Assessment of Nurses Knowledge Related to Nursing Documentation at Pediatric Surgical Wards
Abstract
Objectives: The aim of this study is to assess nurse's knowledge about nursing documentation at pediatric surgical wards.Methodology: Using pre- and post-tests for one set of pediatric surgery ward nurses in Baghdad, this study is the core component of a larger study that used a descriptive study design to fulfill the study objectives. Between December 23, 2021, and July 20, 2022, researchers conducted the study. There were three tests: baseline, post-test 1, and post-test 2 in the study group.
Results: During pre-test time they show poor levels among all items of the scale. During the post-test 1 and 2, the nurses show good level of knowledge about concept of nursing documentation (Total mean score = 0.86 and 0.77) in which the mean scores show good level among all items of this domain.
Conclusion: Nurses has poor knowledge regarding nursing documentation at pediatric surgical wards. There is an association between nurses' knowledge and their (gender, level of education, years of experience and main source of information.
Recommendations: Further research is imperative, that will pay more attention to the accuracy of nursing documentation, factors leading to variation in practice, flaws in nursing documentation quality and the effects of these on nursing practice and pediatric patient outcomes.
Assessment of Nurses Knowledge Related to Nursing Documentation at Pediatric Surgical Wards
Huda Abbass Ibraheam1*, Suad Hassoon Khudhair2
- MSN, Paediatric and Neonate Health Nursing department, University of Baghdad, College of Nursing, Iraq.
- PhD, Assistant Professor, Paediatric and Neonate Health Nursing department, University of Baghdad, College of Nursing, Iraq.
Corresponding author:Huda Abbass Ibraheam
Email: Huda.abbas1204b@conursing.uobaghdad.edu.iq
ABSTRACT
Objectives: The aim of this study is to assess nurse's knowledge about nursing documentation at pediatric surgical wards.
Methodology: Using pre- and post-tests for one set of pediatric surgery ward nurses in Baghdad, this study is the core component of a larger study that used a descriptive study design to fulfill the study objectives. Between December 23, 2021, and July 20, 2022, researchers conducted the study. There were three tests: baseline, post-test 1, and post-test 2 in the study group.
Results: During pre-test time they show poor levels among all items of the scale. During the post-test 1 and 2, the nurses show good level of knowledge about concept of nursing documentation (Total mean score = 0.86 and 0.77) in which the mean scores show good level among all items of this domain.
Conclusion: Nurses has poor knowledge regarding nursing documentation at pediatric surgical wards. There is an association between nurses' knowledge and their (gender, level of education, years of experience and main source of information.
Recommendations: Further research is imperative, that will pay more attention to the accuracy of nursing documentation, factors leading to variation in practice, flaws in nursing documentation quality and the effects of these on nursing practice and pediatric patient outcomes.
Keywords: Nurses, Nursing Documentation, Pediatric surgical wards.
Received: 03 May 2022, Accepted: 14 July 2022, Available online: 28 August 2022
INTRODUCTION
Nursing documentation is the process through which a nurse keeps a record of patient care. It is important in the field of pediatric nursing for accurate, designated nursing documentation to be used as evidence of the amount and quality of care that pediatric nurses should be providing, the outcomes of this care, as well as any treatment and training that the pediatric patient patient received. Surgical pediatric nurses rely on nursing documentation as a key communication tool. Nursing documentation from members of the multidisciplinary pediatric nursing team is frequently used to inform choices, actions, and adjustments to a patient's treatment plan in pediatrics. It is clear when a well-documented surgical record shows a high level of cooperation among the nursing care team members (Collins et al., 20013).
Documentation in the field of nursing also serves as a source of information for research and educational purposes. Researchers and nurse-educators, for example, may examine surgical data in order to evaluate the quality of care or the efficacy of care systems. To improve documentation, they might look at current electronic documentation systems or create customized forms for a particular type of content (Ministry of Health, 2016).
Pediatric surgery nurses have access to their patients' data in real time via nursing documentation, so they are always aware of the situation, needs, and problems that develop. Several alterations to the juvenile patient's situation are represented surgically and can be discussed all at once. It also eliminates mistakes due to illegible signatures and other variations in the layout pediatric surgery nurses employ when recording treatment, as indicated in the literature. Other advantages (Aydin et al., 2010).
AIMS OF THE STUDY
The study aims to assess the nurses knowledge about nursing documentation at pediatric surgical wards in Baghdad City and to find out the relationship between nurses knowledge and participants characteristic.
METHOD
Design of the study
A quasi-experimental design is carried out throughout the present study to assess nurses’ knowledges about nursing documentation at pediatric surgical wards in Baghdad City. The study has been carried out during the period extended from the 23th december 2021 to 20th July 2022.
Method of data collection
The permission was presented to theMinistry of Health directorates in Baghdad city which consisted of Welfare Teaching Hospital Children, And Central Teaching Hospital of pediatric in Baghdad city, to obtain an official permission to carry out the study. Later, the consent presented to the pediatrics surgical wards to ensure the agreement and cooperation. The Consent form facilitated access to the hospital facilities to complete the study.
The Instrument of the study
To assess the effectiveness of instructional program to for nurses’ knowledge's about nursing documentation at pediatric surgical wards; the researcher has constructed and developed a questionnaire – interview format for the purpose of the study; such development is employed through the available literature, clinical background and interview with nurses who working in pediatric surgical wards.
The reliability of the information test
Reliability is refers to an extent to which a questionnaire reports the same results on repeated time measure. Briefly it refers to consistent scores over times or raters (Bolarinwa, 2015).
The reliability of the instrument was determined through the computation of Alpha Cronbach’s test (Alpha Correlation Coefficient); internal consistency method was used for determining the reliability. The Alpha Correlation Coefficient was applied to determine the reliability of the present study instrument by application of Statistical Package for Social Science Program (IBM SPSS) version 26.0.
Data analysis: The data of the present study were analyzed through the use of Statistical Package of Social Sciences (SPSS) version 23.
RESULTS
Table (1): Distribution of Nurses according to their Socio-demographic Characteristics
|
No |
Characteristics |
f |
% |
|
|
1 |
Age M±SD= 32.10±6.168
|
Less than 30 years |
16 |
40 |
|
30 – less than 40 years |
16 |
40 |
||
|
40 ≤ years |
8 |
20 |
||
|
Total |
40 |
100 |
||
|
2 |
Gender |
Male |
13 |
32.5 |
|
Female |
27 |
67.5 |
||
|
Total |
40 |
100 |
||
|
3 |
Marital status |
Unmarried |
15 |
37.5 |
|
Married |
19 |
47.5 |
||
|
Divorced |
4 |
10 |
||
|
Widowed/er |
2 |
5 |
||
|
Total |
40 |
100 |
||
No: Number, f: Frequency, %: Percentage, M: Mean, SD: Standard deviation
Table (2): Distribution of Nurses according to their Professional Characteristics
|
No |
Characteristics |
F |
% |
|
|
1 |
Years of experience M±SD= 9.63±5.732
|
1 – less than 6 years |
8 |
20 |
|
6 – less than 11 years |
18 |
45 |
||
|
11 – less than 16 year |
6 |
15 |
||
|
16 – less than 21 year |
6 |
15 |
||
|
21 ≤ year |
2 |
5 |
||
|
Total |
40 |
100 |
||
|
2 |
Nursing qualification |
Secondary school |
16 |
40 |
|
Diploma |
12 |
30 |
||
|
Bachelor |
8 |
20 |
||
|
Others |
4 |
10 |
||
|
Total |
40 |
100 |
||
|
3 |
Participation in training courses |
No |
26 |
65 |
|
Yes |
14 |
35 |
||
|
Total |
40 |
100 |
||
|
4 |
Duration of training course |
None |
26 |
65 |
|
5 days |
14 |
35 |
||
|
Total |
40 |
100 |
||
|
5 |
Location of training course |
None |
26 |
65 |
|
Inside country |
14 |
35 |
||
|
Outside country |
0 |
0 |
||
|
Total |
40 |
100 |
||
|
6 |
Having information about documentation |
No |
20 |
50 |
|
Yes |
20 |
50 |
||
|
Total |
40 |
100 |
||
|
7 |
Source of information about documentation |
None |
20 |
50 |
|
Internet |
15 |
37.5 |
||
|
Television |
1 |
2.5 |
||
|
Textbooks |
1 |
2.5 |
||
|
Individual/community |
2 |
5 |
||
|
Other sources |
1 |
2.5 |
||
|
Total |
40 |
100 |
||
No: Number, f: Frequency, %: Percentage, M: Mean, SD: Standard deviation
Table (4-3): Assessment of Nurses’ Knowledge about Concept of Nursing Documentation
|
List |
Items |
Pre-test (N=40) |
Post-test1 (N=40) |
Post-test2 (N=40) |
|||
|
Mean |
Asses. |
Mean |
Asses. |
Mean |
Asses. |
||
|
1 |
The nurse introduces himself to patient |
.28 |
Poor |
.92 |
Good |
.90 |
Good |
|
2 |
Nursing documentation is the primary source of clinical information to meet legal and professional requirements |
.30 |
Poor |
.75 |
Good |
.70 |
Good |
|
3 |
Nursing documentation is a written record of data and information written by the nurse |
.33 |
Poor |
.70 |
Good |
.68 |
Good |
|
4 |
Nursing documentation is one of the most widely used means of communicating information about nurses' performance |
.33 |
Poor |
.90 |
Good |
.88 |
Good |
|
5 |
Nursing documentation should be a priority for nurses |
.28 |
Poor |
.95 |
Good |
.95 |
Good |
|
6 |
A medical record is a set of medical documents that have been created to document the medical condition of children |
.28 |
Poor |
.95 |
Good |
.95 |
Good |
|
7 |
The registry is the means by which the various health professionals in the pediatric surgery wards can communicate with each other |
.31 |
Poor |
.83 |
Good |
.83 |
Good |
|
8 |
Medical records are the only evidence that a medical procedure or treatment has been attempted |
.33 |
Poor |
.80 |
Good |
.68 |
Good |
|
9 |
Basic Components of an Integrated Medical Record Each medical record must have specific personally identifiable information |
.30 |
Poor |
.75 |
Good |
.70 |
Good |
|
10 |
Nursing documentation is a required document that guarantees the rights of the nurse during each shift |
.32 |
Poor |
.98 |
Good |
.98 |
Good |
|
11 |
Nursing documentation is one of the most widely used means of communicating information about nurses' performance |
.33 |
Poor |
.93 |
Good |
.93 |
Good |
|
12 |
Nursing documentation is the primary source of clinical information to meet legal and professional requirements |
.40 |
Poor |
.90 |
Good |
.88 |
Good |
|
Total |
.32 |
Poor |
.86 |
Good |
.77 |
Good |
|
f: Frequency, %: Percentage, Asses: Assessment, (Mean: Poor= 0-0.33, Fair= 0.34-0.66, Good= 0.67-1).
DISCUSSION
A total of 40 pediatric surgery nurses are included in the study's sample (study group 40 nurses). 40 percent of nurses in this research were younger than 30 years of age, 40 percent were between 30 and 39 years old, and 20 percent were over 40 years old. A study done by (Beydag, 2011) found that 60% of nurses in his research were between the ages of 20 and 30 years old, which is consistent with this finding. It also corresponds with (Collins et al., 2009) who stated that the nurse's age ranged from (25-29 years) and the WHO (2006), which indicated a minimum nursing age of (25 years) in regions where specialized care is required. It's less stressful to be a nurse on a ward since the number of nurses in the ward is more than the number of nurses in the emergency department, which has the most critical units.
There are 67.5 percent female nurses and 32.5 percent male nurses, according to the gender variable.
According to the data, 47.5% of nurses are married, while 37.5% of them remain unattached. According to the findings of this survey, nurses have an average experience of 9.63 5.732 years, with 45 percent reporting that they have 6-10 years of nursing experience and 20 percent reporting that they have 1-5 years of experience. New nurses should be able to work in surgical units where they are supported by an experienced colleague, according to (Moosa, 2012) who revealed that 57.1 percent of the nurses were hired between the ages of 19 and 30 in obstetric units (Hunges and Fraser 2011).
According to (Santhirani and colleagues, 2017), the majority of participants (29.4%) were 36-40 years old, while 23.5% of those surveyed were under the age of 30. The participants in the research varied in age from 28 to 52 years old, with an average age of 36.2 5.7 years.
When it comes to education, the majority of nurses have a high school diploma or a nursing diploma, while just 20% have a bachelor's degree in nursing. The study is in keeping with a previous study (Rashied, 2014), which found that of the total (68) nurses studied, 40% of the study sample were nursing school graduates. Despite the fact that a study by (Urase et al, 2011) found that the majority of nurses had diplomas or certificates in nursing, a study in Qatar by (Santhirani et al, 2017) found that the highest percentage of nurses (49%) had diplomas or certificates and the highest percentage of nurses (100%) had bachelor degrees.
During the research group's pre-test, the level of nurses' knowledge was a poor (0.33) for all of the above-mentioned areas. Posttest1 showed the most improvement in participant knowledge of nursing, with a mean score more than (0.90), whereas posttest2 had a mean score of (0.80). According to the findings of a post-test, the nurses' understanding of documentation has improved significantly. Those findings have been corroborated by The quality of the paperwork provided by the nursing staff has increased dramatically, and this development has persisted over time. The level of documentation expertise throughout the team has increased dramatically. Errors in documentation were also reduced statistically significant. Nurses were able to achieve and maintain specified documentation requirements because to the combination of peer auditing and continuous education.
Mahdy (2009), who performed a research on the impact of a training program on the performance and empowerment of staff nurses caring for patients undergoing organ and tissue transplantation, found that these findings were consistent with his findings. He found a link between theoretical understanding and practical application. Previous research have shown that if participants' knowledge is strong, their skill level is likely to be high at both the pre-test and post-test levels.
"A ward-based writing coach program to increase the quality of nursing documentation" was investigated by Jefferies, Diana, et al. in 2012. This unique education program is designed to teach nurses how to look at their documentation in a critical perspective, so that they may improve their documentation abilities. The clinical nurse educator on the ward may take on a new function as a result of this strategy.
Please keep in mind, Donohoe, 2015, that the program promotes solid clinical governance and quality assurance mechanisms in order to help prevent such adverse incidents and hence assure pleasant experiences and results for future service users.
CONCLUSIONS
Illustrated from this study, the nurses have poor knowledge regarding nursing documentation at pediatric surgical wards. Association between nurses' knowledge and their (gender, level of education, years of experience and main source of information).
RECOMMENDATIONS
All the pediatrics surgical nurses should be encouraged to participate in the program for nursing documentation for educational, learning and training courses about nursing documentation every six months inside or outside country.
ETHICALCONSIDERATIONSCOMPLIANCEWITHETHICALGUIDELINES
This study was completed following obtaining consent from the University of Baghdad.
FUNDING
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.
AUTHOR’SCONTRIBUTIONS
Study concept, Writing, Reviewing the final edition by all authors.
DISCLOSURESTATEMENT:
The authors report no conflict of interest.
REFERENCES
Adamski, Patricia RN, MS, MB, Aevealed: (2006). National Patient Safety Goals, Nursing Management (Springhouse): August 2005 - Volume 36 - Issue 8 - p 10Departments: JCAHO solutions The Joint Commission reveals 2006 National Patient Safety Goals requirements. @2005 by Lippincott Williams & Wilkins, Inc.
Adamski, Patricia. Revealed: (2006). National Patient Safety Goals. Nursing Management (Springhouse): August 2005 - Volume 36 - Issue 8 - p 10.Departments: JCAHO solutions.
Adib-Hajbaghery, M., Karbasi-Valashani, K., &Heidari-Haratmeh, A. (2012). Correlation of Clinical Skills Self- Assessment of Nursing Internship Trainees with Their Teachers‘ Evaluation. Retrieved from Attribution Access: http://nmsjournal.com/?page=article
Adrian Hayes, Poppy Roberts, Sarah Watson, Adam Figgins, Rosalind Pool, Siobhan Reilly, Christopher Roughley, Thomas Salter, Jessica Scott, Rebecca Woodside and Dr Vinod Patel. (2011). RISC clinical hazards in patient safety. Chips -20th and 22nd September 2011.
Agency for Healthcare Research and Quality. (2014). Hospital Survey on Patient Safety Culture. Retrieved from http://www. ahrq.gov/professionals/quality-patient safety/ Patient safety
Aiken, L.H. (2001). "Evidence-based management: key to hospital workforce stability.https://www.ncbi.nlm.nih.gov/pubmed/11805972; Spec No:117-24. 11805972; [Indexed for MEDLINE]
Alternative Ground Motion Intensity.University of Naples, Federico II, Italy
Alyce S. Ashcraft, Donna C. Owen, (2017). Comparison of standardized and customized SBAR communication tools to prevent nursing home resident transfer, Applied Nursing Research 38 (2017) 64–69, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, TX 79403, United States, EISEVER, http://dx.doi.org/10.1016/j.apnr.2017.09.015.
Andrade, H. & Du, Y. (2007). Student responses to criteria-referenced self-Assessment. Assessment and Evaluation in Higher Education, 32(2), 159-181.
Andreoli, A., Fancott, C., Velji, K., Baker, G., Solway, S., Aimone, E., & Tardif, G. (2010). Using SBAR to communicate fall risk and management in inter-professional rehabilitation teams. Healthcare Quarterly, 13(September Special Issue) 2010.94-101. Retrieved from https://proxy.lib.utc.edu/login?url=http://search.ebscohost.com/login.aspx? direct=true&db=ccm&AN=104939600&site=ehost-live.
cervix cancer. Asian Pacific Journal of Cancer Prevention, 12(2), pp. 481-5. PMID:21545217
Beyea, S.C. (2004). Improving verbal communication in clinical care. AORN Journal, .79(5), 1053-1057.
Bhabra, G. MacKeith, S. Monteiro, P. & Pothier, D. (2007). An experimental comparison on handover methods. Ann R coll Surg Engl, 89(3), 298-300
Blom, Lisbeth, Pia Petersson, Peter Hagell, Albert Westergren. (2015). The Situation, Background, Assessment and Recommendation (SBAR) International Journal of Caring Sciences September-December 2015 Volume 8 | Issue 3| Page 530.
Boaro, N., Fancott, C., Baker, R., Velji, K., & Andreoli, A. (2010). Using SBAR to improve communication in interprofessional rehabilitation teams. Journal of Interprofessional Care, 24, 111-114
Bomba, D. T., & Prakash, R. (2005). A description of handover processes in an Australian public hospital. Australian Health Review, 29(1), 1146-1150.
Borowitz SM, Waggoner-Fountain LA, Bass EJ, et al. (2008). Adequacy of information transferred at resident sign-out.17:6e10.
Adamski, Patricia RN, MS, MB, Aevealed: (2006). National Patient Safety Goals, Nursing Management (Springhouse): August 2005 - Volume 36 - Issue 8 - p 10Departments: JCAHO solutions The Joint Commission reveals 2006 National Patient Safety Goals requirements. @2005 by Lippincott Williams & Wilkins, Inc.
Adamski, Patricia. Revealed: (2006). National Patient Safety Goals. Nursing Management (Springhouse): August 2005 - Volume 36 - Issue 8 - p 10.Departments: JCAHO solutions.
Adib-Hajbaghery, M., Karbasi-Valashani, K., &Heidari-Haratmeh, A. (2012). Correlation of Clinical Skills Self- Assessment of Nursing Internship Trainees with Their Teachers‘ Evaluation. Retrieved from Attribution Access: http://nmsjournal.com/?page=article
Adrian Hayes, Poppy Roberts, Sarah Watson, Adam Figgins, Rosalind Pool, Siobhan Reilly, Christopher Roughley, Thomas Salter, Jessica Scott, Rebecca Woodside and Dr Vinod Patel. (2011). RISC clinical hazards in patient safety. Chips -20th and 22nd September 2011.
Agency for Healthcare Research and Quality. (2014). Hospital Survey on Patient Safety Culture. Retrieved from http://www. ahrq.gov/professionals/quality-patient safety/ Patient safety
Aiken, L.H. (2001). "Evidence-based management: key to hospital workforce stability.https://www.ncbi.nlm.nih.gov/pubmed/11805972; Spec No:117-24. 11805972; [Indexed for MEDLINE]
Alternative Ground Motion Intensity.University of Naples, Federico II, Italy
Alyce S. Ashcraft, Donna C. Owen, (2017). Comparison of standardized and customized SBAR communication tools to prevent nursing home resident transfer, Applied Nursing Research 38 (2017) 64–69, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, TX 79403, United States, EISEVER, http://dx.doi.org/10.1016/j.apnr.2017.09.015.
Andrade, H. & Du, Y. (2007). Student responses to criteria-referenced self-Assessment. Assessment and Evaluation in Higher Education, 32(2), 159-181.
Andreoli, A., Fancott, C., Velji, K., Baker, G., Solway, S., Aimone, E., & Tardif, G. (2010). Using SBAR to communicate fall risk and management in inter-professional rehabilitation teams. Healthcare Quarterly, 13(September Special Issue) 2010.94-101. Retrieved from https://proxy.lib.utc.edu/login?url=http://search.ebscohost.com/login.aspx? direct=true&db=ccm&AN=104939600&site=ehost-live.
cervix cancer. Asian Pacific Journal of Cancer Prevention, 12(2), pp. 481-5. PMID:21545217
Beyea, S.C. (2004). Improving verbal communication in clinical care. AORN Journal, .79(5), 1053-1057.
Bhabra, G. MacKeith, S. Monteiro, P. & Pothier, D. (2007). An experimental comparison on handover methods. Ann R coll Surg Engl, 89(3), 298-300
Blom, Lisbeth, Pia Petersson, Peter Hagell, Albert Westergren. (2015). The Situation, Background, Assessment and Recommendation (SBAR) International Journal of Caring Sciences September-December 2015 Volume 8 | Issue 3| Page 530.
Boaro, N., Fancott, C., Baker, R., Velji, K., & Andreoli, A. (2010). Using SBAR to improve communication in interprofessional rehabilitation teams. Journal of Interprofessional Care, 24, 111-114
Bomba, D. T., & Prakash, R. (2005). A description of handover processes in an Australian public hospital. Australian Health Review, 29(1), 1146-1150.
Borowitz SM, Waggoner-Fountain LA, Bass EJ, et al. (2008). Adequacy of information transferred at resident sign-out.17:6e10.
- Article View: 122
- PDF Download: 69