A retrospective analysis of nursing documentation in the intensive care units of an academic hospital in the Western Cape

Hector, Dawn (2010-03)

Thesis (MCur (Interdisciplinary Health Sciences. Nursing Science))--University of Stellenbosch, 2010.

Thesis

ENGLISH ABSTRACT: Critical care nursing is the specialty within nursing that deals with an individual's response to life-threatening problems. These life threatening problems require continuous in-depth assessment and intense therapeutic measures and interventions. The level of nursing care is intense and the amount of documentation is enormous in the intensive care unit. Failure to document any aspects, may threaten the continuity of care and patient safety. Furthermore, it may result in negligence that may result in litigation. The purpose of this study was to retrospectively analyse nursing documentation in the intensive care units of an academic hospital in the Western Cape. The objectives set for this study were to determine whether the documentation of the: • assessment of the patients were adequate; • diagnoses were based on the assessment; • nursing care plans were based on the diagnoses; • nursing care plans were implemented and • nursing care plan shows evidence of continuous evaluation A retrospective exploratory- descriptive research design with a quantitative approach was applied to audit objectively the status of nursing documentation of patients who were admitted to the ICU’s of an academic hospital in the Western Cape in the first 48 hours of admission. Ethical approval was obtained from the University of Stellenbosch and consent from the Chief Executive Officer of the academic hospital to conduct the research in the hospital under study. The research population (N) was the documentation (files) of patients admitted in the ICU’s between 1 July 2008 and 31 December 2008. A stratified sample was drawn consisting of 151 files. The researcher collected the data personally utilising a pretested audit instrument. The reliability and validity was assured through experts in nursing science and intensive care nursing, a statistician and a research methodologist. A pilot study was conducted to pretest the instrument and the feasibility of the study. Modifications to the instrument were done based on suggestions from the experts and findings of the pilot study. Data analysis included statistical associations between variables using the Chi-square test on a 95% confidence level. Data is presented in the form of figures, tables and frequencies. The findings of the study show that the nursing documentation in the intensive unit is inadequate with the following total mean scores: • Assessment 62.6% • Nursing diagnosis 53.1% • Nursing care plans 37.1% • Implementation 72.6% • Evaluation 40.5%. In conclusion nursing documentation of patients admitted to an ICU is inadequate during the first 48 hours of admission. Poor documentation threatens the safety of patients and demands urgent improvement. Recommendations to improve the documentation include nursing practice supervision, quality improvement programmes, in-service training, evidence based practice and further research.

AFRIKAANSE OPSOMMING: Kritieke-sorg verpleging is die spesialiteit in verpleging wat betrekking het op die individu se reaksie.op lewensgevaarlike probleme.Hierdie lewensgevaarlike probleme benodig deurlopend deeglike beraming en intense terapeutiese benaderings en intervensies. In die intensiewesorg eenheid is die vlak van verpleegsorg baie intens en die dokumentasie hoeveelheid is enorm. Versuim om enige aspekte van sorg deeglik en akkuraat te dokumenteer, kan die deurlopendheid van sorg sowel as die veiligheid van die pasient bedreig. Verder kan dit tot regsstappe lei as gevolg van nalatigheid. Die doel van hierdie studie was om ‘n retrospektiewe analise van verpleeg dokumentasie in die intensiewe sorgeenhede van ‘n akademiese hospitaal in die Wes Kaap te doen. Die doelwitte van hierdie studie was om vas te stel of die dokumentasie van die: • beraming van die pasiênt voldoende gedoen is • verpleegdiagnose gebaseer is op die beraming • verpleegsorgplan gebaseer is op die diagnose • implementering van die verpleegsorgplan en • verpleegsorgplan bewyse toon. van deurlopende evaluasie ‘n Retrospektiewe eksploratiewe-beskrywende navorsingsontwerp met ‘n kwantitatiewe benadering is toegepas ten einde die status van verpleegdokumentasie van pasiente wat toegalaat is tot die intensiewesorg eenhede van ‘n akademiese hospitaal in die Wes Kaap in die eerste 48 uur na toelating te bepaal. Etiese goedkeuring is verkry van die Universiteit van Stellenbosch asook vanaf die Hoof Uitvoerende Beampte van die akademiese hospitaal om die navorsing daar uit te voer. Die navorsings populasie (N) was die dokumentasie (lêers) van die pasiente wat opgeneem is in die intensiewesorg eenheid tussen 1 Julie 2008 en 31 Desember 2008. ‘n Gestratifieerde steekproef is getrek bestaande uit 151 lêers. Die navorser het die data persoonlik kollekteer deur gebruik te maak van ‘n voortoets oudit instrument. Die betroubaarheid en geldigheid is verseker deur kundiges in verpleegkunde en intensiewesorg verpleging, asook ‘n statistikus en ‘n navorsingsmetodoloog. ‘n Loodstudie is gedoen om die instrument vooraf te toets en om die uitvoerbaarheid van die navorsing te bepaal. Veranderinge is aangebring op grond van die voorstelle van die kundiges sowel as die bevindinge van die loodstudie. Data analise het ingesluit die statistiese assosiasies tussen veranderlikes deur gebruik te maak van die Chi-kwadraat toets tot ‘n 95% sekerheidsvlak. Data is aangebied in die vorm van figure, tabelle en frekwensies. Die bevindinge van die studie wys dat die verpleegdokumentasie in die intensiewesorg eenheid is onvoldoende met die volgende gemiddelde telling: • Beraming 62.6% • Verpleegdiagnose 53.1% • Verpleegsorgplanne 37.1% • Implementering 72.6% • Evaluering 40.5% Ten slotte, verpleegdokumentasie van pasiënte wat tot die intensiewesorg eenheid toegelaat is, is onvoldoende gedurende die eerste 48 uur van toelating. Swak dokumentasie bedreig die veiligheid van pasiënte en verg dringende verbetering. Aanbevelings om die dokumentasie te verbeter sluit in toesig oor verpleegpraktyke kwaliteit verbeteringsprogramme, indiensopleiding, bewysgebaseerde praktyke en verdere navorsing.

Please refer to this item in SUNScholar by using the following persistent URL: http://hdl.handle.net/10019.1/4096
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