this
hospital?

87 2007
88 2005
89 2000
90 2006
 79

QUESTION 24: In the immediate post operative phase what must be covered in a
nurse's documentation about the patient?

91 General patient's condition and post operative instructions

92 No need to bother about general condition as long as the
procedure has been done
93 The surgeon will do the documentation of nursing care no
need to worry about the condition of the patient.

QUESTION 25: When doing a dressing, what exactly do you as a nurse

document about the dressing?

94 General condition of the wound

95 Size and appearance only
96 No need for documentation, the wound has been there all
along.

QUESTION 26: If there is a dispute between the nurse and the doctor for
example, should that be indicated in the patient's file?

97 no
98 yes

QUESTION 27: Is it relevant to do documentation about a paediatric patient when

you are nursing him or her?

99 No, he/she is only a child no need to do documentation about

his or her care
100 Yes, it is my duty and responsibility to document my nursing
care about the paediatric patient I took care of
101 Only sometimes it will be required to document
 80

QUESTION 28: Why should a patient be involved in a planning of his or her

nursing care?

102 As a patient's right, a health care provider should involve a

patient in a planning of his care
103 Involve the patient in his care plan as required by the
institution
104 This can only be done if the nurse is concerned that
somebody will be checking on her/his work afterwards.

QUESTION 29: What does a good nursing documentation entail?

105 Clear communication about the patient's general condition

106 Writing about the nurse's personal feelings and preferences
107 To show a nurse's beautiful handwriting when documenting

QUESTION 30: Why should a nurse's handwriting be legible in a documentation

that she has written?

108 To enable people reading his/her documentation understand

what has been written
109 To show how beautiful his/her handwriting can be

QUESTION 31: Why should there be nursing documentation in a patient's file in

the first place?

110 As a professional obligation that nursing care was rendered

and to communicate to other staff members about the
patient's condition
111 Just for fun and the sake of doing it
112 To be done only if a nurse feels like doing it and has time for
it
 81

QUESTION 32: Who are the people that are supposed to have access to the
patient's nursing documentation and why should those people access the
patient's file?

113 Multidisciplinary team members taking care of the patient - to

communicate and monitor the patient's progress
114 Family members - to make sure that the multidisciplinary
members are providing adequate care to their relative
115 Patient's occupational colleagues - to read and correct
whatever has been written about the patient

QUESTION 33: What is your general view on the electronic documentation of

nursing care?

___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
____________________________________
 82

ANNEXURE B: CONSENT LETTER TO THE PARTICIPANT

King Faisal Specialist Hospital And Research Centre – Jeddah

Jeddah, Kingdom Of Saudi Arabia

Dear employee of King Faisal Hospital

I am Aaron Mtsha. I am doing a mini research project as one of my study

requirements. I would like to request your voluntary participation by answering the
following questions. You need not identify yourself though. All you need to do is to
answer the questions freely. If there is anything at any stage that you are unsure
about or it is not clear please do not hesitate to contact me. All the information will be
treated as confidential and will be used for the purpose of the study only.

Thanking you for your cooperation.

Yours Faithfully

Aaron Mtsha

Signature Date
 83

ANNEXURE C: LETTER OF APPROVAL

 84

ANNEXURE D: LETTER OF APPROVAL FROM THE UNIVERSITY

30 August 2007

Mr MA Mtsha
Division of Nursing
Dept of Interdisciplinary Health Sciences

Dear Mr Mtsha

RESEARCH PROJECT "DOCUMENTATION OF NURSING CARE: CURRENT PRACTICES AND

PERCEPTIONS OF NURSES IN A TEACHING HOSPITAL IN SAUDI
ARACBIA"
PROJECT NUMBER N07/08/182

It is my pleasure to inform you that the abovementioned project has been provisionally approved on
28 August 2007 for a period of one year from this date. You may start with the project, but this approval will
however be submitted at the next meeting of the Committee for Human Research for ratification, after which we will
contact you again.

A statistical consultation and review of the questionnaire is advised before starting the project.

Notwithstanding this approval, the Committee can request that work on this project be halted temporarily in
anticipation of more information that they might deem necessary to make their final decision.

Please note that a progress report (obtainable on the website of our Division) should be submitted to the Committee
before the year has expired. The Committee will then consider the continuation of the project for a further year (if
necessary). Annually a number of projects may be selected randomly and subjected to an external audit.

In future correspondence, kindly refer to the above project number.

I wish to remind you that patients participating in a research project at Tygerberg Hospital will not receive their
treatment free, as the PGWC does not support research financially.

The nursing staff of Tygerberg Hospital can also not provide extensive nursing aid for research projects, due to the
heavy workload that is already being placed upon them. In such instances a researcher might be expected to make use
of private nurses instead.

Yours faithfully

~::.fQ,~y

CH AN TONDER
RESEARCH DEVELOPMENT AND SUPPORT (TYGERBERG)
Tel: +27219389207/ E-mail: [email protected]
CJVT/pm
C.\OOCUUENTS AND SETTINGS\POR1lA.OOOWY DOCuUerrTS\KI.INIPROJEKTE\2007\N07.Q8.1!2.ooI.DOC

Verbind tot Optimale Gcsondheid . Committed to Optimal Hcalth Afdeling Navorsingsontwikkeling en "steun . Research
Development and Support Division Posbus/PO Box 19063 . Tygerberg 7505 . Suid-Afrika/South Africa Tel:
+27 21 938 9677 . Faks/Fax: +27 21 931 3352 E-pos/E-mail: [email protected]
85