Documentation of nursing care current practices and perceptions of nurses in a teaching hospital in Saudi Arabia
dc.contributor.advisorStellenberg, E. L.
dc.contributor.otherUniversity of Stellenbosch. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences. Nursing Science.
dc.descriptionThesis (MCur (Nursing Science))--University of Stellenbosch, 2009.
dc.description.abstractENGLISH ABSTRACT: Nursing documentation is the written evidence of nursing practice and reflects the accountability of nurses to patients. Accurate documentation is an important prerequisite for individual and safe nursing care. It is a severe threat for the individuality and safety of patient care if important aspects of nursing care remain undocumented. Nursing staff cannot rely on information that is not documented. Every patient is important and unique hence every patient’s care is individualised and different according to his/her needs. This is why important aspects of his/her care need to be documented. Ultimately, the documentation practices reflect the values of the nursing personnel (Isola, Muurinen and Voutilainen, 2004:79-80).
The goal of this study was to investigate documentation of nursing care with reference to current practices and perceptions of nurses in a teaching hospital in Saudi Arabia
Specific objectives of the study were:
to identify whether the hospital policies are being carried out
to identify whether the procedures regarding current documentation are being carried out and
to explore the perceptions of the nurses regarding the current documentation practices.
For the purpose of this study, a non-experimental descriptive design with a quantitative approach was used. The study was carried out at King Faisal Specialist Hospital in Jeddah in Saudi Arabia. The total population of 90 registered nurses were used in this study. Questionnaires were distributed to the participants and they were answered with no identities written on the questionnaires. After the questionnaires were completed, it was posted in a box and was collected by the researcher. The questions are straightforward, easily understood, unambiguous, non-leading, objectively set and aimed at obtaining views, experiences and perceptions of documentation of nursing care. . Involvement of participants was voluntary and non-coercive. Data analysis were carried out with the support of a statistician, expressed in tables, frequencies and statistical associations were done between various variables based on a 95% confidence interval.
Hospital policies are being carried out N=76 (95%)
Procedures pertaining to documentation of nursing care are being carried out N=67(83,7%).
Nurses N=45(56,3%) indicated that paper documentation included a lot of paperwork.
The Cerner (computer system) is regarded as the best system ever used for documentation of nursing care N=44(55%)
The Mycare system (medication ordering system) is regarded as the most reliable, user-friendly system and nurses are happy with it N=68(85%)
Nurses still need to be taught about the hospital policies
Nurses should be taught the correct procedure on documenting the patient data
Nurse clinicians and managers should check the Cerner for compliance with regard to documentation of physical assessment when conducting audits
Use of paper for nursing documentation should be minimized by shifting some of the nursing documentation procedures from paperwork to electronic version
Continuous updating, in-service training and monitoring to keep nurses abreast with the dynamic nature of computer usage
Reviewing of the system, troubleshooting and suggestions from users need to be attended to on a continuous basis
It is recommended that a backup system (generator) is in place to ensure continuity of documentation.en
dc.description.abstractAFRIKAANSE OPSOMMING: Die dokumentering van verpleegsorg is die skriftelike bewys van die verpleegpraktyk en weerspieël die toerekenbaarheid van verpleegsters teenoor pasiënte. Noukeurige dokumentering is ’n belangrike voorvereiste vir individuele en veilige verpleegsorg. Dit is ’n ernstige bedreiging vir die individualiteit en veiligheid van pasiënte-sorg, indien belangrike aspekte van verpleegsorg nie gedokumenteer word nie. ’n Mens kan nie inligting vertrou wat nie gedokumenteer is nie. Die versorging van elke pasiënt is belangrik en uniek. Dit is waarom belangrike aspekte aangaande haar/sy versorging gedokumenteer behoort te word. Uiteindelik weerspieël die dokumenteringspraktyke, die waardes van die verpleegpersoneel (Isola, Muurinen en Voutilainen, 2004: 79-80).
Die doel van die studie was om dokumentasie van verpleegsorg met verwysing na huidige praktyke en persepsies van verpleegkundiges in ‘n opleidingshospitaal in Saudi Arabia te ondersopek.
Spesifieke doelwitte was
om vas te stel of die hospitaal se beleidsrigtings toegepas word
om vas te stel of die prosedure t.o.v die huidige dokumentering uitgevoer is
en’n ondersoek na die persepsies van verpleegsters aangaande die huidige dokumenteringspraktyke
Vir die doel van hierdie studie is ’n nie-eksperimentele beskrywingsontwerp met ’n kwantitatiewe benadering gevolg. Hierdie studie was in King Faisal Specialist Hospital in Jeddah, in Saudia Arabia gedoen. ’n Totale bevolking van 90 geregistreerde verpleegsters was betrokke. Vraelyste was versprei na die deelnemers en is naamloos beantwoord, sonder dat hulle identiteite op die vraelys aangebring is. Na voltooiing van die vraelyste, is dit in ’n houer geplaas en deur die navorser afgehaal. Die vrae is direk, eenvoudig, maklik verstaanbaar, ondubbelsinnig, nie-afleibaar, objektief opgestel en is daarop gemik om gesigspunte, ervaringe en persepsies oor dokumentering van verpleegsters te verkry.
Betrokkenheid van deelnemers was vrywillig en nie afdwingbaar nie. Data is getabuleer en in histogramme en frekwensies voorgestel. Deur die Chi-square- toets te gebruik, is statisties betekenisvolle assosiasies tussen veranderlikes bepaal.
Bevindinge sluit die volgende in:
Die hospitaalbeleid word toegepas N= 76(95%)
Prosedure t.o.v. dokumentering aangaande verpleegsorg word uitgedra N=67(83,7%)
Verpleegsters het aangedui dat dokumentering op papier, baie papierwerk behels N=45(56,3%)
Die Cerner (rekenaarstelsel) word beskou as die beste stelsel ooit in gebruik vir die dokumentering van verpleegsorg N==44(55%)
Die Mycare stelsel (medisyne bestellingstelsel) word beskou as betroubaar en gebruikersvriendelik, en een waarmee verpleegsters gelukkig is N=68(85%).
Aanbevelings is gemaak, gebaseer op die volgende bevindinge:
Dit is steeds nodig dat verpleegsters die hospitaal se beleidsrigtinge geleer moet word
Verpleegsters moet die korrekte prosedure aangaande die dokumentering van die pasiënt se data geleer word
Verpleegklinici en bestuurders moet die Cerner nagaan ter voldoening van die dokumentering van fisiese waardebepalinge tydens ouditeringe
Die gebruik van papier vir verpleegdokumentering behoort afgeskaal te word deur van die praktyk van papierwerk na elektroniese dokumentering te skuif
Voortdurende bywerking van data, indiensopleiding en monitering van verpleegsters om hulle op die hoogte te hou van die dinamiese aard van rekenaargebruik
Hersiening van die stelsel, foutspeurdery en voorstelle van gebruikers moet op ’n voortdurende basis aandag geniet.af
dc.subjectNursing -- Saudi Arabiaen
dc.subjectNursing care plans -- Saudi Arabiaen
dc.subjectDissertations -- Nursingen
dc.subjectTheses -- Nursingen
dc.subjectAssignments -- Nursingen
dc.titleDocumentation of nursing care current practices and perceptions of nurses in a teaching hospital in Saudi Arabiaen_ZA
Masters Degrees (Nursing Science)116