Abstract:
Background: Documentation provides evidence of care, communicate medical information effectively with the health care team, ensure continuity of care, and improve patient safety. In Bangladesh, still paper-based systems have been introduced to support nursing documentation.
Objective: To explore the need assessment of computer-based nursing documentation among nurses in Bangladesh.
Methods: A descriptive exploratory design with a focus group discussion and key informant interviews were applied conducted. A total of 829 registered nurses was recruited convinienty. The data were collected using structured questionnaire and FGD guidelines. The instruments were comprised (1) Personal Information, (2) Structural related Questionnaires, and (3) Computer-based Nursing Documentation Need Assessment Questionnaires and Questions of the Focus Group Discussion & Key Informant Interviews. The study was approved from the Institutional Review Board NIANER. Quantitative data were analyzed by using descriptive and inferential statistics. Content analysis was used to analyze the data regarding need of computer-based nursing documentation.
Results: The mean age of the participants was 35.92 (SD=8.38) years. Most of the participants (88.3%) were female. The average number of existing bed was 32.06(SD=24.09) in each ward. The mean number of nurse was 4.33(SD=5.02) and supporting staff was 4.83 (SD=4.68) in each duty shift at their ward. About availability of computer around 60% of the participants said that they don’t have computer. Regarding necessity of computer in their ward, around hundred percent (99.5%) of the participants were thought that they need comuter in their ward and agreed with benefits of compiter-based nursing documentation. Most of the participants (86.4%) wanted to record patients documents using electronic documentation. The results showed that there were statistically significant relationship between participants charaeterists, hospital related information and nurses knowledge and perception, current practices, means and way, and challenges regarding computer-based nursing documentation (p<0.05). It was found that there was a significantly negative relationship between knowledge and current practices of nurses (r=-.599, p<.001).
Conclusion: The results of the study provide base line data for policy maker to formulate policy to adopt computer-based nursing documentation system for nurses. Action plan and guidelines should be made to establish computer-based nursing documentation system. Training on computer-based nursing documentation system for nurses may be conducted. Further study is needed on factors identifying computer-based nursing documentation.
