Perceptions of nurses on documentation of nursing care at selected public hospitals in Vhembe District, Limpopo Province

Abstract

Introduction: Good nursing practice involves detailed documentation, which should be timely, appropriate, comprehensive, and accurate. Therefore, documents contain the who, why, how, where, what, and when of patient care. However, poor documentation practices among nurses have been identified and understood to have been influenced by numerous factors. Poor documentation practices have a negative impact on health care provision and clinical decision-making during patients’ hospitalisations. The perceived challenges experienced by nurses during documentation of patient care are more evident in clinical practice; hence, this is an area that needs attention by health care management to ensure quality patient care. Purpose of the study: The study aimed to determine the perceptions of nurses about nursing care documentation in selected public hospitals in Vhembe district, Limpopo Province. Research setting: The study was conducted in a public regional hospital and a district hospital in Vhembe district, Limpopo Province. Research method: A qualitative, exploratory, descriptive, and contextual research designs were used. A non-probability-purposive sampling technique was used to select the participants in the study. Data was collected through a semi-structured one-on-one interview using an interview guide. Tesch’s open-coding method was used for data analysis, where themes and sub-themes were developed. Measures to ensure trustworthiness, credibility, dependability, transferability, and conformability were all taken into consideration. All ethical principles were adhered to throughout the study. Findings: The findings of this study revealed that registered professional nurses perceive the documentation of nursing care as an essential practice that benefits patients, health care workers, and the health system as a whole. However, due to the numerous challenges they are faced with, such as lack of resources, shortage of staff, lack of time, workload, poor handling of patient documents, and ward allocation barriers, the documentation standards are poor. Such challenges place patients’ health and safety at risk, and health care workers and the health care system are at risk of litigation. Recommendations: This study recommends that hospital management advocate for more nurses to be hired to reduce the issue of a shortage of nurses and workload. Educated and well-trained clerks should be employed to promote good documentation management. There must be a supply of material resources, such as papers, to use for documenting patient care. Training workshops should be conducted to educate nurses on the importance of documenting nursing care. Hospital management must supply managers in the wards with documentation policy guidelines and must also elaborate on the actions that will be taken against people who do not comply with such guidelines. Conclusions: The study concluded that there are evident challenges with documentation of patient care amongst nurses in public hospitals, and this affects the provision of quality patient care. The study findings revealed a need for continuous in-service training, commitment, and teamwork among all categories of nurses to improve nursing documentation practices.