Abstract:
Background: Nursing documentation is an essential component of nursing practice that has a
potential to improve patient care outcomes. Poor documentation of nursing care activities among
Nurses have been shown to have negative impacts on health care quality. Therefore, the current
study aimed to determine nursing documentation practice and its associated factor among nurses
working in north shoa zone public hospitals, northeast Ethiopia.
Objective: To assess nursing documentation practice and it’s associated factors among nurses
who were working at North Shoa zone public hospitals, northeast Ethiopia.
Method: Institutional based cross sectional study was conducted at North Shoa zone public
hospitals. A simple random sampling technique was used to select 421 nurses. Nurses who have
been working in a selected hospital were participated. Data was collected by using structured
pre-tested self-administered questionnaires. Data was entered by Epi data version 3.1 and further
analysis was conducted by using SPSS version 23.0. Binary and multiple logistic regressions
were performed. All variables with p-value <0.25 on bivariate analysis were taken to
multivariate analysis. Adjusted odd ratio was calculated and P-value less than 0.05 with 95% CI
taken as statistically significant.
Result: In the current study the proportion of good nursing documentation practice was found to be
201 (47.7 %) with 95% CI (43.2, 52.7). Availability of operational standard (AOR=1.67(95% CI
(1.12, 2.52), good knowledge (AOR= 1.826 (1.202, 2.776), and availability of monitoring system
AOR =1.509(1.002, 2.272) were significantly associated with nursing care documentation practice.
Conclusion: Nursing documentation practice was poor among nurses under the study.
Availability of operational standard for nursing documentation, knowledge, and monitoring
system for nursing documentation were significantly associated with practice of nursing care
documentation. policy makers should include nursing care documentation as one of health
package to implement it as part of day to day activities in all health facilities and health
institutions provide to sustain continues monitoring system and operational standard for nursing
documentation to familiarize them with the guide line regarding documentation. Nurses should
improve their documentation practice by updating their knowledge. .
