Nursing Documentation Practice and Associated Factors Among Nurses Working in Felege Hiwot Comprehensive Specialized Hospital, Bahir Dar Town, North West, Ethiopia, 2025

This 2025 cross-sectional study at Felege Hiwot Comprehensive Specialized Hospital in Ethiopia found that only 40.1% of nurses demonstrated good documentation practice, with educational level, positive attitude, patient load, and knowledge identified as significant associated factors.

The Gist

Imagine a hospital as a giant, bustling orchestra. The doctors are the conductors, the surgeons are the soloists, but the nurses are the ones keeping the rhythm, tuning the instruments, and making sure every musician knows exactly what to play next.

In this story, Nursing Documentation is the sheet music. It's the written record of everything the nurse does: the medicine given, the pain relieved, the advice shared. If the sheet music is messy, missing pages, or written in a language no one understands, the orchestra falls apart. Patients get confused, treatments get missed, and the whole performance suffers.

This research paper is like a quality control inspection of that sheet music at a specific hospital in Ethiopia called Felege Hiwot. Here is the story of what they found, told in simple terms.

🕵️‍♂️ The Mission: Checking the Scorecard

The researchers wanted to know: Are the nurses at this hospital writing down their work clearly and completely?

They went to the hospital in August 2025 and asked 349 nurses to fill out a survey. Think of it like a pop quiz where the nurses had to say, "Yes, I always write this down," or "No, I sometimes forget."

📉 The Big Reveal: The "Good" vs. The "Missing"

The results were a bit of a mixed bag, but mostly leaning toward "we need to do better."

• The Score: Only 40% of the nurses were doing a "good job" with their paperwork.
• The Reality: That means 60% of the time, the "sheet music" was incomplete, messy, or missing entirely.

Imagine if a chef cooked a delicious meal but forgot to write down the recipe. If the chef gets sick, no one else can make that dish again. That's what happens when nursing notes are poor.

🧩 The Mystery: Why Was the Paperwork So Bad?

The researchers didn't just stop at the numbers; they dug deeper to find out why the paperwork was suffering. They found four main "villains" causing the trouble:

1. The Education Gap (The "Level Up" Factor)

• The Finding: Nurses with a Master's degree were 10 times more likely to have good documentation than those with just a basic degree. Nurses with a Diploma were twice as likely to have poor records.
• The Analogy: Think of documentation like building a house. A nurse with a Master's degree is like a master architect who knows exactly how to draw the blueprints. A nurse with less training might be trying to build a house with a sketch on a napkin. The more training you have, the better you understand why the blueprints matter.

2. The Attitude Problem (The "Mindset" Factor)

• The Finding: Nurses who thought documentation was boring, useless, or a waste of time were 2.6 times more likely to do it poorly.
• The Analogy: Imagine a gardener who thinks, "Why bother watering the plants? They'll grow anyway." If they don't care, the garden dies. Nurses who don't see the value in writing things down treat the paperwork like a chore rather than a vital part of saving lives.

3. The Knowledge Gap (The "Toolbox" Factor)

• The Finding: Nurses who didn't know how to document correctly were 3.7 times more likely to have poor records.
• The Analogy: You can't play a piano if you don't know where the keys are. Many nurses simply didn't know the rules of the game—what to write, when to write it, and how to make it clear. They weren't lazy; they were just lost without a map.

4. The Overload (The "Too Many Cooks" Factor)

• The Finding: Nurses who were taking care of too many patients at once were 5.6 times more likely to have poor documentation.
• The Analogy: Imagine a waiter trying to serve 50 tables at once. They might get the food to the tables, but they won't have time to write down who ordered what. When nurses are drowning in patients, the paperwork is the first thing to get dropped in the water.

🚧 The Other Hurdles

The study also found that the hospital environment wasn't helping:

• No Guidelines: About 60% of nurses said they didn't have a rulebook or a guide to follow.
• No Time: 80% said they simply didn't have enough time to write everything down properly.
• No Motivation: Supervisors weren't encouraging them to do it right.

💡 The Solution: How to Fix the Orchestra

The researchers concluded that to fix the music, we need to tune the instruments. Here is their plan:

1. Train the Musicians: Give nurses more training on how to write good notes and why it matters.
2. Upgrade the Skills: Encourage nurses to get more education (like Master's degrees) because it clearly makes them better at this job.
3. Change the Mindset: Help nurses realize that writing things down isn't just "paperwork"—it's a shield that protects them legally and a tool that saves lives.
4. Reduce the Noise: Hire more staff so nurses aren't drowning in patients, giving them the time to actually write down what they did.

🏁 The Bottom Line

This paper is a wake-up call. In the hospital, if it isn't written down, it didn't happen.

The nurses at Felege Hiwot are working hard, but they are fighting against a lack of training, bad attitudes, and overwhelming workloads. If the hospital wants to provide the best care, they need to stop treating documentation as an afterthought and start treating it as the safety net that keeps patients from falling through the cracks.

Technical Summary

1. Problem Statement

Nursing documentation is a critical component of safe, ethical, and effective healthcare, serving as legal evidence, a tool for continuity of care, and a basis for research. However, deficiencies in documentation—such as incompleteness, inaccuracy, and lack of standardization—are prevalent globally, particularly in Sub-Saharan Africa. In Ethiopia, nursing records are often limited to handwritten formats with critical reflections missing, leading to potential malpractice risks, medication errors, and compromised patient outcomes. Despite the professional obligation to document, barriers such as inadequate staffing, lack of training, heavy workloads, and poor leadership support persist. This study addresses the gap in understanding the current status of documentation practices and the specific factors influencing them within a major Ethiopian referral hospital.

2. Methodology

• Study Design: Institutional-based cross-sectional study.
• Setting: Felege Hiwot Comprehensive Specialized Hospital (FHCSH), Bahir Dar, Ethiopia.
• Study Period: August 1 to August 30, 2025.
• Population: All staff nurses working in inpatient (IPD) and outpatient (OPD) departments.
• Sample Size & Sampling:
  • A sample size of 349 was calculated using the single population proportion formula (based on a 30.4% prevalence of good practice from a previous study, 95% CI, and 5% margin of error), adjusted for a 10% non-response rate.
  • Sampling Technique: Simple random sampling with proportional allocation across wards (Medical, Surgical, Pediatrics, Gyn/Obs, OPD, and Others).
• Data Collection: Self-administered questionnaires in English, developed based on literature. Data collectors (BSc nurses) and a supervisor (MSc) were trained for two days.
• Variables:
  • Dependent: Documentation practice (categorized as "Good" or "Poor" based on mean scores).
  • Independent: Socio-demographics, knowledge, attitude, and organizational factors (staffing, guidelines, training, time).
• Data Analysis: Data were entered into EpiData 3.1 and analyzed using STATA version 14. Binary logistic regression was used to identify associations. Variables with $p < 0.25$ in bivariate analysis were entered into the multivariable model. Statistical significance was set at $p < 0.05$ with a 95% Confidence Interval (CI).

3. Key Results

• Demographics: Of the 349 respondents (100% response rate), 59.9% were female, 57.3% held a Bachelor's degree, and 40.1% had 5 years or less of work experience.
• Documentation Practice:
  • Only 40.1% of nurses demonstrated good documentation practice.
  • Specific gaps were noted in documenting patient education (only 20% "always" documented) and fluid balance status.
• Knowledge and Attitude:
  • 50.1% had good knowledge of documentation standards.
  • 70.2% held a positive attitude toward documentation.
• Associated Factors (Multivariable Analysis):
  Four factors were statistically significantly associated with documentation practice:
  1. Educational Level: Nurses with a Master's degree were 10.3 times more likely to have good practice compared to those with a Bachelor's degree (AOR: 10.3; 95% CI: 3.4–31.8). Diploma holders had nearly double the odds of poor practice compared to Bachelor's holders.
  2. Workload (Number of Patients): Nurses caring for 6–10 patients per shift had 5.6 times higher odds of poor documentation compared to those caring for ≤5 patients (AOR: 5.6; 95% CI: 1.9–16.3).
  3. Attitude: Nurses with a negative attitude had 2.6 times higher odds of poor practice compared to those with a positive attitude (AOR: 2.6; 95% CI: 1.5–4.7).
  4. Knowledge: Nurses with poor knowledge had 3.7 times higher odds of poor practice compared to those with good knowledge (AOR: 3.7; 95% CI: 2.1–6.2).
  • Note: Time adequacy and organizational factors like guideline availability were not statistically significant in the final multivariable model, though 59.9% reported a lack of guidelines.

4. Key Contributions

• Contextual Evidence: Provides up-to-date empirical data on nursing documentation specifically within a comprehensive specialized hospital in Northwest Ethiopia, a region with limited recent literature on this specific topic.
• Quantification of Barriers: Identifies and quantifies the specific impact of educational level, workload, attitude, and knowledge on documentation quality, moving beyond general observations to statistical evidence.
• Educational Correlation: Highlights a strong positive correlation between advanced education (MSc) and documentation quality, suggesting that higher academic training directly translates to better clinical record-keeping.
• Workload Impact: Confirms that high patient-to-nurse ratios significantly degrade the quality of documentation, linking staffing levels directly to legal and safety risks.

5. Significance and Recommendations

• Clinical Significance: Poor documentation poses direct risks to patient safety (e.g., medication errors) and legal liability for nurses and the institution. Improving practice is essential for patient continuity of care and legal protection.
• Recommendations:
  • For Nurses: Pursue higher education (MSc) and engage in continuous professional development to improve knowledge and attitude.
  • For Hospital Administration: Implement sustained in-service training on documentation standards, ensure the availability of standardized forms/guidelines, and critically address staffing shortages to reduce patient loads per nurse.
  • For Researchers: Conduct longitudinal studies to observe actual documentation behaviors over time and large-scale studies to generalize findings across Ethiopia.

Limitations: The study acknowledges potential social desirability bias (nurses over-reporting good practices) and the limitations of self-reported data, which may not perfectly reflect actual charting behaviors.

Conclusion: The study concludes that nursing documentation practice at Felege Hiwot Hospital is suboptimal (only 40.1% good practice). It is significantly driven by educational attainment, workload, attitude, and knowledge. Targeted interventions focusing on education, workload management, and attitude modification are necessary to improve patient care quality and legal safety.