Documentation Practice and Associated Factors among Nurses in Harari Regional State and Dire Dawa Administration Governmental Hospitals, Eastern Ethiopia

Abstract Background: Nursing documentation is an integral and vital professional nursing practice, deals the process of recording nursing activities concerned with the care given to individual clients to assure continual effective, safe, qualified, evidence-based and individualized care. Despite of this, in Ethiopia there is a paucity of information on nursing documentation practice and its associated factors due to limited studies with methodological limitations. So this study aimed to assess documentation practice and identify its associated factors among nurses in six Governmental Hospitals of Harari Regional State and Dire Dawa Administration, Eastern Ethiopia. Methods: Institutional based cross-sectional study was conducted among 430 nurses and 421 medical records. Simple random sampling was employed for the selection of nurses and charts after the total sample size had allocated proportionally for each hospital. Data were collected by using self-administered questionnaire and review of records; entered and analyzed by using Epi data version 3.1 and statistical package for social sciences version 20.0 respectively. Logistic regression was used to identify the associated factors. Result: In this study, 47.5% of nurses were found to have good nursing documentation practice whereas good nursing documentation was found to practiced on 38.5% of medical records. Age, attitude, in-service training, nurse to patient ratio, availability of motivation and familiarity with standards of nursing documentation were found to had statistically significant positive association with documentation practice with AOR and 95%CI of 3.54 (1.170-10.8), 5.66 (3.17- 10.11), 2.53(1.477-4.35), 2.24(1.24-4.047), 4.60 (2.721-7.76) and 1.98 (1.137-3.44) respectively. Conclusion: Documentation was practiced poorly due to the identified factors. Therefore, it is better to put further effort towards improving documentation practice through providing training on standards of documentation and enhancing favorable attitude of nurses towards documentation by motivating them for their documentation activities.