Improving Quality of Nursing Care Documentation in Clinical Practice in County Referral Hospitals in Kenya

Abstract

Nursing care documentation is a core responsibility of professional nurses, spanning from patient admission to discharge and ensuring 24-hour continuity of care. Accurate documentation reflects patients’ conditions, nursing interventions, and outcomes, while deficiencies compromise care quality, continuity, and safety, exposing nurses to legal risks. In Kenya, persistent challenges with documentation prompted adoption of the global nursing process, positioning documentation as its final and essential step in improving healthcare outcomes. This study addressed health systems’ service delivery pillar, aiming to enhance nursing care documentation practices. Specific objectives were i) assessing the influence of individual nurse factors on the quality of nursing documentation in selected counties in Kenya; ii) establishing the influence of institutional factors on the quality of nursing documentation; iii) determining the impact of multidisciplinary collaboration on nursing documentation quality; iv) evaluating the influence of patient factors on nursing care documentation; and v) developing a framework to enhance nursing care documentation quality. The study was guided by general systems theory, McGregor’s Theory Y, and Deming’s theory. The study took place in Nyeri, Nyandarua, and Isiolo referral hospitals. Stratified sampling technique led to identification of three counties, census technique identified eight nurse managers, and random sampling identified 86 nurses and 158 patient case files. The study was organized into three phases. Phase one established a baseline using a descriptive research design. Phase two implemented applied research design, during which a Continuous Professional Development (CPD) module was developed, delivered at Nyeri County Referral Hospital, with a one-week follow-up. Phase three evaluated the effectiveness of the intervention using a descriptive design, with a sample size of 31 nurses and 31 patient case files. The study population included nurse managers and clinical nurses from the medical and surgical units and patient case files from those units in the three hospitals. Data collection instruments comprised questionnaires, a key informant guide, and an observation checklist, yielding both qualitative and quantitative data. Content analysis was used for the qualitative data, while quantitative data were analyzed using regression analysis with SPSS (version 26.0). Baseline results revealed that 78% of nursing care documentation was poor. Individual nurse factors, such as knowledge and attitude significantly influenced the quality of documentation. Institutional factors included standard operating procedures (SOPs), supervision, and institutional culture. Multidisciplinary factors influencing documentation quality included joint setting of clinical outcomes and collaborative clinical meetings. Patient factors affecting documentation included patient acuity, socio-economic empowerment, and inquisitive patients. Regression analysis of individual, patient and institutional factors demonstrated P values of <0.005, indicative of significant association. Post intervention, nursing documentation quality rose from 22% to 81.2%, demonstrating significant effectiveness. In summary, the findings show nursing documentation depends on many factors. Sustainable improvement requires identifying and addressing individual, institutional, and systemic influences through comprehensive, multi-faceted strategies, not singular approach. The study recommends i) adoption of systems thinking in improving nursing care documentation practice, ii) strengthening efforts for sustainability, iii) comparative study between manual versus electronic documentation, and iv) correlational study between public and private institutions.