Abstract:
Background
Nursing care plan is a process by which nurses identify patient’s problem and determine their
needs to be addressed. The high level of undocumented nursing care plan has been pointed
out by evaluation of accreditation done by the Ministry of Health. It was reported that only
40% of nursing care plan were documented. The objective of the project was to improve the
rate of documentation of nursing care plan in surgical ward of Kibogora Level Two Teaching
Hospital from 40% to 85%.
Methods
The study was done in surgical ward of Kibogora Level two Teaching Hospital. The study
was conducted from July 2021 until March 2023.The researcher conducted pre intervention
assessment and a post-intervention study to determine the result of the implementation of
nursing care plan documentation. In pre-intervention assessment of 261 files were audited as
sample size selected randomly from 747. The possible root causes were identified through the
fishbone. The root cause analysis was conducted and it was found that lack of training,
shortage of the staff nurses and computers are the most leading causes. Intervention was done
through training about documentation of nursing care plan and advocacy was done to
increase the number of nurses and computers. In post intervention 209 files were randomly
selected from 438 files to analyze the impact of intervention on documentation of nursing
care plan
Results
After intervention, the overall nursing care plan documentation is improved from 40 to
80.8%. It shows that nursing assessment was completed at 85.6%, nursing Diagnosis
completed at 85.1% and Nursing objectives completed at the level of 84.4%. Nursing
intervention at the level of 84.4% and Nursing Evaluation were documented at 80.8%
respectively. The contributing factors to the improvement are staff training, increase of staff
nurse, increase of computers and more supervision.
Conclusion and recommendations
The findings indicate that staffs training on nursing care plan and regular supervision
improve the level of documentation of nursing care. It is recommended to the hospital to use
the same strategy to improve nursing care plan documentation in other department of the
hospital.
