Nursing documentation in Maternity clinical practice : Reflection of actual nurse's work load

The purpose: is to evaluate nurses' attitudes toward documentation for endorsing patient care and its value as mean of communication. Also to identify the problems and barriers in the nursing documentation for reflecting actual nurse work Load from nurses’ perspective. Methods:1. Design :An exploratory descriptive study design was used. 2. Setting: The study was conducted over three months (March - May 2010) in pre natal ,post natal and nursery departments, at Al aziziah Maternity and children hospital, in Jeddah. 3. Sample; A total of (160 ) female nurses working at the wards of the study settings, 60 of them of different nationality were recruited thought simple random sampling 4. Tools; A questionnaire sheet was developed by researchers for data collection, also Likert rating scale consisting of 10 items divided into two sections: documentation barrier (5 items), and Documentation-tension (5 items). The research tools was generated through review of the literature and consultation with nursing experts. The descriptive statistics of mean was use to analyze the data with a criterion mean at 2.50. Results:. The present study findings revealed significant percentages of nurses’ agreement upon the benefit of documentation to patient care ,(48.7%) reported that nursing notes always facilitate the movement toward the nursing goals, documentation leads to improve patient care recorded (30%). Furthermore, the majority had reported that documentation is always related to nursing care that provided to patient (61.7%). On the other hand, 41.7% were thinking that documentation is often an accurate reflection of patient nursing care. Concerning the value of documentation to the nurses, (51.7%) agreed that use of documentation are often more of help for nurses than load, while (38.3%) reported that nursing notes are often important to every health provider and documentation is not wasting of time. Regarding documentation barriers, (30%) had agreed upon that documentation is too heavily structured by quality assurance, and Workload demands hinder the completing of patient documentation. while (35%) agreed upon the statement that Shortage of staff work hinder completing of patient documentation. While only (16.7%) agreed upon the statement that Language barrier decrease quality of nursing documentation, and (21.7%) reported that documentation consist a lot of double-charting and repetition