Factors affecting documentation of intraoperative nursing care at Kenyatta National hospital main theatre

Abstract

Documentation plays a key role in the construction of social reality (Anderson 2006, Levy2003, Searle 1996). A descriptive cross-section study conducted among nurses working at Kenyatta national hospital (KNH) main theatre within a period of 9 months, where both qualitative and quantitative methods used to collect data. The study aimed at determining factors affecting documentation of intraoperative nursing care given to patients while undergoing surgery in KNH theaters. A self-administered structure questionnaire for the respondents, an interview guide for face-to-face interview of the key informants and an observation guide using the record files of patients who were ready for discharge from the unit back to the ward to collect data on intraoperative nursing documentation. A simple random sampling method was used to select a sample of 83 out of 96 qualified nurses, employed by KNH and working in the operating theatre, who were willing to participate in the study. The results showed Results showed that knowledge on hospital policy and perception which included; lack of time, lack of provision in file to document and perception that no nursing is done in theatre were statistically significant to intraoperative documentation (p < 0.05). The study concluded that nurses perception and knowledge on hospital policy affected intraoperative nursing care documentation.