Background: Nursing documentation is an integral and vital professional nursing practice that refers to the process of recording nursing activities concerned with the care given to individual clients to ensure continual effective, safe, quality, evidence-based, and individualized care.
Objective: To assess documentation practice and identify its associated factors among nurses in six Governmental Hospitals of Harari Regional State and Dire Dawa Administration, Eastern Ethiopia.
Methodology: An institutional-based cross-sectional study was conducted among 430 nurses and 421 medical records. Simple random sampling was employed for the selection of nurses and charts after the total sample size had been allocated proportionally for each hospital. Data were collected by using a self-administered questionnaire and review of records, and entered and analyzed by using EpiData version 3.1 and statistical package for social sciences version 20.0, respectively. Logistic regression was used to identify the associated factors.
Results: In this study, 47.5% of nurses were found to have good nursing documentation practice whereas good nursing documentation practice was found in 38.5% of medical records. Age (AOR, 95% CI 3.54, 1.170– 10.8), attitude (AOR, 95% CI 5.66, 3.17– 10.11), in-service training (AOR, 95% CI 2.53, 1.477– 4.35), nurse to patient ratio (AOR, 95% CI 2.24, 1.24– 4.047), motivation (AOR, 95% CI 4.60, 2.721– 7.76), and familiarity with standards of nursing documentation (AOR, 95% CI 1.98, 1.137– 3.44) were found to have a statistically significant positive association with documentation practice.
Conclusion: Poor documentation practice was due to the identified factors. So, it is better to put further effort toward improving documentation practice through providing training on standards of documentation and enhancing the favorable attitude of nurses toward documentation practice by motivating them regarding documentation activities.



中文翻译：

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埃塞俄比亚东部哈拉里地区国家和德雷达瓦政府政府医院护士的文档实践和相关因素

背景：护理文件是一种不可或缺的、重要的专业护理实践，是指记录与给予个体客户的护理有关的护理活动的过程，以确保持续有效、安全、优质、循证和个性化护理。
目的：在埃塞俄比亚东部的哈拉里地区州和德雷达瓦政府的六家政府医院评估文件实践并确定其相关因素。
方法：在 430 名护士和 421 份病历中进行了一项基于机构的横断面研究。在为每家医院按比例分配总样本量后，采用简单随机抽样选择护士和图表。数据通过自填问卷和记录审查收集，并分别使用EpiData 3.1版和社会科学统计包20.0版进行输入和分析。使用逻辑回归确定相关因素。
结果：在这项研究中，发现 47.5% 的护士具有良好的护理文档实践，而在 38.5% 的医疗记录中发现了良好的护理文档实践。年龄（AOR，95% CI 3.54，1.170-10.8），态度（AOR，95% CI 5.66，3.17-10.11），在职培训（AOR，95% CI 2.53，1.477-4.35），护士与患者的比例（ AOR, 95% CI 2.24, 1.24–4.047)、动机 (AOR, 95% CI 4.60, 2.721–7.76) 和熟悉护理文件标准 (AOR, 95% CI 1.98, 1.137–3.44)与文档实践有统计学意义的正相关。
结论：糟糕的文档实践是由于已确定的因素造成的。因此，最好通过提供文档标准培训和通过激励护士进行文档活动来提高护士对文档实践的积极态度，从而进一步努力改善文档实践。