Enhancing Quality of Documentation of Nursing Care in Selected County Referral Hospitals in Kenya

Abstract

Purpose: Good health is a key Sustainable Development Goal, and quality nursing care documentation plays a vital role in achieving this goal by enhancing patient safety, care continuity, and accountability. Despite its importance, studies consistently show persistent gaps in nursing documentation that can compromise care outcomes and patient trust. This study describes efforts towards enhancing quality of nursing care documentation in County Referral Hospitals in Kenya.

Methodology: Using a mixed-methods design, the research combined baseline audits of 158 patient files with surveys from 88 nurses and interviews with five nurse managers. An intervention phase followed, where a Continuous Professional Development (CPD) module was implemented in Nyeri County Referral Hospital. This training used a systems thinking approach to highlight how people, processes, and resources interact to affect documentation practices.

Findings: Post-intervention, 62 patient files were audited, showing marked improvements: 93.5% of files contained patient details on every sheet (up from 44.4%), detailed assessments increased to 51.6%, and documentation of interventions, patient responses, and shift instructions all rose above 80%. Overall, there was improvement from 22% to 81.2% good nursing care documentation. Despite these gains, gaps remain, especially in timeliness and workload-related barriers.

Unique Contribution to Theory, Practice and Policy: This study makes a unique contribution by demonstrating the effectiveness of a systems thinking approach in improving nursing documentation within resource-constrained settings. The study recommends conducting routine refresher training, and addressing staffing shortages to allow nurses adequate time for thorough, timely records. High-quality documentation supports critical thinking, legal protection, interprofessional collaboration, and patient-centered care. Sustaining these improvements demands committed leadership and continuous mentorship. This research highlights that targeted interventions, guided by systems thinking, can significantly enhance nursing documentation quality, ultimately contributing to safer, more effective healthcare delivery in Kenyan County Referral Hospitals and beyond.