Nursing documentation: Experience of the use of the nursing process model in selected hospitals in Ibadan, Oyo State, Nigeria.
Summary of "Nursing documentation: Experience of the use of the nursing process model in selected hospitals in Ibadan, Oyo State, Nigeria."
The descriptive study was conducted to determine the extent of utilization of the nursing process for documentation of nursing care in three selected hospitals, Ibadan, Nigeria. One hundred fifty nurses and 115 discharged clients' records were selected from the hospitals. Questionnaires and checklists were used to collect data. Utilization of nursing process for care was 100%, 73.6% and 34.8% in the three hospitals. Nurses encountered difficulties in history taking, formulation of nursing diagnoses, objectives, nursing orders and evaluation. Most nurses disagreed or were undecided with the use of authorized abbreviations and symbols (34.3%, 40.3% and 69.5%), recording errors that occurred during care (37.1%, 56.1% and 52.2%) and inclusion of change in clients' condition (54.3%, 56.1% and 73.8%). Most nurses appreciated the significance of documentation. Lack of time, knowledge and need for extensive writing are the major barriers against documentation. Seventy-seven point four per cent of the 115 clients' records from one hospital showed evidence of documentation, no evidence from the other two. Study findings have implications for continuing professional education, practice and supervision.
Affiliation
Department of Nursing, University of Ibadan, Ibadan, Oyo State, Nigeria.
Journal Details
This article was published in the following journal.
Name: International journal of nursing practice
ISSN: 1440-172X
Pages: 354-62
Links
- PubMed Source: http://www.ncbi.nlm.nih.gov/pubmed/22845635
- DOI: http://dx.doi.org/10.1111/j.1440-172X.2012.02044.x
Medical and Biotech [MESH] Definitions
Models, Nursing
Theoretical models simulating behavior or activities in nursing, including nursing care, management and economics, theory, assessment, research, and education. Some examples of these models include Orem Self-Care Model, Roy Adaptation Model, and Rogers Life Process Model.
Family Nursing
The provision of care involving the nursing process, to families and family members in health and illness situations. From Lippincott Manual of Nursing Practice. 6th ed.
Nursing Audit
A detailed review and evaluation of selected clinical records by qualified professional personnel for evaluating quality of nursing care.
Transcultural Nursing
A nursing specialty created to answer the need for developing a global perspective in the practice of nursing in a world of interdependent nations and people. The focus of this nursing discipline is on the integration of international and transcultural content into the training. Courses include study in the area of cultural differences, nursing in other countries, and international health issues and organizations, as an example.
Nursing Process
The sum total of nursing activities which includes assessment (identifying needs), intervention (ministering to needs), and evaluation (validating the effectiveness of the help given).
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