| dc.description.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. | en_US |
