Abstract:
Nurses are expected to provide quality care to their patients and families using
the nursing process and document as such. However, it is unclear whether the
content of the 24-hour nursing reports reflects the nursing process in Ghana.
This thesis, therefore, sought to explore how the 24-hour nursing report
reflects the nursing process, and identify factors that influence documentation
of the 24-hour nursing reports at Effia Nkwanta Regional Hospital. The study
used a descriptive qualitative approach. Thirty-nine (39) reports and nine (9)
registered nurses were purposively selected for document review and one-on one interviews respectively. The findings showed that the most documented
phase of the nursing process in the 24-hour nursing reports were assessment
and interventions (100%). The most documented assessment data was the vital
signs which were found in all reports. Interventions recorded were mostly
routine care such as vital signs and serving medication. Nursing diagnosis,
objectives and outcome criteria and patient strength were the least documented
(0%, 0%, and 4% respectively). Evaluation statements were presented in 95%
of the records. However, no evaluation statement met the standard as indicated
by the nursing process. Nurse characteristics and work situations were
reported to have influenced documentation. A standardised format for report
writing must be developed by the nursing administration based on the nursing
process in the study area. Staffing and supplies must be improved by hospital
management to enhance documentation.
