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Survey of knowledge, attitude and performance of nursing students towards

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European Journal of Scientific Research
ISSN 1450-216X Vol.80 No.2 (2012), pp.191-198
© EuroJournals Publishing, Inc. 2012
http://www.europeanjournalofscientificresearch.com

Survey of Knowledge, Attitude and Performance of Nursing

Students towards Nursing Documentation

Mohajjel Aghdam A.
MS in Nursing Education, Faculty Member, School of Nursing and Midwifery
Tabriz University of Medical Sciences

Lak Dizaji S.
MS in Nursing Education, Faculty Member, School of Nursing and Midwifery
Tabriz University of Medical Sciences

Rahmani A.
PhD Candidate, School of Nursing and Midwifery
Tabriz University of Medical Sciences

Hassankhani H.
PhD, Assistant Professor, School of Nursing and Midwifery
Tabriz University of Medical Sciences

Ahmadizadeh A.
Corresponding Author, MS in Nursing Education, Aras International School
Tabriz University of Medical Sciences

Abstract

Accurate nursing documentation leads to the evolution of knowledge and enhance

professional autonomy. It can also be a useful source in educating students and for nursing
researches. Students, as the main recipients of educational services, are the key source of
identifying educational issues. Therefore, the first step in improving the quality of training
is to understand the client's perspective. Thus this study was conducted to assess
knowledge, attitude and performance of nursing students towards nursing documentation.
This is a descriptive study which examines knowledge and performance of Tabriz
University of Medical Sciences nursing students. 120 students out of 130 were selected
using census sampling method. The research instrument consisted of three parts: questions
concerning knowledge, questions on attitude and performance checklist completed by
students and analyzed using descriptive statistical method.
Findings showed that most students' knowledge of recording nursing reports was
moderate; the attitudes of majority of them were "good", too.
In order to promote nursing students' knowledge and attitude towards recorded
reports as well as improving their performance taking training course on nursing
documentation is recommended. The implementation of these programs should be
integrated with clinical and theoretical training by authorities of nursing schools.
Survey of Knowledge, Attitude and Performance of
Nursing Students towards Nursing Documentation 192

Keywords: Nursing documentation, Knowledge, Attitude, Performance

Introduction
Patient documentation is an integral component of providing patient care and one of the most
important functions of nursing practice (1). It represents credibility of nurses' professional (2) as well
as the relevant health care institution (3). Nursing Documentation aims to provide a comprehensive
review of nursing observations and interventions carried out for the patient. It will demonstrate the
patients' response to interventions and reflect the quality of care provided for them (2-4). The main
advantages of a proper nursing record are to ensure care planning quality and continuity through
professional communication, to provide legal documents to support nursing cares, developing criteria
for nursing education programs and standards for clinical training, and to direct nursing knowledge
development and students' training (5). Nursing Documentation is a method for planning and decision
making and discharge plan for patient (3) as well as improving clinical education (6). Any failure in
nursing records may lead to confirm the negligence (7). Despite performing well on nursing tasks,
statements, in the absence of valid documentation or unregistered nursing interventions, cannot be
accepted by a court (8, because recorded performance is verifiable and just fully documented reports
are acceptable (7).
Despite its importance the results of various studies indicate that nursing documenting
performance is poor. Results of studies conducted by Ghazanfari et al (9), Jasemi et al (10), Khoddam
et al (11), Kahouei et al (12), Mashoofi et al (13), Hanifi et al (7) in Iran and also studies of
Choakasmosok et al (Thailand,5), Rosendal Darmer ( Denmark, 9) and Bejoroul et al ( Sweden, 14-15)
indicated a strong need for high quality educational programs to train nurses on documentation. In
addition most nursing students express that during training courses they were not educated enough
about nursing reports .the novice nurses had little knowledge and attitude about documentation of
nursing diagnosis and care (16).
It is necessary to determine the patient's response to medical and pharmaceutical treatment
which can only be achieved through nursing documentation. During the four-year nursing education
program there is no formal training or education about documentation; thus the students are to acquire
the knowledge and skills from their educators and clinical nurses. To provide any educational planning
on nursing documentation to get basic information around it is needed which prompted us to undertake
a research assessing knowledge, attitude and performance of nursing students on documentation.

Methods
This was a descriptive study which examines documentation knowledge, attitude and performance of
nursing students of Tabriz Nursing & Midwifery School (2011). The study sample included all nursing
students of 4-5-6-7 and 8th semesters. 121 students out of 133 were selected by utilizing census
sampling method. According to the research objectives Three self-reporting checklist and questionnaire
were developed reviewing textbooks, ; data collection: knowledge, performance and attitude .
A 20-question (4-choice) was used to assess students' knowledge of the topic. A score of 1 was
assigned to each correct answer while a score of zero was assigned to each incorrect ones. The
knowledge Score of the students were between 0 and 20. The individual scores were categorized into
three levels (20 points): poor (0-6), average (7-13) and good (14-20).
In order to assess attitudes of the students a Likert scale questions with 25 statements (Jasemi,
2008) was adopted. Each of the answers were given scores of 1 to 5: 5= completely agree, 4= agree, 3=
no idea, 2= disagree, 1= completely disagree. Scores for the negative statements were reversed.
According to these points attitudes were ranked (125 points) as poor (0-45), average (46-85) and good
(86-125).
193 Mohajjel Aghdam A., Lak Dizaji S., Rahmani A., Hassankhani H. and Ahmadizadeh A.

The performance of the students about nursing documentation was surveyed by using Likert
scale with 25 statements in which each of the answers were given scores of 1-5 (5=always, 4=often,
3=no idea, 2=rarely, 1=never). Scores for the negative statements were reversed. The performance
(self-reporting) of this group was classified (125 points) as poor (0-45), average (46-85) and good (86-
125).
validity of the questionnaire determined by content validity. for which the research instruments
were evaluated by 10 expert faculty members of Tabriz Nursing & Midwifery School and the
feedbacks applied. Test retest reliability applied for reliability assessment of the questionnaires which
that coefficient alpha for knowledge, performance , and attitude questionnaires was .92- .97. Data were
analyzed using SPSS/17. Descriptive statistics were used including frequency, percentage and mean.
Ethics approval for this study was provided by Tabriz University of Medical Sciences Regional
Ethics Committee.

Results
The analysis of socio-demographic characteristics revealed that the mean age of participants was 22.
Of most of the students were in their 4th and 6th semester of college ( 26.1%), single (87%), and female
(55%). the knowledge of the students on nursing documentation was as follows: 82.6% = average,
14%= poor, 3.3% good. knowledge scorers of the students (Table1) revealed that the most correct
answers were around this items: "nursing documentation after the end of a shift (83.5%)", " proper
nursing documentation (80.7%)" and" Documenting patient's refusal of taking the medicines (77.7%)".
Most of the participants answered the following questions incorrectly: "the most important reason for
nursing documentation (96.6%)", "patient's response to treatment (79.2%)" and "recording telephone
orders (64.7%). results of nursing students' attitudes towards nursing records (Table2) showed that
most subjects had positive attitude towards these options :"nursing documentation have positive impact
on care practices (81%)", " nursing reports are legally valid documents (78%), "proper documentation
will enhance professional credibility (61%). the lowest attitude scores were towards following options :
"It will be better to focus on patient care rather than documentation (29%)","fully nursing
documentation leads to reduced workload pressure on nurses (31%),"nursing documentation can be a
valuable source of data for researches (41%). A total "attitude" score was 10.2 while majority of the
respondents (85.8%) had high attitude towards documentation.

Table 1: Knowledge of nursing students about nursing documentation

Correct Answers
Questions
No. Percent
Posting wrong during documentation (pulling the line on the mistakes & writing the right one) 74 61.7
Documenting patient's refusal of taking the medicines ( circling time of drug administration &
94 77.7
inserting the explanation)
Accurate record of post-operative urine output (urine volume was 100cc) 78 65.5
Filling out drug cards (writing medication orders with black pencil) 31 25.8
How to correct the report after pouring tea on it( writing this report & keeping the previous one) 56 46.7
The most important reason for nursing documentation (research) 4 3.3
which one is incorrect about nursing documentation (leaving blank space at the end of the report) 96 80.7
Which one is legally validated (report on measures taken) 88 75.9
Which reporting measures should be implemented at the end of the shift (drawing a line under
101 83.5
the report)
Which one is more important in Canola replacement procedure ( number of Angiocaths used) 12 9.9
Which one is more important in documentation of PRN medication effects ( the patient's
25 20.8
response to the treatment
What is the impact of priority in documentation (properly clarifying the patient's condition) 48 40.3
How shall we record telephone instructions ( developing the instruction & read it to the
42 35.3
physician)
The main cause of accidents recorded (development of preventive measures) 56 46.3
Survey of Knowledge, Attitude and Performance of
Nursing Students towards Nursing Documentation 194

Table 1: Knowledge of nursing students about nursing documentation - continued

Which report is correct* (patient slept last night from 22 p.m. until 10 a.m. 48 40
Which of the following is true about the documentation (the patient should not read the medical
60 50
records & can only obtain information through questions)
What is wrong with this sentence: the blood pressure is 110/60 (no mention of the unit of
58 48.3
measurement for blood pressure)
Which one is a proper report*: (some blood drained from Mrs. Ahmadi's wound) 79 65.8
Which record is correct ( patient had headache in the forehead) 61 50.4
Which documentation can be delayed (massaging the patient) 62 59.9

Table 2: Attitudes towards Nursing Documentation

Completely Completely
Agree No Idea Disagree
Options ** Agree Disagree
No. Percent No. Percent No. Percent No. Percent No. Percent
Nursing documentation has a
81 68.1 37 31.1 0 0 1 0.8 0 0
positive impact on care given
Nursing documentation affects
63 52.9 49 41.2 6 5 1 0.8 0 0
patient's safety
Nurses should spend sufficient
61 51.7 46 39 7 5.9 4 3.4 0 0
time to document the reports
Nursing documentation is based
39 33.1 48 40.7 17 14.4 11 9.3 3 2.5
on students' training
Accurate documentation
61 51.7 43 36.4 11 9.3 3 2.5 0 0
enhance professional autonomy
Nursing documentations are
78 65.5 30 25.2 10 8.4 1 0.8 0 0
legally valid documents
Nursing documentation
50 42.4 46 39 17 14.4 3 2.5 2 1.7
promotes the healing process
Nursing documentation
43 36.1 42 35.3 26 21.8 7 5.9 1 0.8
improves patient care time
Nursing documentation is an
important competency for 54 45.4 49 41.2 14 11.8 2 1.7 0 0
nursing practice
Nursing documentations help
nurses gain knowledge about 65 54.6 45 37.8 6 5 3 2.5 0 0
patients
Nursing documentation can
52 44.8 51 44 12 10.3 1 0.9 0 0
protect the patient's rights
Nursing documentation is a
41 34.7 46 39 19 16.1 10 8.5 2 1.7
source for study
Nursing documentation
improves interaction between 56 48.3 40 34.5 15 12.9 2 1.7 3 2.6
medical team members
Nursing documentation makes
41 34.7 34 28.8 23 19.5 13 11 7 5.9
hospital discharge go smoothly
Nursing documentation leads to
55 46.6 43 36.4 13 11 6 5.1 1 0.8
professional autonomy
Tariffs would be paid based on
64 53.8 33 27.7 14 11.8 5 4.2 3 2.5
nursing documentation
It will be better to put emphasis
on nursing care rather than 29 24.8 35 29.9 20 17.1 26 22.2 7 6
documentation
Nursing documentation leads to
reduced workload pressure on 31 26.5 30 25.6 22 18.8 29 24.8 5 4.3
nurses
195 Mohajjel Aghdam A., Lak Dizaji S., Rahmani A., Hassankhani H. and Ahmadizadeh A.
Table 2: Attitudes towards Nursing Documentation - continued

It is essential to document all

61 51.3 39 32.8 9 7.6 6 5 4 3.4
nursing interventions
Documentation can help
accelerate the resolution & 45 38.1 47 39.8 18 15.3 7 5.9 1 0.8
increase patient’s satisfaction
Nursing documentation
improves the quality of nursing 45 38.1 58 49.2 10 8.5 5 4.2 0 0
care
Nursing documentation helps
55 46.2 41 34.5 17 14.3 6 5 0 0
expedite delivery of patients
Nursing documentation enables
medical staff to detect changes 58 48.7 50 42 9 7.6 1 0.8 1 0.8
in patient’s condition
Documentation can help to
43 36.4 41 34.7 20 16.9 11 9.3 3 2.5
promote nursing knowledge
Documenting nursing
58 48.7 37 31.1 17 14.3 3 2.5 4 3.4
interventions is a valuable skill

The results showed that the self-reporting performance level of the students, respectively,
81.8% and 18.2% , were high and average. the most appropriate answers were on the options about
"signing and sealing the report (76.3%)", "inserting date and time info (71.17%)" and "writing a legible
report (70.6%)"(Table3). The poor performance seen in "documenting patient's response to treatment",
"patient's response to PRN and STAT" and "reporting information about a patient's condition change".

Table 3: ursing Documentation Self-reporting performance

Options** always often No idea rarely never

Filling out the header information 83 69.2 25 20.8 3 2.5 3 2.5 6 5
Inserting date & time of report 86 71.7 27 22.5 4 3.3 1 0.8 2 1.7
Using the 24-hour reporting system 53 44.5 44 37 15 12.6 3 2.5 4 3.4
Writing a legible report 84 70.6 25 21 7 5.9 3 2.5 0 0
Documentation using black/blue
81 68.6 27 22.9 9 7.6 1 0.8 0 0
pen
Not to leave empty lines in the
77 65.3 30 25.4 6 5.1 4 3.4 1 0.8
report
To draw a continuous line under the
84 70.6 25 21 5 4.2 1 0.8 4 3.3
report
Scratching the mistakes & re-
writing down the correct ones next 71 59.2 33 27.5 7 5.8 8 6.7 1 0.8
to it
signing and sealing documents 90 76.3 20 16.9 7 5.9 1 0.8 0 0
Using common terminology 52 43.7 40 33.6 11 9.2 11 9.2 5 4.2
Documenting patient’s original
66 55.5 44 37 6 5 3 2.5 0 0
condition & any occurring changes
Documenting changes in time of
47 39.2 44 36.7 10 8.3 13 10.8 6 5
patient’s condition
Reporting significant signs &
59 49.2 46 38.3 10 8.3 4 3.3 1 0.8
symptoms in the patient
Documenting nursing interventions
67 56.8 37 31.4 7 5.9 3 2.5 4 3.4
provided to meet the patient’s needs
Inserting the time of interventions 58 48.7 31 26.1 9 7.6 12 10.1 9 7.6
Documenting patient's response to
43 35.8 41 34.2 17 14.2 12 10 7 5.8
interventions
Reason for administration of PRN 7
55 46.2 36 30.3 16 13.4 10 8.4 2 1.7
STAT medications
Survey of Knowledge, Attitude and Performance of
Nursing Students towards Nursing Documentation 196

Table 3: ursing Documentation Self-reporting performance - continued

Recording patient's response to

45 37.8 44 37 12 10.1 12 10.1 6 5
PRN and STAT
Writing reports in chronological
55 45.8 35 29.2 15 12.5 12 10 3 2.5
orders
Recording the date & time of Para
55 45.8 29 24.2 21 17.5 11 9.2 4 3.3
clinical tests
Recording the date of invasive
69 58 30 25.2 9 7.6 9 7.6 2 1.7
interventions
Using measurable criteria for
44 36.7 47 39.2 19 15.8 8 6.7 2 1.7
nursing documentation
Recording significant change in
46 38.2 44 36.7 15 12.5 14 11.7 1 0.8
medical orders
Determination of cases for follow-
53 44.2 43 35.8 12 10 8 6.7 4 3.3
up

Discussion
Findings indicated that the knowledge level of most of the participants (82.6%) was moderate while
14% and 3.3% of the subjects had , respectively, low and high level of knowledge on nursing
documentation. It seems that the lack of formal education could be the reason for moderate level of
knowledge. It reveals the educational needs of students for learning nursing documentation. Similar
studies conducted in Iran (2, 10, 11, 12, 13, 7), Thailand (5) and sewed (14) suggest the nurses'
educational need to learn more about nursing documentation which is consistent with the results of the
present study. the findings of the research conducted in Iran (18, 2,19,20), Sewed (21,15) and Denmark
(9), showed that participating in nursing documentation educational programs leads to positive attitude
and knowledge towards the importance of nursing documentation as well as improving its quality.
The subjects' attitude scores revealed that most of them (85.8%) had high attitude towards
nursing documentation reflecting its prominent status among nursing students valuing documentation.
Several Iranian studies 4, 20,10 showed that 80% of nurses had high attitude towards documentation
which is according with the results of our study. Studies by Karami & et al as well have revealed the
greatest knowledge and attitude on improving the quality of documentation (18). Researches by
Bjoryell (15) and Rosendal Darmer (9) indicated low attitudes of nurses; meanwhile different factors
including cultural differences and public ministration system can influence it.
Surveying students' attitude showed that they reported their own performance as "good". The
scores of performance checklists explored that they had the best performance in the following issues:"
signing and sealing the report (90%)", "inserting date and time info (86%)" and "writing a legible
report (86%)". The poor performance were for " documenting patient's response to treatment", "
documenting patient's response to PRN and STAT" and "reporting information about a patient's
condition change". The case study using checklists on patients' reports recorded by nurses in medical
surgical units of teaching hospitals of Tabriz (10) showed that the nurses had the most performance in "
signing and sealing the reports" and "recording date and time" and the lowest level in " documenting
patient's response to treatment" and "reporting patient's time change in condition" which was consistent
with the findings of our study.
Nursing documentation is a legal document so this issue should be paid more attention. To
develop patient-oriented care, it is important to record any events in recovery process because in most
cases nursing documentation makes it possible to record patient's response to treatment and
medication.
197 Mohajjel Aghdam A., Lak Dizaji S., Rahmani A., Hassankhani H. and Ahmadizadeh A.

Conclusion
In regard to results obtained, it seems that the knowledge of students toward record of the well-nursing
documentation must be promoted by doing the training courses, applying the training to bed and
making the masterful professors teach the credits so that the capable students are trained to have the
ability to present the comprehensive and the general-looked care reporting.

Acknowledgement
We are grateful to all of the nursing students participated in this study.

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