Using Nursing Documentation as a Proxy for Quality of Care at Public Hospitals in Jamaica

Using Nursing Documentation as a proxy for quality of care at public hospitals in Jamaica

Abstract

The complex task of nursing documentation is often guided by the nursing process, a framework for solving patient care problems and ensuring the provision of high quality nursing care (Yildirim, & Ozkahraman, 2011). Nursing documentation is a written or electronic communication tool, which describes patient’s care and response to treatment. Among others, Universal Health Coverage  advocates, recommend research activities relating to  measurable indicators such as nursing documentation to assist in determining the overall quality of care delivered to clients (Dye, Reeder, & Terry, 2013).

Objectives:This study assessed the quality of nursing documentation on medical wards at three hospitals in Jamaica with a view of making inferences about the quality of care provided for hospitalized clients.

Methods:This cross sectional study audited a multi-level stratified sample of 245 client’s records from three type ‘B’ hospitals (referred to as H1, H2 and H3) in Jamaica. Data extraction was facilitated using an audit instrument which assessed nursing documentation of client’s history, biological data, physical assessment, nursing standards, discharge planning and patient teaching.  Eligibility of records included length of stay for 4 days or more.  The study incorporated the learning activities of final year undergraduate students from four schools of nursing who were trained as data collectors. Data analysis was done using SPSS, Version 19 and univariate and bivariate descriptive statistics completed the data analysis process.

Findings:  A total of 245 male and female records from three hospitals [H1-119; 48.6%, H2-56; 22.9%, H3=70; 28.6%] across Jamaica were audited. Documented elements of nursing assessments audited showed, client’s chief complaint (81.6%), history of present illness, (78.8%), past health (79.2%) were present in majority of the records audited. While family health, number of children, marital status, occupation, education, religious affiliation or living accommodations of clients were far less likely to be present. The conduct of a physical assessment within 24hours of admission was noted in 90% of patients’ records and nurses favored focused assessments (44.7%).  Almost all the records (98-100%) assessed had been timed, dated and signed by a nurse. Within the first three days of admission less than 5 % of dockets had any evidence of patient teaching and 14% had documented discharge planning.

Conclusions: This study underscores weaknesses in nursing documentation on the medical wards at the institutions studied where student nurses gained valuable clinical experience. Additional training of nurses and evaluation of documentation are indicated at health facilities across Jamaica. Finally, in light of the current epidemiologic transition of chronic diseases in the region continuous monitoring of nursing documentation may be an appropriate means of quality assurance.