FACTORS INFLUENCING UTILIZATION OF VITAL SIGNS

OBSERVATION CHARTS AMONG NURSES AND MIDWIVES AT

KAMPALA INTERNATIONAL UNIVERSITY TEACHING HOSPITAL

A RESEARCH REPORT SUBMITTED TO UGANDA NURSES AND

MIDWIVES EXAMINATION BOARD

IN PARTIAL FULFILLMENTS OF REQUIREMENTS FOR THE AWARD

OF A DIPLOMA IN NURSING SCIENCE

KAMALANJI DONATA

RESEARCH STUDENT

NOVEMBER 2020
FACTORS INFLUENCING UTILIZATION OF VITAL SIGNS

OBSERVATION CHARTS AMONG NURSES AND MIDWIVES AT

KAMPALA INTERNATIONAL UNIVERSITY TEACHING HOSPITAL

A RESEARCH REPORT SUBMITTED TO UGANDA NURSES AND

MIDWIVES EXAMINATIONS BOARD

IN PARTIAL FULFILLMENTS OF REQUIREMENTS FOR THE AWARD

OF A DIPLOMA IN NURSING SCIENCE

KAMALANJI DONATA

JAN2019U011/DNE/008

NOVEMBER 2020
 ii

ABSTRACT

Uganda ranks among highest countries with less monitoring of hospitalized

patients where only 28% of patients admitted in Ugandan hospitals have their vital

signs monitored.

The purpose of this study was to assess factors influencing utilization of vital

signs observation charts

A quantitative cross-sectional study was carried out among 50 nurses and

midwives at KIU-TH selected by simple random sampling.

Results revealed more than three quarters 43(86%) of nurses and midwives were

confident about their knowledge and skills on vital signs monitoring, 41(82%) of

the nurses and midwives had never received any training on vital signs

documentation in the chart. All 50(100%) nurses and midwives said the facility

had other instruments and machines for monitoring vital observations apart from

usual vital observation tray, Most 37(74%) reported having high patient to nurse

ratio above 4:1 where majority 20(40%) of nurses and midwives reported heavy

workload that hindered vital signs documentation. 48(96%) of nurses used team

nursing for their patients and most 39(78%) of nurses and midwives reported that

there was no team on ground specific for monitoring documentation of vitals

In conclusion, positive influencing factors were nurses knowledge on monitoring

vitals, constant supply of equipments for vital signs monitoring while negative

influencing were high patient to nurse ratio, team nursing design, lack of extra

training on monitoring, vital signs and lack of support and monitoring staffs to

relieve workload and monitor documentation of vitals by nurses.

 iii

COPYRIGHT

Copyright © 2020 Kamalanji Donata

All rights Reserved

 iv

AUTHORIZATION
 v

ACKNOWLEDGEMENT

I acknowledge the almighty GOD that has given me grace to accomplish this

study dissertation as I continue to fully trust Him to take me through the whole

research process. Also my tutors and lecturers, fellow scholars that we have

walked together throughout academic hustle.

 vi

DEDICATION

This research work is fully dedicated to my parents and siblings for their unfailing

support in the life of education.

 vii

TABLE OF CONTENTS

ABSTRACT.............................................................................................................ii

COPYRIGHT ......................................................................................................... iii

AUTHORIZATION ................................................................................................ iv

ACKNOWLEDGEMENT ....................................................................................... v

DEDICATION ........................................................................................................ vi

LIST OF TABLES .................................................................................................. xi

................................................................................................................................. xi

LIST OF FIGURES ...............................................................................................xii

LIST OF ACRONYMS ....................................................................................... xiii

OPERATIONAL DEFINITIONS ......................................................................... xiv

CHAPTER ONE ...................................................................................................... 1

1.0 Introduction ............................................................................................... 1

1.1 Background ............................................................................................... 1

1.2 Problem statement ..................................................................................... 3

1.3 Purpose of the study .................................................................................. 4

1.3.1 Main objective ................................................................................... 4

1.3.2 Specific objectives ............................................................................. 4

1.4 Research questions .................................................................................... 4

1.5 Justification of the study ........................................................................... 5

CHAPTER TWO ..................................................................................................... 6

 viii

LITERATURE REVIEW ........................................................................................ 6

2.0 Introduction ............................................................................................... 6

2.1 Individual related factors influencing utilization of vital signs

observation charts. ................................................................................................... 6

2.2 Facility related factors affecting utilization of vital observation charts. ... 8

CHAPTER THREE ............................................................................................... 11

METHODOLOGY ................................................................................................ 11

3.0 Introduction. ........................................................................................... 11

3. 1 Study Design and rationale. ................................................................... 11

3.2 Study setting and rationale ...................................................................... 11

3.3 Study Population and rationale ............................................................... 12

3.4.1 Sample size determination. ................................................................. 12

1.4.2 Sampling procedure and rationale ....................................................... 13

1.4.3 Selection criteria .................................................................................. 13

3.5.1 Dependent variables ........................................................................... 14

Utilization of vital observations chart .................................................................... 14

3.2.2 Independent variable. ...................................................................... 14

Nurses and midwives related factors ..................................................................... 14

Health facility related factors ................................................................................. 14

3.6 Research Instruments .............................................................................. 14

3.7.1 Data collection procedure. ................................................................... 14

 ix

3.7.2 Data management and analysis ..................................................................... 15

3.8 Quality control techniques. .............................................................................. 16

3.9 Ethical consideration. ....................................................................................... 16

3.10 Study limitations. ................................................................................... 16

3.11 Dissemination of results .......................................................................... 17

CHAPTER FOUR .................................................................................................. 18

DATA PRESENTATION ...................................................................................... 18

4.0 Introduction ............................................................................................. 18

4.1 Demographic data ................................................................................... 18

4.2 Individual factors influencing documentation of vital signs ................... 19

4.3 Facility related factors influencing documentation of vital signs ........... 22

CHAPTER FIVE ................................................................................................... 26

DISCUSSION OF FINDINGS, CONCLUSIONS, RECOMMENDATIONS AND

IMPLICATIONS TO NURSING PRACTICE ...................................................... 26

5.0 Introduction ............................................................................................. 26

5.1 Discussion of findings ............................................................................. 26

5.1.2 Individual related factors influencing utilization of vital observations charts

................................................................................................................................ 27

5.1.3 Facility related factors influencing utilization of vital observations charts .. 29

5.2 Conclusions ............................................................................................. 32

5.3 Recommendations ................................................................................... 33

 x

5.4 Implication to nursing practice ................................................................ 34

REFERENCES ...................................................................................................... 35

APPENDIX I: CONSENT FORM FOR PARTICIPANTS. ................................. 42

Appendix II: STUDY PARTICPANTS QUESTIONNAIRE................................ 43

APPENDIX III; AUTHORIZATION LETTER .................................................... 48

APPENDIX V: MAP OF UGANDA SHOWING LOCATION OF BUSHENYI

DISTRICT.............................................................................................................. 49

APPENDIX VI: MAP OF BUSHENYI SHOWING LOCATION OF KIU-TH .. 50

 xi

LIST OF TABLES

Table 1 showing demographic factors of study population ................................... 18

Table 2 Showing whether a nurse knew and monitored patient’s vital observations

................................................................................................................................ 19

Table 3 showing use of vital monitors machines, ability to document reading of

such machines, nurse to patient ratio and priority for documenting their vitals. ... 22

Table 4 showing whether the facility has semiprofessionals employed to take

vitals, nursing design adopted on ward and monitoring documentation in vitals

observations chart .................................................................................................. 25

.
 xii

LIST OF FIGURES

Figure 1 showing various vital signs nurses and midwives commonly monitor ... 19

Figure 2 showing nurses that took vitals, interpreted and documented their

findings. ................................................................................................................. 20

Figure 3 showing confidence of nurses and midwives in knowledge and skills in

monitoring and documenting vitals ....................................................................... 21

Figure 4 showing whether they had ever been trained in documentation of vital

signs documentation in vital observation chart ...................................................... 21

Figure 5 showing whether health worker had ever wanted to take document vitals

had failed. ............................................................................................................... 23

Figure 6 showing what reasons hindered nurses from documenting vitals ........... 24
 xiii

LIST OF ACRONYMS

APPGGH All Party Parliamentary Group of Global Health

BP Blood Pressure

ED Emergency Department

HMIS Health Management Information System

HR Heart Rate

IAH Ishaka Adventists Hospital

KH Kenyatta Hospital

KIU TH Kampala International University Teaching Hospital

MOH Ministry of Health

RR Respiratory Rate

SPO2 Saturation Pressure of Oxygen

SPSS Statistical Package for Social Scientists

SSA Sub Saharan Africa

 xiv

OPERATIONAL DEFINITIONS

Factors Refers to all those characters that are either due to the facility of

nurses and midwives that may affect Rate of vital signs of

monitoring

Influencing Refers to directly or indirectly enhancing monitoring of vital signs

either positively or negatively

Vital Signs Refers to those key changes that indicate physiological functioning

including blood pressure, respiration, temperature, oxygen

concentration to determine health status of the body

Monitoring Refers to observing, documenting and interpreting the meanings of

the vital signs

Nurse Refers to a male or females that is trained and qualified to offer

nursing care including monitoring their vital signs of patients

Midwive Refers to a male or females that is trained and qualified to offer

midwifery care to mothers and early care for neonates including

monitoring their vital signs

Utilization The act of observing patient vital signs, recording them in the

appropriate chart and interpreting the findings from the chart

Vital signs observation chart. A paper that is used to record findings of patients’

vital signs measurements

 CHAPTER ONE

1.0 Introduction

This chapter deals with general back ground of the research study, the problem

statement, objective of this research study, research questions justification to why

this study is being carried out

1.1 Background

Globally, debate continues on the appropriate frequency of vital signs monitoring,

what comprises an abnormality in vital signs in documentation, however; there is

a general consensus that regular patient assessment and documentation may help

detect deterioration (Jones, 2010).

Throughout the scope of professional nursing, Vital signs monitoring and

documentation in the vital observation chart is an integral component of nursing

care, Nurses are taught in school that Blood Pressure (BP), temperature, Heart

Rate (HR), Oxygen Saturation (SpO2) and Respiratory Rate (RR) are crucial in

reflecting patient wellness on patient chart (Rose and Clarke, 2010).

In developed countries for last few decades, vital signs monitoring and

documentation have become an area of active research and numerous studies have

reported that changes in vital signs occur several hours prior to a serious adverse

event (Kellete et al., 2017, Barfod et al., 2012). However in developing countries,

severely deranged vital signs are common in more than 75% of severely ill

patients and infrequently lead to acute treatment modifications since they are

rarely documented or sometimes documentation is done when it is late to save the

patient (Henriksen et al., 2014).

1
In Africa, vital signs have been underemphasized by nurses where by more than

50% patient condition deteriorates without being noticed by nurses due to failure

of monitoring and documenting vital signs (Ludikhuize et al., 2012).

In Sub Saharan Africa (SSA), the act of vital signs monitoring by nurses failure to

reliably assess, document in vital signs observation charts leading to unnoticed

patients deterioration (Moore and Sanko, 2010, Chimwaza et al., 2014).

In East Africa, vital signs documentation hasn’t been studied in most settings

(Winteres et al., 2013). Although in case study of Tanzania, nurses in more than

857 facilities are not monitoring vitals, of which only 15% of nurses that do

monitoring do it correctly and document in vital observation charts (Barker et al.,

2013).

In Uganda, vital signs are only documented in highly specialized private facilities

where patient care is a priority (Andrews et al., 2014). However in government

managed facilities, good care for patients cannot thrive because 80% of the

patients’ vitals are not monitored (Kwizera et al., 2012).

Vital signs monitoring and documentation improves patient safety (Chester et al.,

2011), and reduces morbidity in more severely ill patients (Barfod et al., 2012).

Even though progress of the health status is accurately predicted by vital sign

changes which are cheap and almost affordable at all levels of health care setting,

clinical deterioration often goes unnoticed, or is not detected until it is too late to

treat because nurses caring for patients do not take it as their priority for un known

reasons (Sankey et al., 2016). The study will therefore help in improving vital

signs documentation.

2
1.2 Problem statement

Uganda ranks among highest countries with less monitoring of hospitalized

patients, only 28% of patients admitted in Ugandan hospitals have their vital signs

monitored and documented in vital observation chart, the median monitoring and

documentation frequency per day being 1.1 for blood pressure, 1.0 for temperature

and pulse, and 0.5 for respiratory rate, the frequency of vital signs monitoring

decreased during the course of hospitalization (Asiimwe et al., 2014).

Although monitoring and documentation of vital signs is often considered a key

nursing task and often contributes to early warning scores designed to detect

patients who are at risk of deterioration, it’s still least practiced by nurses (Seiger

et al., 2014).

At KIU-TH, a pilot sample study carried out by reviewing the files of discharged

patients, a total of 40 files were reviewed where 38(95%) had vital observation

charts, 31.5% of those with vital observation charts were utilized although the

fully filed vital observation charts from time of patient’s admission to discharge

were 8.3% only(Records KIU-TH 2019).

Kampala International University Teaching Hospital has put in place these vital

observation tools, and also provided accessory equipment required for vital

observation chart utilization, but the reason why there is poor utilization and

inconsistency in recording in vital observation charts remains unclear, a reason

why this study have to be done.

3
 1.3 Purpose of the study

1.3.1 Main objective

This study determined factors influencing utilization of vital signs observation

charts among nurses and midwives at Kampala International University Teaching

Hospital.

1.3.2 Specific objectives

I. To assess the individual related factors influencing utilization of vital signs

observation charts among nurses and midwives in Kampala International

University Teaching Hospital

II. To assess facility related factors that are influencing utilization of vital signs

observation chats among nurses and midwives in Kampala International

University Teaching Hospital.

1.4 Research questions

1. What are the individual related factors influencing utilization of vital signs

observation charts among nurses and midwives in Kampala international

university teaching hospital

2. How does facility related factors that are influencing utilization of vital signs

observation chats among nurses and midwives in Kampala international

university teaching hospital

4
1.5 Justification of the study

Although RR has been termed as the most useful predictor of deterioration,

assessment of other vital signs are equally important. There seems to be consensus

from existing evidence that the five core vital parameters such as RR, HR, BP,

temperature, and SpO2 should always be monitored to identify at-risk ward

patients (DeVita et al., 2010). Currently there are inadequate studies addressing

nurses’ failure to reliably assess, document and interpret vital signs(Moore and

Sanko 2010). Therefore, this research study will help us in the following ways

Nursing education

The results of this study will act as a basis for emphasis of nursing educators for

vital signs monitoring and documentation among the training nurses.

Nursing practice

These findings will cite out the weakness areas on vital signs documentation

hence help to strengthen the practice of taking and documenting patients’ vital

signs by practicing nurses.

Nursing research

The study will act as a source of literature to other researchers that are interested

on patient care and patient monitoring practice of nurses and other health care

professionals.

Nursing management

The study will act a check to cite out areas that need to be strengthened in order to

encourage vital signs monitoring and documentation and also will generally bring

out other factors that may be influencing nursing practice documentation and how

they can be improved.

5
 CHAPTER TWO

LITERATURE REVIEW

2.0 Introduction

This chapter deals with presenting reviewed literature that is relevant to this

research study, the literature is arranged according to the objectives.

2.1 Individual related factors influencing utilization of vital signs

observation charts.

2.1.1 Qualification

According to the journal of clinical nursing, nurses across various continents need

to have the clinical knowledge to interpret abnormal vital signs accurately in order

to detect deterioration early, there were evidences that non registered nurses were

unable to recognize or unaware of clinical deterioration hence they did not

document such vital signs (DeMeester et al., 2012).

2.1.2 Experience

All-Party Parliamentary Group on Global Health (APP-GGH) (2016) found out

that facilities which recruited and maintained staffs on wards for a longer period

of time were more likely to do vital observations of their patients than those that

constantly introduced new faces of nurses and midwives in patient care, newly

recruited nurses for less than 3 years were among those that did not monitor vital

signs compared to the long serving nurses and midwives although female and

male nurses did not have a difference in their vital observations and monitoring

behavior.

6
2.1.3 Time consuming

A research study in Kenya among nurses and midwives that were caring for

pediatric patients found out that they 46.3% did not utilize vital observation charts

while taking vital signs that they are time consuming since they are not reviewed

to determine subsequent care of the patient (Aluvaala et al., 2015).

2.1.4 Nurses priorities in vital signs

A retrospective review of 63 patients records of patients admitted in Kenyatta

Hospital (KH) by Ludikhuize et al., (2012), revealed a total absence of RR

documentation in all of the patients’ charts within eight hours preceding their

admission which as the result, RR has been frequently termed the neglected vital

sign.

A research study in Naivasha hospital on vital signs observation found out that the

study showed that patients who were more likely to have their blood pressure

checked but the least checked vital sign from the records of study respondents

were body temperature with only 38% of patients and 1/3 of population never

tested SPO (Kairithia et al., 2015)..

2.1.5 Documentation behavior

According to Mwakani et al., (2014), a research study in Kenya found out that

nurses did monitor vital observations however, more than 50% of them had poor

documentation behavior regarding vital observations taken although they took

them.

2.1.6 Confidence in reading and recording vitals

Research studies have found out that nurses and other health care professionals

lack adequate confidence on their knowledge on interpretation and correct

7
documentation of patients’ vital signs, Documentation errors have been reported

at 7.3% in adults’ vital signs and higher rates in those caring for pediatric patients

due to complexity of the documentation charts (Fleming et al., 2011).

2.1.7 Training

According to the research studies carried out by Gerri et al., (2017), All-Party

Parliamentary Group on Global Health (2016), in Liverpool hospital for children

found out that All nurses and midwives had post school training and experience of

using the automated machines for vital signs monitoring for a minimum of 3

weeks and they knew well interpretation of software and they entered vitals in

software that interfaced wirelessly with the hospital patient information system.

In Kenya and Ethiopia, results by Preece et al., (2012) and All-Party

Parliamentary Group on Global Health (2016) respectively indicated that more

than 70% of nurses and midwives did not have confidence in their knowledge and

skills in electronically talking vitals and interpretation of the findings to make

clinical diagnosis basing on vital signs which was basically attributed to lack of

training

2.2 Facility related factors affecting utilization of vital observation charts.

2.12 Technology

A research study in Kenya on effect of introduction of machines in the patient

monitoring found out that the effect of technology on nurses’ role in vital signs

monitoring to detect deterioration needs further exploration which has reduces

nurses critical analysis of the readings on patient monitors and interaction with

patients hence leading to limited vital signs documentation and delayed detection

of condition deterioration (Bellomo et al., 2012).

8
According to a research studies by Fegan et al., (2012), Gross et al., (2011) and

Cahill et al., (2013) in Kenya’s community hospitals, Although automated

machines gave continuous vital signs monitoring alarms were true, they also gave

patients alarm fatigue, hence it turned out to be counter-productive as alarm

fatigue can desensitized the ward staff to the alarms that are originally intended to

safeguard patients hence the nurses did not give them attention.

2.2.2 Population of patients

According to the research study in Singapore by Mok, et al., (2015) found a high

nurse-patient ratio on general wards, as a result, 42% non-registered nurses felt

distracted approximately five times by other patients when taking a patient’s vital

signs, Consequently, RR and temperature values or even other vital signs were

overlooked by the nurse hence ended up not doing them.

According to the studies by Wakaba et al., (2016) research study in Cameroon and

Kenya respectively found out high patient to nurse ratio where a single nurse was

responsible for caring for average of 10-40 patients which hindered them from

monitoring and documenting patients’ vital observations in patients chart.

2.2.3 Supply of Equipments

A research study in sub Saharan Africa by Vukoja, et al., (2014) on reasons why

vital signs were not being s monitored found out that there was shortage of vital

signs equipment like blood pressure machines, thermometers, among others which

hindered the routine monitoring and documentation of vital signs.

2.2.4 Task shifting

A research study in Malawi by Olson, et al., (2013) study found out that enrolled

nurses that are in health care system to support registered nurses specifically on

9
patient monitoring and care giving shifted into registered nurses role of patient

care which hindered vital observation monitoring and documentation.

2.2.5 Severity of patients on ward

A research study to assess vital observation among nurses in Kenyan hospitals by

Ogero et al., (2018) revealed that more than 75% of nurses did not take vitals in

relatively stable patients, the same study also revealed that lack of tools like

thermometers, vital observation charts which hindered vital observations

monitoring and documentation.

2.2.6 System of nursing

according to Jones et al., (2015), Watson et al., (2016), research studies in sub-

Saharan countries revealed low level of monitoring and documentation of vital

observations by nurses and midwives, the contributing factors cited were system

of team nursing commonly adopted in facilities hence patient care and monitoring

although it seems everyone’s responsibility, ends up being no one’s responsibility.

2.2.7 Monitoring

According to the research study by Enoch et al., (2016), results found out no vital

observation documentation monitoring teams in Kenyatta national hospital, hence

this contributed to failure of nurses and midwives utilizing vital observation

charts.

In related studies, Luettel et al., (2016) studied effect of monitoring nursing

activities in Singapore and found out that monitoring nurses and midwives

activities including monitoring and documentation of patients’ vital observations

contributed more than 70% of nurses monitoring of vital signs.

10
 CHAPTER THREE

METHODOLOGY

3.0 Introduction.

This chapter presents the research methodology which is the detailed procedure of

the study. The chapter comprises of the following sections: study design, study

setting, study population, selection criteria, and sample size determination,

sampling technique, study variables, data collection techniques, research

instruments, data management, data analysis, quality control techniques and

ethical considerations of the study.

3. 1 Study Design and rationale.

This study employed a quantitative descriptive cross-sectional study design. The

study design was used because it allowed rapid data collection and a snap short

interaction with respondents at a certain point in time thus allowing conclusions

about phenomena across a wide population to be drawn in short time.

3.2 Study setting and rationale

The study was carried out at Kampala International University Teaching Hospital

(KIU-TH). It is a private not for profit hospital located in Ishaka Bushenyi

municipality, Bushenyi district. It is approximately 375km by road North West of

Kampala, Uganda’s largest city and capital. The hospital has a capacity of 400

beds receiving both inpatient and outpatients with ultramodern technology and

advanced patient care. It’s comprised of both private and public wing. The

hospital is used to enhance learning of nursing and medical students.

11
The hospital receives approximately 750 admissions per month. The facility has a

total of 120 nurses and midwives that carry out patient nursing care for inpatients

and outpatients. This area was chosen basing on reviewed record which revealed a

high percentage of patient files that had unutilized vital observation charts where

even those that were utilized were mostly incompletely filled.

3.3 Study Population and rationale

The study consisted of nurses and midwives attending to patients in KIU-TH

hence a reason why they were chosen.

3.4.1 Sample size determination.

Sample size was determined using Yamane (1999) method in which the sample

size is given by the expression

𝑁
:𝑛 = (1+𝑁(𝑒2))

n = desired sample size

e= level of precision 0.05 at 95% confidence interval

N= Total number of population (114 Number of nurses and midwives in KIU-TH)

114
n=(1+114(0.05𝑥0.05))

88

Therefore, 88 nurses and midwives determined study sample size. However only

50 nurses returned fully completed questionnaires hence the final sample size

being 50

12
1.4.2 Sampling procedure and rationale

Simple random sampling method was used, papers of proportionate numbers

containing YES and NO were folded and put in a basket. Nurses and midwives

were asked to choose randomly. Whoever who chose YES were included in the

study, while those that chose NO were left out as non-representative of the study

population. Those that picked a paper were required to place them back in order to

keep the probability of choosing yes or no by any individual nurse/midwife equal

so as all nurses/midwives remain with equal chances of being selected as study

representatives. This was continued until the study population was realized.

1.4.3 Selection criteria

Inclusion criteria

The study included all nurses and midwives that were attending to patients at

KIU-TH.

Exclusion criteria

The study excluded those that did not consent to freely participate in the study.

13
3.5 Definition of variables.

3.5.1 Dependent variables

Utilization of vital observations chart

3.2.2 Independent variable.

Nurses and midwives related factors

Health facility related factors

3.6 Research Instruments

A semi- structured questionnaire was used as a tool for gathering information. The

structured questionnaire was divided into three sections; the first section was used

to collect data about bio demographic profile of nurses and midwives, the second

section was used to assess nurses and midwives related factors, third section was

used to assess health facility related factors influencing utilization of vital signs

observation charts.

3.7.1 Data collection procedure.

The researcher introduced herself to the prospective participants and read to the

individual participant the consent form that were detailing the title and purpose of

the study as well as the rights of the participant. Whenever a participant agreed to

be interviewed he/she was asked to provide written consent by signing followed

by a self-administered questionnaire. If one of them refused to participate, the

interview did not proceed.

14
After obtaining the written consent, the researcher entered the questionnaire serial

number and date of interview and proceed from the first up to the last question

using English since it was presumed to be understood by all nurses and midwives.

Nurses and midwives entered responses given by ticking the appropriate response

and entering the same number in to the coding box.

This was done to ensure data quality as the response number ticked is supposed to

be the same as the one entered in the coding box. If the numbers were found to be

different, it was not counted as a valid response.

The researcher reviewed questionnaires on a daily basis to ensure they were being

completed correctly and any errors were corrected to avoid being repeated. The

process of data collection was continued until every effort to contact every study

participant in the sample was exhausted to realize the study sample.

3.7.2 Data management and analysis

Completed questionnaires were checked for accuracy, for any missing data and

completeness on a daily basis after data collection at the end of each day. This was

followed by coding and entry of the data using Epi info 3.4.1 software for

Windows and double entry into Statistical Package for Social Scientists (SPSS)

version 20.0 software for analysis.

Data was analyzed by descriptive statistics using SSPS version 20.0 software and

presented in frequency tables, pie charts and bar graphs using Microsoft excel

sheet 2013 version.

15
3.8 Quality control techniques.

For reliability and validity, questionnaires were pretested in Ishaka Adventists

hospital (IAH) before they were taken for data correction in Kampala international

university teaching hospital. Questionnaires were then be revised and content

adjustments made accordingly for any gap or unclear question that was found out

before data collection. After data collection, questionnaires were checked daily,

for completeness, clarity, consistency and uniformity by the researcher.

3.9 Ethical consideration.

A letter of introduction was obtained from Kampala International University

School of Nursing to permit the researcher to carry out the research.

Permission was obtained from Kampala International University Teaching

Hospital Principal Nursing Officer (PNO) for acceptance into their facility and

consent was sought from every participant nurse and midwife before data

collection from him or her.

The study was on voluntary basis and information was kept private and

confidential. Participants' anonymity was kept. The study was conducted while

upholding the professional cord of conduct in a manner that did not compromise

the scientific inclinations of the research.

3.10 Study limitations.

Financial and time requirements were too much; however, these were overcome

by drawing and following the budget from the beginning to avoid over straining in

finances.

16
Some nurses and midwives were off duties and others busy with work on their

wards, however I had to commit myself to going there several times until I got

each of them in convenient time to participate in the study.

3.11 Dissemination of results

After approval, copies of the results have been produced and distributed as

follows.

Uganda Nurses and Midwives Examinations Board

Kampala International University School of Nursing And Midwifery library

Kampala International University Teaching Hospital library for implementation of

recommendation findings

Supervisor and the researcher also remained with a copy for reference

presentation in seminars and workshops relevant to the study.

17
 CHAPTER FOUR

DATA PRESENTATION

4.0 Introduction

This chapter presents the data as tarried from the research tool used. The data is

presented in form of tables, graphs and pie charts followed by brief description of

key the research findings.

4.1 Demographic data

Table 1 showing demographic factors of study population

(n=50)

Sample characteristic Frequency(n) Percentage (%)

Sex Male 18 36
Female 32 64
Designation Nurse 39 78
Midwife 11 22
Qualification Enrolled nurse/midwife 36 72
Registered nurse/midwife 14 28
Years in 0-4 31 62
nursing 5-9 13 26
/obstetric care 10-14 6 12
Total 50 100

Findings of this study revealed that most 32(64%) of the respondents were

females whereas 18(36%) were male, majority 39(78%) of the respondents were

nurses compared to11 (22%) were midwives.

Research findings from the study found out that majority 36(36%) of the

respondents were enrolled nurses/midwives while 14(28%) who were registered

nurses/midwives. findings also revealed most 31(62%) of nurses and midwives

had experience of 0-4 years where as the least 6 had 10-14 years’ experience in

offering nursing care.

18
4.2 Individual factors influencing documentation of vital signs

Table 2 Showing whether a nurse knew and monitored patient’s vital

observations

(n=50)

Variable Frequency Percent

Knew and monitor vital signs 50 100

Do not know and not monitor vital signs 00 100

Finding revealed all 50(100%) of nurses and midwives knew and monitored vital

patients observations.

(n=50)

50

40
Frequency

30
100%
20 82%
72%
52%
10 30%
0
Heart rate Blood Tempraure Oxygen Respiration
pressure saturation

Vital signs taken

Figure 1 showing various vital signs nurses and midwives commonly monitor
Findings of the research study revealed all 50(100%) of nurses and midwives

monitored blood pressure while only 15(30%) of nurses and midwives monitored

SPO2 for their patients.

19
 (n=50)

35 64% Key
60% 60%
30

25 Always
Percentage

20 36%
28%
15
22% Some
18% times
10

8%
5 4%
Not at
0
all
Do vital Take time and Ensure
observation do interpretation documentation

Vital signs observation, interpretation and documentation

Figure 2 showing nurses that took vitals, interpreted and documented their

findings

Findings in figure 3 above revealed that most 32(64%) of the respondents reported

that, they sometimes do vital observations compared to 4% who do not do vital

observations at all, 30(60%), and 30(60%) of nurses and midwives sometimes

monitored vital signs, interpreted and documented findings whereas the least

2(4%) and 4(8%) did not monitor nor interpreted vitals at all, where and 9(18%)

ensured documentation of vital signs.

20
 (n=50)

14% KEY

YES

86% NO

Figure 3 showing confidence of nurses and midwives in knowledge and skills

in monitoring and documenting vitals

Research findings revealed that more than three quarters 43(86%) of the

respondents were confident about their knowledge and skills on vital signs

monitoring and documentation in vital observation chart compared to 7(14%) who

reported not confident enough.

(n=50)

18% KEY

YES

82% NO

Figure 4 showing whether they had ever been trained in documentation of

vital signs documentation in vital observation chart

The study findings revealed more than three quarters 41(82%) of the respondents

said had never received any training on vital signs documentation in the chart

21
while 9(18%) had ever been trained on documentation of vital signs in vital

observation chart.

4.3 Facility related factors influencing documentation of vital signs

Table 3 showing use of vital monitors machines, ability to document reading

of such machines, nurse to patient ratio and priority for documenting their

vitals.

(n=50)

Characteristic Variable Frequency Percent

(n) (%)
Use of machines to monitor patients Yes 50 100
vitals No 00 00
Able to record vitals from machines Yes 36 72
No 14 28
Nurse/Midwife to patient ratio 1:2 2 4
1:4 11 22
Above 1:4 37 74
Influence of patient ratio to vital Heavy load Interferes 20 40
sign monitoring and documentation with monitoring
Does not have any effect 8 16
on vitals documentation
Monitor a few of vital 11 22
signs
Eventually monitors only 11 22
unstable patients
Patients of vitals for All patients 16 32
Only severely ill 12 24
Newly admitted 14 28
Postoperative patients 8 16

The study findings in table 6 above revealed all 50(100%) nurses and midwives

said the facility had other instruments and machines for monitoring vital

observations apart from usual vital observation tray and three thirds 36(72%) of

the respondents were confident in their knowledge and skills on documentation of

vital signs compared to 14(28%) that said that they were not confident enough.

22
Most 37(74%) of nurses and midwives reported having high nurse to patient ratio

above 1:4, whereas only 2(4%) reported a ratio of 1:2.

Furthermore, majority 20(40%) of nurses and midwives reported heavy workload

due to high nurse to patient ratio hence they could not effectively monitor and

document patients vital signs in the vital observation chart compared to 8(16%)

who reported the nurses to patient ratio to not having an effect on their vitals

documentation.

Finally, the findings of this study revealed that most 16(32%) of the respondents

said that it was required by them to document vitals for all patients compared to

8(16%) who said that documentation of vitals was mostly required for

postoperative patients.

(n=50)

Key
36%
Yes
64%
No

Figure 5 showing whether health worker had ever wanted to take document

vitals had failed.

According to the study findings in figure 7 above results reveals most 32(64%) of

the respondents had ever wanted to take vital observations and document them but

could fail while 18(36%) said too have never had any reason that hindered them

from monitoring and documenting a patients vital signs in vital observation chart.

23
 (n=32)
Reasons why nurses could not take
vitals even when they wanted too

scarcity of instrument to use 25.1%

Lacked paper for documentation 3.1%

Too busy shedule on ward 71.8%

0 10 20 30

Frequency

*Asked to only those that had ever wanted to take the vitals and failed to chat

for a certain reason

Figure 6 showing what reasons hindered nurses from documenting vitals

According to the study findings in figure 8 above show that majority 23(71.8%) of

nurses and midwives that had ever wanted to document vital signs and failed was

due to a heavy workload on ward whereas the least 1(3.1%) reported to have

lacked a paper for documentation of vital signs.

24
Table 4 showing whether the facility has semiprofessionals employed to take

vitals, nursing design adopted on ward and monitoring documentation in

vitals observations chart

(n=50)

Character Variable Frequency (n) Percent (%)

Have semiprofessionals for Yes 3 6
monitoring vitals No 47 94
Nursing design used on Team nursing 48 96
ward Patient centered 2 4
Presence of team to Yes 11 22
monitor documentation of No 39 78
vitals

Findings from this research study revealed most 47(94%) of nurses and midwives

that reported that there were no other semiprofessionals employed specifically to

monitor and document vital signs whereas the least 3(6%) reported that they were

there.

Findings also revealed almost all 48(96%) of nurses used team nursing for their

patients but only the very few 2(4%) reported nursing care to be client centered. it

was also found out that that most 39(78%) of nurses and midwives reported that

there was no team on ground specific for monitoring documentation of vitals in

the patients vital observation chart while the least 11(22%) reported to have a

group that monitors vitals documentation.

25
 CHAPTER FIVE

DISCUSSION OF FINDINGS, CONCLUSIONS, RECOMMENDATIONS

AND IMPLICATIONS TO NURSING PRACTICE

5.0 Introduction

This chapter presents discussion of the findings of this research study, conclusions

from the study, recommendations and implications to nursing practice. Discussion

follows specific objectives of this research study and followed by researchers’

intuition of the reason for possible findings and comparison with other written

articles.

5.1 Discussion of findings

5.1.1 Demographic factors

Findings of this research study revealed most 32(64%) were females which could

be because nursing and midwifery profession were originally known to be

feminine profession not until of recent when males also started adopting the same.

This could not have influence on utilizing the vital observation charts since all

males and females that care for patients are trained to use the chart similarly to

APP-GGH (2016) whose studies in vital observation and monitoring behaviors

among nurses and midwives showed no differences in the way how males and

female monitor their patients vital signs.

Research the study findings, results revealed majority 36(36%) of the participants

who were enrolled nurses/midwives which could be because these form the

majority in the employment system of nursing care since they are easy to train and

maintain compared to their highly ranking counterparts. These are less likely to

26
have lesser knowledge and skills in recording, interpreting and documenting

patients’ vitals in the vital observation chart. These findings agree with those of

DeMeester et al., (2012) which found that non registered nurses were unable to

recognize or unaware of clinical deterioration hence they did not document such

vital signs.

Furthermore, the findings also revealed most 31(62%) of nurses and midwives had

experience of 0-4 years which could be an indicator that the facility employ newly

trained professionals to offer nursing care for patients. these are likely to have had

less exposure in monitoring and documentation of their patients vitals hence likely

not to utilize vital observation charts effectively. Findings of this research study

agree with those of All-Party Parliamentary Group on Global Health (APP-GGH)

(2016) which found out that facilities with newly recruited nurses for less than 3

years were among those that did not monitor vital signs compared to the long

serving nurses and midwives.

5.1.2 Individual related factors influencing utilization of vital observations

charts

Finding revealed that all 50(100%) of nurses and midwives knew and monitored

vital patients observations where all most 50(100%) of nurses and midwives

monitored blood pressure and documented in vital observations chart which could

be because they understand it as an essential vital observation hence they are

likely to monitor and document it in the vital chart. These findings agree with

those of Kairithia et al., (2015) in Naivasha hospital that found out that patients

who were more likely to have their blood pressure checked but the least checked

27
vital sign from the records of study respondents were body temperature with only

38% of patients and 1/3 of population never tested SPO .

Research study findings revealed most 32(64%), 30(60%), and 30(60%) of nurses

and midwives sometimes monitored vital signs, interpreted and documented

findings respectively which could be because due to the fact that nurses value.

these findings are similarly to those of Mwakani et al., (2014) in Kenya which

found more than 50% of nurses had poor documentation behavior regarding vital

observations taken although they took them.

More so the results revealed that more than three quarters 43(86%) of the

participants were confident about their knowledge and skills for vital signs

monitoring and documentation in vital observation chart which could be from

training from institutions since most nurses and midwives trainees are trained in

observation and documentation in vital observations chart hence could facilitate

proper monitoring and documentation of vital observations in the charts. These

findings disagree with those of Preece et al., (2012) in Ethiopia which indicated

more than 70% of nurses and midwives that were not confident of their ability to

make clinical diagnosis document in vital observation chart basing which was

basically attributed to lack of training

The study findings revealed that more than three quarters 41(82%) of nurses and

midwives had never received any training/workshop on vital signs documentation

in the chart except what they had acquired while they being trained as students in

training schools which could be because vital observation chart utilization had not

been previously prioritized especially in less highly specialized settings hence are

less likely to be able to interpret and document findings in vital observations chart.

28
these findings are contrary to those of Gerri et al., (2017) in Liverpool hospital for

children that found All nurses and midwives who had post school training and

experience of for vital signs monitoring for a minimum of 3 weeks hence

monitored and documented in patients vital observation charts.

5.1.3 Facility related factors influencing utilization of vital observations

charts

The study findings revealed all 50(100%) nurses and midwives reported that the

facility had other instruments and machines for monitoring vital observations

apart from usual vital observation tray instruments which could be because of

trend in the nursing and medical practice that has become more complexed by

machinery in both medical and nursing care. These are likely hinder monitoring

and documentation of vital observations in vital observations charts since they

require a lot of knowledge and skills in operating. These findings are similarly to

those of Bellomo et al., (2012) in Kenya which found that effect of technology on

nurses’ role in vital signs monitoring reduces vital signs documentation in the vital

observation charts and delayed detection of condition deterioration.

Research study findings also revealed most 37(74%) of nurses and midwives

reported high patient to nurse ratio above 1:4 and most 20(40%) of nurses and

midwives reported that there was heavy workload due to high patient to nurse

ratio hence they could not effectively monitor and document patients vital signs in

the vital observation chart. This could be a pictorial representative of the staffing

for nursing care in the study area hence these are not likely to adequately monitor

and document patients vitals in vital observations charts due to inadequate time

for all patients. Findings of this research study are similarly to those of Wakaba et

29
al., (2016) in Cameroon which found high patient to nurse ratio with average of

10-40 patients which hindered them from monitoring and documenting patients’

vital observations in patients chart.

In addition, findings of this research study further revealed majority 16 (32%) of

participants said that they were required to document vitals for all patients which

could be because they understood the importance of vital signs of the patient in

monitoring the progress of the patient hence if conditions are favorable, this could

positively influence monitoring and documentation of vital signs. These findings

are similarly to those of Ogero et al., (2018) in Kenyatta hospital which revealed

that 75% of nurses that did not take or document vitals in relatively stable patients

except the severely ill.

Findings of the study revealed three thirds 23(71.8%) of nurses and midwives that

had ever wanted to document vital signs and failed was due to a heavy workload

on ward which could be because of high patient to nurse ration that gives nurses

and midwives too much work hence making monitoring and documentation of

patients vitals effectively difficult to achieve. These findings are similarly to those

of Vukoja, et al., (2014) which found out that there was shortage of vital signs

equipment like blood pressure machines.

More so, the study also revealed that almost all 47(94%) participants reported that

there were no other semiprofessionals employed specifically to monitor and

document vital signs hence leaving the duty for monitoring, interpreting and

documenting vitals in patients vital observations charts to nurses where with other

chores on ward like drug administering, ensuring hygiene of ward and patents

among others could easily outcompete the necessity of having every patients vitals

30
properly recorded in the observation chart. These findings are contrary to those of

Olson, et al., (2013) in Malawi which found out that facilities that employed

enrolled nurses as support staffs to registered nurses specifically to facilitate

patient monitoring and documentation and avoid task shifting in nursing care

which facilitated vital observation monitoring and documentation.

In addition, the study further revealed that, nearly all 48(96%) of nurses studied

that were caring for patients used team nursing (not patient specific) for their

patients which could be because of the inadequate staffing and hospital policy that

adopt such a system despite it being very well known for ineffective nursing care

for patients including in having patients vitals monitored and documented in the

patients vital observation chart. Findings from this research study are similarly to

those of Jones et al., (2015) and Watson et al., (2016) that revealed low

documentation of vital observations by nurses where the contributing factor cited

was a system of team nursing commonly adopted in facilities.

The study also found out that most 39(78%) of nurses reported that, there was no

team on ground specific for monitoring documentation of vitals in the patients

vital observation chart which could be due to less priority given to documentation

of patient vitals. this could lead to laxity among nurses and midwives hence will

not document patients vitals in vital signs observations chart. These results are

similarly to those of Enoch et al., (2016), which found no vital observation

documentation monitoring teams in Kenyatta national hospital which contributed

to failure of nurses and midwives utilizing vital observation charts.

31
5.2 Conclusions

Factors that positively influenced monitoring and documentation of vital

observations readings in patients vital observation charts were lesser extent and

they included nurses and midwives having knowledge on monitoring and

documentation of patients’ vitals, confidence in interpretation and proper

Documentation of patients vital observations chart, and constant supply of

necessary equipment for vital signs monitoring and documentation in the chart

which facilitated nurses to monitor and document vital signs.

Factors that negatively influenced utilization of vitals observation charts among

nurses and midwives included high patient to nurse ratio that resulted into

overload, team nursing design commonly used in nursing care within the facility

that create less patient care ownership among nurses, lack of extra training on

necessity, monitoring, interpretation and documentation of patients vital signs

which possibly compromise confidence and skills of vital observation and

monitoring, in addition to lack of support staffs to relieve heavy workload from

nursing staff and lack of monitoring team for vital signs documentation

monitoring among nurses.

32
5.3 Recommendations

Kampala International University Teaching Hospital

I recommend Kampala International University Teaching Hospital to recruit more

man power in nursing field in order to ensure adequate nursing staff for

monitoring and documenting each patient’s vital sign in the vital observation

chart.

Nursing Council

I recommend the nursing council to campaign for better nursing designs that are

more clients centered and more effective to meet all patients requirements than

team nursing so that each patient can get maximum timely assessment and

documentation for vital signs in clients chart in order to detect any deterioration

timely and implement interventions for quality life and better treatments

outcomes.

Nursing management of KIU-TH

I recommend nursing managers in Kampala International University Teaching

Hospital to instate a team and empower it to mentor, monitor and evaluate nurses

and midwives vital signs monitoring, interpretation and documentation in order to

ensure that it is done, in a correct manner and documented for evidence based

nursing care.

33
5.4 Implication to nursing practice

Nursing education

Nursing educators should put emphasis on role of monitoring patients’ vital signs

and documenting in the vital observation charts in order to train nurses and shape

the trainees attitudes towards this practice thereby improving nursing care.

Nursing practice

Practicing nurses should ensure that despite their heavy duties, spare some time

for patients’ vital signs assessment and documentation for them alone can form

the baselines for nursing care decisions to the patient.

Nursing research

Nursing researchers should make a detailed study on factors influencing

persistence of team nursing its known poor nursing outcomes in order to improve

on patients’ assessment and individualized care.

Area for further research

Further studies thoroughly could assess nurses’ ability on use and interpretation of

patients vital signs using modern machinery that are being introduced in health

care especially in limited resource settings where traditional measures had been

used predominantly to ascertain the ability of nurses to use them for patient care.

34
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41
APPENDIX I: CONSENT FORM FOR PARTICIPANTS.

Good morning/afternoon?

My name is Kamalanji Donata

The purpose of the study is to establish Factors influencing utilization of vital

signs observation charts among nurses and midwives at Kampala

International University Teaching Hospital. The study will involve asking you

some questions concerning you.

All the information collected will be treated in confidence and used only for

purposes of this study; the dissemination of results will be by way of summarized

information that will have no reference to any particular individual.

You are free to choose whether to take part in the study or not, and feel free to

Withdraw at any time during the interview.

Statement of informed consent

The above information has been clearly explained to me and I have

read/understood it. I do here by voluntarily agree to participate in this study.

Respondents signature …………………………………………………..

42
Appendix II: STUDY PARTICPANTS QUESTIONNAIRE

Questionnaire No.…………………………………….

Date: ____/_____/____

Dear respondent, I am Kamalanji Donata from Kampala International University

school nursing conducting a research study “Factors influencing utilization of

vital signs observations charts among nurses and midwives in Kampala

International University Teaching Hospital”. You are kindly requested to

answer the following questions and your answers will be treated with utmost

confidentiality.

SECTION A: SAMPLE DESCRIPTION

Instructions. Where necessary, use a (Tick)

Answer all questions

1. Demographic description of the sample

SAMPLE CHARACTERISTIC TICK HERE

Sex Male
Females
Designation Nurse
Midwife
Qualification Enrolled nurse/midwife
Registered nurse/midwife
Specialist nurse/ midwife
Experience in 0-4 years
obstetric/nursing care 5-9
10-14
15-above

43
SECTION B: INDIVIDUAL FACTORS

2 a) do you know vital signs in nursing care?

Yes

No

b) i) Do you monitor patients vital signs

Yes

No

ii) If yes, what do you monitor as vital signs for your patients?

………………………………………………………………………………………

c) Rate yourself on observation, interpretation and documentation of vital

signs for your patients. Tick in accordance to how comfortable and confident you

feel on subject under study

Character Always Some times Not at all

Do Observation

Take time and do Interpretation

Ensure Documentation of findings

d) i) are you very confident in your knowledge and skills for vital signs

monitoring and interpretation?

Yes

44
No

ii) Apart from what you studied from school, have you ever got any other

extra training on vital signs observation?

Yes

No

SECTION C: Facility related factors

2 a) Besides the usual vital signs observation tray instruments, does your facility

have other machines to monitor patent vital signs?

Yes

No

b) If yes, are you able to perfectly interpret their readings and alarms for all

vital signs and different age groups?

Yes

No

c) i) What is the nurse to patient ratio on your ward?

a) 1:1

b) 1:2

c) 1:4

d) Above 1:4

45
ii) How does it affect your vital signs monitoring and documentation?

………………………………………………………………………………………

d) i) Have you ever wanted to monitor and document patient vital signs

but you could not for a reason?

Yes

No

ii) If yes, what was the reason that you couldn’t monitor your patients’ vital

signs?

………………………………………………………………………………………

e) Which kind of patients does your ward encourage mostly to monitor their

vital signs

a) Only those severely ill

b) All patients

c) Newly admitted

d) Post-operative patients

e) Others specify…………………………………………………………..

f) Do you have a team of other professionals or semiprofessionals your

facility administration primarily employs for monitoring and documenting

patients’ vital signs?

Yes

46
No

g) Which nursing design does your facility adopt?

………………………………………………………………………………………

h) Is there a team responsible to monitor whether vital signs are monitored,

interpreted rightly and documented by nurses and midwives?

Yes

No

END

Thanks for your cooperation

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APPENDIX III; AUTHORIZATION LETTER

48
APPENDIX V: MAP OF UGANDA SHOWING LOCATION OF

BUSHENYI DISTRICT

LOCATION OF BUSHENYI BDISTICT

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APPENDIX VI: MAP OF BUSHENYI SHOWING LOCATION OF KIU-TH

Location of KIU-TH

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