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

BACKGROUND: Nursing documentation is an integral and vital professional nursing practice that refers to the process of recording nursing activities concerned with the care given to individual clients to ensure continual effective, safe, quality, evidence-based, and individualized care. OBJECTIVE: 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. METHODOLOGY: An 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 been allocated proportionally for each hospital. Data were collected by using a self-administered questionnaire and review of records, and entered and analyzed by using EpiData version 3.1 and statistical package for social sciences version 20.0, respectively. Logistic regression was used to identify the associated factors. RESULTS: In this study, 47.5% of nurses were found to have good nursing documentation practice whereas good nursing documentation practice was found in 38.5% of medical records. Age (AOR, 95% CI 3.54, 1.170–10.8), attitude (AOR, 95% CI 5.66, 3.17–10.11), in-service training (AOR, 95% CI 2.53, 1.477–4.35), nurse to patient ratio (AOR, 95% CI 2.24, 1.24–4.047), motivation (AOR, 95% CI 4.60, 2.721–7.76), and familiarity with standards of nursing documentation (AOR, 95% CI 1.98, 1.137–3.44) were found to have a statistically significant positive association with documentation practice. CONCLUSION: Poor documentation practice was due to the identified factors. So, it is better to put further effort toward improving documentation practice through providing training on standards of documentation and enhancing the favorable attitude of nurses toward documentation practice by motivating them regarding documentation activities.