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KNOWLEDGE, ATTITUDE AND PRACTICE TOWARDS DOCUMENTATION AND QUALITY RECORD KEEPING AMONG NURSES IN FAITH MEDIPLEX HOSPITAL BENIN CITY
Abstract
This study focused on exploring nurses’ knowledge, attitudes, and practices regarding documentation and quality record-keeping in a healthcare setting. A quantitative survey research design was adopted to gather data on these aspects from a sample of 120 respondents. A structured questionnaire was designed to collect relevant information, covering areas such as the level of knowledge, attitudes towards documentation, adherence to protocols, and perceived importance of accurate record-keeping. The data collected were then presented and analyzed using frequency tables to provide a descriptive overview of the responses. In analyzing the hypotheses, a t-test was employed to compare means and determine whether there were significant correlations between nurses’ knowledge, attitudes, and actual practices related to documentation and quality record-keeping. The findings from the t-test indicated significant positive correlations, contrary to the null hypotheses. This suggests that nurses with higher levels of knowledge and more positive attitudes towards documentation tend to demonstrate better practices and adherence to quality record-keeping standards. Based on the results, the study concluded that there is indeed a positive correlation between nurses’ knowledge, attitudes, and practices regarding documentation and quality record-keeping. This underscores the importance of continuous education and training programs to enhance nurses’ understanding of documentation protocols and to foster positive attitudes towards accurate record-keeping. Additionally, the study highlights the need for ongoing monitoring and evaluation of documentation practices within healthcare institutions to ensure compliance with established standards and guidelines. In light of these findings, several recommendations can be made. Firstly, healthcare organizations should prioritize investment in training programs that focus on documentation practices and emphasize the importance of accurate record-keeping for patient safety and care continuity. Secondly, regular audits and assessments should be conducted to evaluate nurses’ adherence to documentation protocols and identify areas for improvement. Finally, future research in this area should consider longitudinal studies or mixed-method approaches to gain a more comprehensive understanding of the factors influencing nurses’ behaviors and attitudes towards documentation and quality record-keeping.
Top of Form
CHAPTER ONE
INTRODUCTION
1.1 Background to the Study
Documentation and quality record-keeping are crucial components of healthcare delivery, playing vital roles in ensuring continuity of care, legal compliance, and quality improvement (Federal Ministry of Health, 2021). In the context of nursing, accurate and comprehensive documentation serves as a cornerstone for effective communication among healthcare professionals, contributes to patient safety, and establishes legal accountability (Kebede et al., 2017). These aspects are particularly pertinent in healthcare settings like Faith Mediplex Hospital in Benin City, where the complexities of patient care demand meticulous attention to documentation practices to uphold standards of care and ethical responsibilities.
Nurses’ knowledge, attitudes, and practices (KAP) regarding documentation and quality record-keeping significantly impact healthcare outcomes (Jasemi et al., 2022). Understanding nurses’ perceptions and behaviors in this domain is crucial for identifying areas of improvement and enhancing the overall quality of care provided (Okaisu et al., 2022). The Federal Ministry of Health’s guidelines and standards play a foundational role in shaping these practices, providing frameworks and expectations for healthcare facilities like Faith Mediplex Hospital to adhere to (Federal Ministry of Health, 2022).
Assessing nurses’ KAP towards documentation in a hospital setting like Faith Mediplex Hospital offers valuable insights into the challenges and successes within the organization (Mohammed, 2017). This assessment can lead to targeted interventions and training programs aimed at improving documentation practices and fostering a culture of excellence in record-keeping (Hana, 2017). Furthermore, it allows for the alignment of hospital policies and practices with national standards, promoting consistency and efficiency in healthcare delivery (Federal Ministry of Health, 2016).
The attitudes of nurses towards electronic health records (EHRs) also influence documentation practices and record-keeping (Juliet & Sudha, 2023). Hospitals like Faith Mediplex that integrate technology into their healthcare systems must consider nurses’ acceptance and utilization of EHRs to optimize documentation accuracy and efficiency (Salameh et al., 2019). Training and support in EHR usage can enhance nurses’ confidence and competency in digital documentation, leading to improved data management and patient care outcomes (Olivier, 2020).
Quality record-keeping not only serves immediate patient care needs but also contributes to broader research and quality improvement initiatives (Paans et al., 2020). Hospitals like Faith Mediplex can leverage accurate and comprehensive records to track trends, identify areas for improvement, and implement evidence-based practices (Nakate et al., 2020). This cyclical process of documentation, analysis, and action supports continuous quality enhancement and promotes a culture of learning and innovation in healthcare organizations (Petkovšek & Skela-Savič, 2021).
In essence, the knowledge, attitudes, and practices of nurses regarding documentation and quality record-keeping are pivotal in ensuring high-quality healthcare delivery. Hospitals like Faith Mediplex in Benin City play a crucial role in this context, serving as platforms for assessing and improving documentation practices to enhance patient care, legal compliance, and overall healthcare quality. By aligning with national guidelines, embracing technology, and fostering a culture of continuous improvement, healthcare organizations can optimize documentation processes and ultimately improve patient outcomes.
1.2 Statement of Problem
The landscape of nursing documentation and quality record-keeping at Faith Mediplex Hospital in Benin City presents several critical areas that require investigation and improvement.
There is a noticeable gap in the literature concerning the specific challenges and strengths related to nurses’ knowledge, attitudes, and practices (KAP) regarding documentation within the context of Faith Mediplex Hospital. While existing studies emphasize the importance of documentation and record-keeping in healthcare (Federal Ministry of Health, 2021; Kebede et al., 2017), there is a lack of focused research on the intricacies faced by nurses within this hospital setting.
Furthermore, while national guidelines and standards exist (Federal Ministry of Health, 2016), it remains unclear how effectively these guidelines are translated into practice at Faith Mediplex Hospital. Understanding the discrepancies between guidelines and actual implementation is crucial for ensuring consistent, high-quality documentation practices and legal compliance.
The rapid integration of electronic health records (EHRs) into healthcare systems introduces both opportunities and challenges in documentation practices (Juliet & Sudha, 2023). However, little is known about nurses’ perceptions, training, and utilization of EHR systems at Faith Mediplex Hospital, highlighting a significant knowledge gap in the current literature.
Moreover, there is a need for updated data and insights into the current state of nursing documentation and record-keeping practices at Faith Mediplex Hospital. Without recent assessments tailored to this specific setting, it becomes challenging to identify emerging issues, address existing challenges, and implement targeted interventions to improve documentation quality and efficiency.
Addressing these gaps in understanding is essential not only for enhancing patient care and safety but also for aligning hospital practices with national standards and promoting a culture of continuous improvement in healthcare delivery.
1.3 Objectives of the Study
The following specific objectives were examined:
- To assess the level of knowledge among nurses at Faith Mediplex Hospital regarding documentation and quality record-keeping practices.
- To evaluate the attitudes of nurses towards documentation and quality record-keeping and their perceived importance in patient care.
- To examine the actual practices of nurses in terms of adherence to documentation protocols and quality record-keeping standards.
1.4 Research Questions
The following research questions were asked:
- What is the level of knowledge among nurses at Faith Mediplex Hospital regarding documentation and quality record-keeping practices?
- What are the attitudes of nurses towards documentation and quality record-keeping, and how do they perceive its importance in patient care?
- What are the actual practices of nurses concerning adherence to documentation protocols and quality record-keeping standards?
1.5 Research Hypotheses
The following hypotheses were tested:
- There is no positive correlation between nurses’ level of knowledge about documentation and their adherence to quality record-keeping practices.
- Nurses with more positive attitudes towards documentation and quality record-keeping are more likely to demonstrate better practices in this area compared to those with negative attitudes.
1.6 Significance of the Study
The significance of studying nurses’ knowledge, attitudes, and practices (KAP) towards documentation and quality record-keeping at Faith Mediplex Hospital in Benin City encompasses several crucial aspects that contribute to the overall improvement of healthcare delivery.
Firstly, this study holds immense importance in enhancing patient care and safety. Accurate and comprehensive documentation is fundamental in ensuring that patients receive the right treatments, medications, and interventions at the right time. By understanding nurses’ KAP regarding documentation, healthcare providers can identify areas of improvement and implement strategies to reduce errors and improve patient outcomes.
Secondly, investigating nurses’ perceptions and behaviors towards documentation is crucial for legal compliance and accountability. Proper documentation not only facilitates communication among healthcare professionals but also serves as a legal record of the care provided to patients. By improving documentation practices, Faith Mediplex Hospital can ensure that they meet regulatory standards and mitigate legal risks associated with incomplete or inaccurate records.
Furthermore, this study is significant in promoting efficiency and effectiveness in healthcare operations. Well-maintained records and quality documentation contribute to streamlined workflows, better resource allocation, and improved coordination among healthcare teams. Understanding nurses’ utilization of electronic health records (EHRs) can also lead to enhancements in digital documentation practices, reducing redundancy and enhancing data management.
Moreover, the findings of this study can inform targeted training and educational programs for nurses. By identifying areas where nurses may lack adequate knowledge or face challenges in documentation practices, Faith Mediplex Hospital can develop training modules to enhance nurses’ skills and competencies in documentation. This can lead to increased confidence among nurses, improved documentation accuracy, and a culture of continuous learning within the healthcare organization.
Additionally, the study’s insights can contribute to broader discussions and best practices in healthcare documentation nationally and internationally. By sharing experiences and lessons learned from studying documentation practices at Faith Mediplex Hospital, other healthcare facilities can benefit from implementing similar strategies to improve their own documentation standards.
1.7 Scope of the Study
This study focuses on nurses working at Faith Mediplex Hospital in Benin City, Nigeria. The assessment covers their knowledge, attitudes, and practices towards documentation and quality record-keeping within the hospital setting. Data collection methods include surveys, interviews, and observations to gather comprehensive insights into the subject matter.