Assessment of Nurses Knowledge Related to Nursing Documentation at Pediatric Surgical Wards

Ibraheam, Huda Abbass; Khudhair, Suad Hassoon

doi:10.33899/mjn.2022.175410

Journals List

Assessment of Nurses Knowledge Related to Nursing Documentation at Pediatric Surgical Wards

Mosul Journal of Nursing (Print ISSN: 2311-8784 Online ISSN: 2663-0311)

Article 19, Volume 10, Issue 3, August 2022, Pages 134-139 PDF (680.26 K)

Document Type: Original Articles

DOI: 10.33899/mjn.2022.175410

Authors

Huda Abbass Ibraheam¹; Suad Hassoon Khudhair²

¹MSN, Paediatric and Neonate Health Nursing department, University of Baghdad, College of Nursing, Iraq.

²PhD, Assistant Professor, Paediatric and Neonate Health Nursing department, University of Baghdad, College of Nursing, Iraq.

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

Full Text

Assessment of Nurses Knowledge Related to Nursing Documentation at Pediatric Surgical Wards

Huda Abbass Ibraheam^1*, 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 23^th december 2021 to 20^th 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)
List	Items	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.

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