Improvement of Nursing Care Plan Documentation in Surgical Ward at Kibogora Level Two Teaching Hospital

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.