Abstract

Mary Grace Nakate*, Dr. Diane Dahl,Dr. Karen B. Drake and Dr. Pammla Petrucka

Ideally through documentation, nurses track changes in a patient’s condition, make decisions about needs, and ensure continuity of care. However, nursing documentation has often not met these objectives. In Uganda, the systematic nursing specific approach is not reflected in documentation of nursing care. A mixed methods intervention study was conducted to determine knowledge and attitudes of nurses towards documentation, including an evaluation of nurses’ response to a designed nursing documentation form. Forty participants were selected through convenience sampling from six wards of a Ugandan health institution. The study intervention involved teaching nurses the importance of documentation and using of the trial documentation tool. Pre and post testing and open-ended questionnaires were used in data collection. On both pre and post-tests, most participants strongly agreed that nursing notes were meaningful and necessary for legal protection, as well as a nursing priority. Most participants strongly disagreed that there was familiarity with policies on nursing documentation, and that an uninterrupted environment for care documentation existed. Although participants’ knowledge about documentation improved by 20% following the intervention, there was no significant change in attitudes toward documentation. Participants consistently reflected on documentation as an important practice, but highlighted contextual constraints limiting implementation and quality of documentation. The study findings have implications for pre and post-service training, documentation policies, and organizational supports for nursing documentation.