Factors affecting quality nursing documentation of patient information at selected primary health care facilities in Vhembe District, Limpopo Province

Abstract

Nursing documentation arises from actual happenings or events where a true picture of an incident that has happened is recorded. However, for nursing documentation to serve their provision of reliable evidence, patient information must be complete, accurate, legible and comprehensive. This study explored and described factors affecting quality nursing documentation of patient information at selected Primary Health Care (PHC) facilities in Vhembe District, Limpopo Province. The study sought to achieve the following objectives: explore factors affecting quality nursing documentation of patient information on Antiretroviral Therapy (ART) files, forms, and registers; describe factors affecting quality nursing documentation of patient information on ART files, forms, and registers. The research design in this study was qualitative, explorative, des criptive and contextual in nature. The study population consisted of professional nurse working at PHC facilities in Vhembe District, Limpopo Province.

on-probability purposive sampling was used to select PHC facilities and professional nurses. The objectives of the study were met during data collection which was conducted through the u e of individua] face-to-face, in-depth interviews. Permission to conduct study was obtained from relevant stakeholders. The ethical considerations adhered to were confidentiality maintained and informed consent obtained from participants. Trustworthiness was ensured throughout by employing the principles of credibility, dependability, conformability and transferability.

Data col lection was done up to 10 participants as no new information was forthcoming from professional nurse . Professional nurses were 3 males and 7 females. Their ages ranged from 24 to 49 year . Tesch's open-coding methodology was used to analyze data. Data from participant were collated into themes and sub-themes. The following themes emerged from raw data: increased professional nurses' workload, knowledge deficit, Jack of resources and unavailability, illegible and incomplete documents. It is recommended that health care executives develop responsible actions for delivering quality patient care through working towards ensuring good supply of professional nurses to PHC facilities, by recruiting, attracting and thriving to retain required staff to deal with issues of professional nurses' workload. Professional nurses should undergo sufficient (comprehensive) short course training in relation to quality nursing documentation of patient information. It is recommended that quality nursing documentation of patient information be fully presented and emphasized in the nursing workshops. It was proposed that each individual professional nurse should receive full support and mentoring after workshop training at bis/her respective facility by programme supervisors and managers. Each patient's document at PHC facilities must be assessed with a tool designed for that programme.

Research should be conducted in other districts in Limpopo Province in order to compare the findings. The study suggested that dates for ordering and delivery of stationery should be drafted, agreed upon and adhered to between supervisors and facilities' staff members. Facilities' infrastructures should be modified and maintained continuously. The study also suggested that policy in relation to PHC facilities' documents must include control measures to be followed if documents are not well created and updated by individual professional nurses.