Record Keeping: Self-Reported Attitudes, Knowledge and Practice Behaviours of Nurses in Selected Cape Town Hospitals

RECORD KEEPING: SELF-REPORTED ATTITUDES, KNOWLEDGE AND PRACTICE BEHAVIOURS OF NURSES IN SELECTED CAPE TOWN HOSPITALS JOHANN MARTHINUS OLIVIER (OLVJOH006) SUBMITTED TO THE UNIVERSITY OF CAPE TOWN In partial fulfilment of the requirements for the degree MASTER OF SCIENCE IN NURSING Faculty of Health Sciences Division of Nursing and Midwifery UNIVERSITY OF CAPE TOWN August 2010 University of Cape Town SUPERVISOR Ms Una Kyriacos, MSc(Nursing) UCT Division of Nursing and Midwifery UNIVERSITY OF CAPE TOWN The copyright of this thesis vests in the author. No quotation from it or information derived from it is to be published without full acknowledgement of the source. The thesis is to be used for private study or non- commercial research purposes only. Published by the University of Cape Town (UCT) in terms of the non-exclusive license granted to UCT by the author. University of Cape Town i. DECLARATION I, Johann Marthinus Olivier, hereby declare that the work on which this thesis is based is my original work (except where acknowledgement indicates otherwise) and that neither the whole work, nor any part of it has been, is being, or is to be submitted for another degree at this or any other University. I empower the University to reproduce, for the purposes of research, either the whole or any portion of the contents in any manner whatsoever, whilst acknowledging my contribution. 14 August 2010 ……………………………………. ……………………… JOHANN MARTHINUS OLIVIER Date ii. DEDICATION In loving memory of my Mother, who always believed… “We walk through this life but once and along the way we touch people’s lives… Thank you for touching mine!” iii. ACKNOWLEDGEMENTS The completion of this thesis has been a long and laborious process. To God all the glory for providing me with the resolve, patience and ability to complete it, sending the following people across my path to make it possible: • Ms U. Kyriacos, my supervisor, for her unconditional support, advice, guidance and encouragement. You must have shaken your head on many occasions, but you always remained the ultimate role model. • Dr P. Mayers, MSc (Nursing) program coordinator at the University of Cape Town, for your support, guidance and advice during the difficult times. • Ms E. Jordaan, the General Manager Nursing at Medi-Clinic, for her prompt approval for access to the Medi-Clinic hospital. • Mr T. Mabuda, Director Nursing Services, Western Cape Department of Health, for approval to conduct the study at public health facilities. • Brigadier General N.C. Madlala-Msimango, Director Nursing at the South African Military Health Service (SAMHS) Head Quarters, for approving and supporting, via Brigadier General L.J. Smith, Colonel A. Fischer, Colonel N.P. Maphaha, Lieutenant Colonel P.de Waal (for Defence Intelligence) and Major A.M. Wagner, access to 2 Military Hospital. • Ms A. Dorse, Nursing Service Manager, Life Vincent Pallotti Hospital, for approving hospital access and allowing nursing personnel to participate, as well as her hands-on support prior to, and during the data collection period. • Lieutenant Colonel R.B. Hill, Deputy Director Nursing, 2 Military Hospital, for supporting the request for inclusion of the hospital’s nursing personnel in the study, her support for, and continuous encouragement during the project (and for the approval of additional leave). • Ms F. Redfurn, Nursing Service Manager, Constantiaberg Medi-Clinic, for allowing nursing personnel to participate, and her enthusiasm for the study during our initial meeting. • Ms S. Reijnders, Nursing Service Manager, UCT Private Academic Hospital (Netcare), for her prompt approval of access to the hospital and allowing nursing personnel to participate. iv. • Ms S.E. Roodt, Manager Nursing, Red Cross Children’s Hospital, for confirming access to the hospital and allowing nursing personnel to participate. • Ms C.J. Thorpe, Manager Nursing, Groote Schuur Hospital, for providing written confirmation, allowing nursing personnel to participate. • Ms M.J.H. Ross, Assistant Director Nursing, Medical Services, Groote Schuur Hospital, for her enthusiasm during our initial meeting and her support and assistance with regards to the logistics of conducting the survey at the hospital. It makes a difference if you’ve been there and done that… • The following Research Contact Persons: o Ms T. de Villiers (RN), Red Cross Children’s Hospital, for assisting with the sampling. Give Amelie a hug from me, you know why… o Ms S. Erikson (RN), Groote Schuur Hospital, for assisting with the personnel name lists and the sampling. I envy your quick and efficient retrieval of personnel information from the computer. o Ms L. Levey (RN), UCT Private Academic Hospital, for assisting with the sampling, distribution and collection of the questionnaires. Enjoy your retirement. o Ms M. Pinna (RN), Constantiaberg Medi-Clinic, for assisting with the sampling, distribution and collection of the questionnaires. I trust your own research is progressing well. o Ms D. Rossouw (RN), 2 Military Hospital, for assisting with the sampling, your encouragement and always being willing to listen. o Ms P. Stoffels, Red Cross Children’s Hospital, for answering all my questions, assisting with the personnel name lists and collection of the questionnaires. The tea you provided saved the day. • Mr J. Irlam, Senior Lecturer at UCT’s Primary Health Care Directorate, for providing the initial guidance, during the proposal stage, with regards to possible methods for statistical analysis, and for introducing me to the marvels of pivot tables. • Associate Professor J.M. Juritz, Department of Statistical Sciences at UCT, for assisting me with statistical analysis and support. Your availability, friendliness and trust are appreciated (I also enjoyed 7de Laan and the Macaroni & Cheese…). v. • Dr M. Badri, Statistician at the Department of Medicine, UCT, for assistance and guidance. Your compassion, time and understanding is appreciated. • The respondents who participated in the pre-test, pilot study and survey. Without your participation, positive feedback and constructive criticism, this research project would not have been possible. Keep up the good work! • Ms M.A. Cohen, colleague, friend and fellow student, for providing encouragement, acting as a sounding board and for listening. Thanks to you, we will always have ‘MCL’. • My colleagues and extended ‘UCT family’, for their encouragement. • My family and friends who saw so little of me. Without you, I’m nothing – thank you for your unconditional support and encouragement. I thank you! vi. TABLE OF CONTENTS Page no. DECLARATION ..........................................................................................................i DEDICATION ............................................................................................................ ii ACKNOWLEDGEMENTS ......................................................................................... iii ABSTRACT ............................................................................................................. xv ABBREVIATIONS AND OPERATIONAL DEFINITIONS ........................................ xvii CHAPTER 1 ..............................................................................................................1 INTRODUCTION .......................................................................................................1 1.1 Introduction ......................................................................................................1 1.2 Orientation to the field of study.........................................................................1 1.3 Background and significance of the study ........................................................2 1.4 Quality in health care .......................................................................................3 1.5 The South African situation ..............................................................................4 1.5.1 Nurse training and workplace structures.............................................5 1.5.2 Quality in South African health care....................................................7 1.6 Problem statement...........................................................................................8 1.7 Research questions .........................................................................................8 1.8 Aim of the study ...............................................................................................8 1.9 Objectives of the study.....................................................................................9 1.10 Assumptions ....................................................................................................9 1.11 Layout of dissertation and brief summary of contents.....................................10 1.12 Chapter summary...........................................................................................10 CHAPTER 2 ............................................................................................................11 LITERATURE REVIEW ...........................................................................................11 2.1 Introduction ....................................................................................................11 2.2 Nursing: A systematic process of phases and record keeping.......................12 2.3 Purpose of record keeping in nursing.............................................................14 2.4 Standards and guidelines for record keeping in nursing .................................15

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