Abstract

Background: Ideally, through documentation, nurses/midwives track changes in a patient’s condition, make decisions about needs and ensure continuity of care. However, midwifery documentation has often not met these objectives. In Buea health district, there is a huge gap between the care implemented and the care documented.

Objectives: This study was carried out to assess the different factors affecting the effective documentation of care by nurses and midwives working in five maternities in the Buea Health District

Methods: A cross sectional hospital based descriptive study was used for this study. A total of 40 participants were enrolled for this study and a purposive sampling method was used. Data collection was done through a well structured questionnaire that was administered to the health personnel. Statistical Package for the Social Sciences (SPSS), version 21.0 was used for a statistical descriptive data analysis.

Results: The results showed that the greatest factors affecting documentation is the lack of a good monitoring system (94.4%), followed by no system of appraisal and punishment by the institution (75%), the workload that is the nursing to patient ratio (25%) and the length of shift or lack of time (25%).

Conclusions: The health workers had a good knowledge on documentation of practice. Most of the participants’ practice of documentation was neither influenced by length of shift (75%) nor workload (75%). In order to increase the documentation skills of staff, there must be a monitoring system on documentation and a system of praises and punishment for the staff pertaining to their documentation practice.

CHAPTER ONE

INTRODUCTION

1.1 Background

Since the beginning of nursing, documentation has always been an essential part of the profession. From the time of Florence nightingale in the late 1800s, nurses have viewed documentation as a very important aspect of their profession practice. Nightingale described the need to document use of air, light, warmth, cleanliness and proper selection of diet with an aim of collecting and retrieving data to aid in proper patient management (1).

Virginia Henderson, a nurse theorist, promoted the use of documentation when she introduced the idea of using the nursing care plans to communicate nursing care during the 1930s but the nursing documentation was discarded at the patient’s discharge. As the profession has evolved with time different tools have been invented to ease documentation like the nursing care plan came upon by Ellen L.

Buell in the 1930s-40s and was implemented in the 1960s-70s in USA and later on spread worldwide (2). Also, the nursing process discovered by Ida Jean Orlando in 1958 contributed to the facilitation of the documentation process. It creates a certain framework or route to nursing care and ease the process of documentation, it is made up of assessment, diagnosis, expected outcome, planning, implementation, rationale, evaluation (3).

In midwifery all these tools are being used for the proper management of the patient and the partogragh is used in the labor and delivery room for the proper monitoring of the progress of intrapartum and postpartum. The partograph was first introduced by Friedman, graphically depicting the dilatation of the cervix during labor. Philpott and Castle in 1972 developed Friedman’s concept into a tool for monitoring labour by adding action and alert lines (4).

Documentation is the key to continuity of midwifery care. In the medical profession, the practice of documentation is essential for the survival of the patient. This is because good skills and proper practice without documenting is null and void, it is considered not done. Midwives are professionally and legally accountable and responsible for the standard of practice to which they contribute and this includes record keeping (5). In the profession of midwifery, documentation helps to understand the when?, why?, and how things occur as it occur from the antenatal visit to the labor room thereby covering the whole period of pregnancy. Midwifery documentation refers to any and all forms of records done by the midwife in a professional capacity in relation to the provision of midwifery care (6).

The quality of midwifery care depends on one’s ability of accurate documentation entered into the patient’s record. Documentation serves multipurpose including communication, education, research, auditing and monitoring [7, 9-11]. Documentation and record keeping are essential to record the provision of safe and effective care for women and their babies and are an integral part of midwifery practice [12]. A high standard of record keeping is fundamental to the delivery of safe and professional care (9).

Professional record keeping includes all forms of recorded communication that supports the midwifery care provide in partnership with all women – all written ad electronic health care records, audio and text, emails, laboratory reports, photos, videos, health talks, group discussions or any other form of communication pertaining to a woman’s care (13). There are basically three (03) forms of record keeping which are: Hand-written records, Computer based systems electronic) and a combination of both (14). Hospital records can be broadly classified into four categories based on the areas of usage. They are: Patients clinical record, individual staff records, ward records, administrative records with educational value like government reports NGOs reports etc (15)

Components of a patient’s report keeping include: medical records, nurses admission assessments, nursing records/ progress notes, medication charts, laboratory orders and reports, vital signs observation charts, hand over sheets and admission, discharge and transfer checklists/ letters, patient’s assessment forms (14). Although midwifery documentation is a valuable tool for communicating patient’s information to nurses and other health professionals, it is often difficult for busy clinicians to see the benefits. Communication, whether written or orals, has been identified as contributing to approximately 50% of all adverse events for patients (16). Looking at the actual work documentation gives, it is quite difficult to practice it properly.

In the Buea health district, written records are mostly used and the patient’s medical file has the following section to be filled by the midwife: Nurses admission assessments, Progress notes, Medication charts, Laboratory orders and reports, Vital signs observation charts, Discharge and transfer letters, Partograph, and a Consent form. In addition, there is an end-of-shift report, as well as government and NGOs reports to be filled by midwives

1.2 Statement of the problem

Though sometimes neglected due to several reasons, documentation is the backbone of effective midwifery practice (7). Communication, whether written or orals, has been identified as contributing to approximately 50% of all adverse events for patients (16). Inaccurate documentation slows the progress of nursing/midwifery profession by rendering research difficult and safe patient care is compromised due to midwife’s incomplete/inaccurate clinical chart (17).

It is often difficult for busy clinicians to see the benefits (16). Studies have pointed out that 45.8% of nursing care given was not recorded and 63% of nursing notes were not written after the first day (18). Umezileke et al. evaluated the use of the partograph in a Nigeria teaching hospital where only 24% midwives stated that they used the partograph routinely.

This was found to be attributed to the high maternal mortality in that hospitals, as up to the 76% of the personnel were not using the partograph (19). An evaluation of the use of a partograph in two hospitals in Kenya by Rotich et al. revealed to the finding that each of the 234 reviewed partographs were either incomplete or incorrectly filled (20).  However, although its significance has been discussed in numerous articles, midwifery documentation remains problematic. Thus, a need to understand the different factors, that may hinder effective documentation in the labor room of our health setting.

1.3 Research questions

1.3.1 General research question

Which factors affect the practice of documentation among midwives in the maternities of Buea health district?

1.3.2 Specific research question

1. What is the level of knowledge about documentation among midwives?
2. What is the relationship between workload and quality of documentation?
3. What is the relationship between the length of shift and the quality of documentation?
4. Which factors affect midwives’ practice of midwifery documentation in the maternities of Buea Health District?

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