Nursing documentation as a communication tool : (a case study from Ghana)

Abstract

Quality patient’s information has been proven to enhance the quality of care the patients receive as well as the guarantee of their safety. This is because information would be available to inform others and subsequently aid appropriate decision making concerning patients care. On the other hand, nurses being the professionals who spend twenty-four hours with the patients have a lot of information to capture from patients observation and care. Hence Nursing Documentation provides a lot of information to guide decision-making, and it therefore needs to be efficient in order to be effective. The purpose of this study was to assess the effectiveness of nursing documentation as a communication tool among health professionals involved in patients care. Other aims were the extent to which nursing documentation fosters communication in the care setting and also to exploit ways in which nursing documentation could be improved upon to enhance efficiency. The study was conducted within a period of two months at the Volta Regional Hospital, Ho, in Ghana. Qualitative research method particularly case study was used to find answers to the research question. Also Actor Network and Information Infrastructures theories guided the study. 27 nurses with different work experience and ranks, 2 physicians and 1 information officer were interviewed to exploit their divergent viewpoints on nursing documentation. In addition, participant observation was done in 4 of the wards on health personnel during work practice. The findings of the study indicated that work overload resulting from scarcity of nurses prevents the nurses from making time for documentation. Also there were too many sources of documentation with some levels of duplication without any definite structure. Further, a standard to guide nursing documentation was absent. In addition, nurses are trained in nursing care plan but had to use other types of documentation style at the work setting. Also the nurses make use and rely more on oral account of patient care than the written documentation. In conclusion the study revealed that at times the information captured was not adequate to communicate to others. However deployment of electronic nursing documentation at the wards was found to be appropriate in addressing this problem. Also the study provides insight into issues in the nursing documentation and accordingly would inform the Nursing Body in Ghana.