Assessing the Utilisation of the Nursing Process in the 24-hour Nursing Reports at Effia Nkwanta Regional Hospital

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