Assessment of Nurses’ Documentation Skills in Neonatal Intensive Care Units

Background: Documentation is a fundamental nursing responsibility with professional, legal and
financial ramification. Aim: This study aimed to assess the nurses' documentation skills in neonatal intensive
care unit through assessing nurses’ knowledge and practices toward the documentation and assessing nurses’
attitude toward documentation in neonatal intensive care units. Research design: descriptive study. Setting:
The study was conducted at Neonatal Intensive Care Units at Maternity and Gynecological Hospital and
Pediatric Hospital affiliated to Ain Shams University Hospitals and Said Galal Hospital affiliated to Al-Azhar
University hospitals. Subjects: A purposive sample the subject of the study included of nurses (60) and
purposive sample of neonates (60) who admitted in NICU in the previously mentioned settings. Tools: four
tools were used: First tool, Structured questionnaire format: to assess nurses’ knowledge as regard to
documentation skills. Second tool, neonates' assessment sheet. Third tool, Standardized frame for
documentation skills for common neonatal problems. Fourth tools, nurses' attitude regarding documentation
skills in NICU. Results: The mean age of the studied nurses was 26.5±5.91 years. Regarding educational
qualification, 53.3% of studied nurses had nursing technical institute education. In relation to mean years of
experience in neonatal intensive care, the mean was 6.62±2.87 years. Three quarters of nurses had no
attendance of previous training courses in nursing documentation. There is a statistically significant relation
between total knowledge of the studied nurses and their socio-demographic characteristics (age, educational
qualification and years of experience in NICUs). There is a statistically significant relation between total
practice of the studied nurses and their socio-demographic characteristics (age, educational qualification and
years of experience in NICUs). There is a statistically significant relation between total attitude of the studied
nurses and their educational qualification. Conclusion: More than half of nurses had satisfactory knowledge
regarding documentation skills in NICUs. The majority of nurses had positive attitude regarding documentation
skills in NICUs. More than half of nurses had competent practices regarding documentation skills in NICUs.
There is a highly statistically significant positive correlation between total nurses' knowledge, attitude and
practice. Recommendations: In-service education for upgrading nurses’ skills toward documentation in
neonate intensive care units. Further research studies are needed for ongoing assessment of nurses including
large sample for generalization of results.