Nursing Process Training to Improve the Quality of Nursing Care Documentation
Main Article Content
Abstract
Background: The role of medical caretakers as well-being specialists incorporates a major commitment to well-being administrations in an effort to improve the quality of well-being administrations. A few variables that impact nursing documentation include the need for time, the need for vitality, the persistent stack, the need for information from medical caretakers around the documentation framework, the significance of reporting nursing care, and the need for support from nursing pioneers. The aim of this study is to analyze the effect of nursing process training on the quality of nursing care documentation.
Methods: The research to be conducted uses a pre-experiment design research design with a one-group pre-post test-only model consisting of one intervention group. Data collection will be carried out from October to November 2023 in the inpatient room at the hospital. The population in this study was 486 nurses in Surakarat City. The sample was determined based on simple random sampling, so 82 nurses were selected.
Results: The results of statistical tests explain that the value is -48.538 (t≠0). The t value can illustrate that there is a difference in the average score between the pre-test and post-test, where the average pre-test score (69.40) is smaller than the average post-test score (90.57) with a significant value ( p) = 0.000 (p<0.05). The pre-test score (69.40) is smaller than the average post-test score (90.57), with a significance value (p) = 0.000 (p<0.05).
Conclusion: Nursing process training has been proven to be effective in influencing the documentation of the nursing process. It is recommended that health institutions provide ongoing training for nurses, not just as a one-time event.
Article Details
References
Agustina, A. M., Pranatha, A., & Puspanegara, A. (2021). Faktor faktor yang berhubungan dengan pelaksanaan asuhan keperawatan berbasis sdki, slki dan siki di rumah sakit kuningan medical center kabupaten kuningan tahun 2021. Jurnal Ilmu Kesehatan Bhakti Husada: Health Sciences Journal, 12(2), 149–159. https://doi.org/10.34305/jikbh.v12i2.325
Asmirajanti, M., Hamid, A. Y. S., & Hariyati, R. T. S. (2019). Nursing care activities based on documentation. BMC Nursing, 18(32), 1–5. https://doi.org/10.1186/s12912-019-0352-0
Benawan, S., Citraningtyas, G., & Wiyono, W. I. (2019). Faktor penyebab medication error pada pelayanan kefarmasian rawat inap bangsal anak rsud tobelo. Pharmacon, 8(1), 159–167.
Bolado, G. N., Ayalew, T. L., Feleke, M. G., Haile, K. E., & Geta, T. (2023). Documentation practice and associated factors among nurses working in public hospitals in Wolaita Zone, Southern Ethiopia. BMC Nursing, 22(1), 1–11. https://doi.org/10.1186/s12912-023-01490-8
Chiappinotto, S., & Palese, A. (2022). Unfinished nursing care reasons as perceived by nurses at different levels of nursing services: Findings of a qualitative study. Journal of Nursing Management, 30(7), 3393–3405. https://doi.org/10.1111/jonm.13800
Collins, S. A., Cato, K., Albers, D., Scott, K., Stetson, P. D., Bakken, S., & Vawdrey, D. K. (2013). Relationship between nursing documentation and patients’ mortality. American Journal of Critical Care, 22(4), 306–313.
Erna, N. K., Dewi, N. L. P. T., & Azis, A. (2020). Kepatuhan Perawat dalam Melakukan Dokumentasi Asuhan Keperawatan. Journal of Holistic Nursing and Health Science, 3(1), 17–23.
Fajar, I., Simanjuntak, T. M., & Simanjuntak, Y. T. (2023). The relationship between motivation and performance of implementing nurses in providing nursing care at tuan rondahaim regional hospital pamatang raya simalungun regency. Morfai Journal, 2(4), 896–902.
Ghozali, I. (2011). Aplikasi analisis multivatiate dengan program IBM SPSS 19 [Application of Multivariate Analysis with IBM SPSS 19 Program]. Badan Penerbit Universitas Diponegoro.
Hussein, S. Z., Khalip, N., Hashim, R., Harun, R., & Fazilah, N. F. (2021). Patient care delivery: electronic nursing documentation in malaysia. Makara Journal of Health Research, 25(2), 101–106. https://doi.org/10.7454/msk.v25i2.1288
Janggeng, A., Sianturi, S. R., & Lina, R. N. (2022). Knowledge and Attitude of Nurses with Computerized Based Nursing Care Documentation. Media Keperawatan Indonesia, 5(4), 267. https://doi.org/10.26714/mki.5.4.2022.267-273
Jaya, K., Mien, & Rasmiati, K. jaya1, M. K. R. S. (2019). Gambaran pendokumentasian asuhan keperawatan di ruang rawat inap rsud buton utara. Jurnal Keperawatan, 2(3), 27–36. https://stikesks-kendari.e-journal.id/JK
Jumiati, Usman, S., & Kamil, H. (2020). The Influence of Nursing Process and Documentation Training on Implementing of Nursing Process Documentation In Bireuen District Hospital. EAS Journal of Nursing and Midwifery, 2(2), 122–128. https://doi.org/10.36349/easjnm.2020.v02i02.003
Kartini, M., & Ratnawati, E. (2022). Efektivitas Pelatihan Dokumentasi Keperawatan terhadap Pengetahuan Perawat Mengenai SDKI, SLKI, dan SIKI. Jurnal Kesehatan, 11(1), 2721–8007.
Kholifah, S., & Asda, P. (2022). Knowledge and training of nurse influence the quality of nursing documentation. Majalah Ilmu Keperawatan Dan Kesehatan Indonesia, 11(1), 62–72.
Lagarija, S. C., Hasanica, N., Tukulija, S., Brankovic, S., Mahmutovic, J., Galic, D., Peric, K., Cajdric, S., Mujacic, S., Slijepcevic, S., Mrakic, E., & Dervisevic, E. (2020). Evaluation of nursing documentation: The experience of nurses from the primary and secondary/tertiary health care. Journal of Health Sciences, 10(3), 234–240. https://doi.org/10.17532/JHSCI.2020.1086
Lee, T.-T. (2005). Nursing diagnoses: factors affecting their use in charting standardized care plans. Journal of Clinical Nursing, 14(5), 640–647.
Lotfi, M., Zamanzadeh, V., Khodayari-Zarnaq, R., & Mobasseri, K. (2021). Nursing process from theory to practice: Evidence from the implementation of “Coming back to existence caring model” in burn wards. Nursing Open, 8(5), 2794–2800. https://doi.org/10.1002/nop2.856
Manuhutu, F., Novita, R. V. T., & Supardi, S. (2020). Pendokumentasian asuhan keperawatan oleh perawat pelaksana setelah dilakukan pelatihan supervisi kepala ruang di rumah sakit x, kota ambon. Jurnal Ilmiah Perawat Manado (Juiperdo), 8(1), 171–191. https://doi.org/10.47718/jpd.v8i01.1150
Nahak, M. P. M. (2023). The Effectiveness of Nursing Documentation Training Using Technical Guideline on Nursing Documentation skills in Nursing Students at Universitas Timor. Jurnal Ilmiah Keperawatan (Scientific Journal of Nursing), 9(1), 130–139.
Namadi-Vosoughi, M., Zamanzadeh, V., Valizadeh, L., Lotfi, M., Ghahramanian, A., Pourmollamirza, A., Taleghani, F., Bagheriyeh, F., & Avazeh, M. (2023). The impact of institutionalizing the nursing process based on TPSN model on the quality and quantity of nursing diagnoses. Nursing Open, 10(8), 5560–5570. https://doi.org/10.1002/nop2.1796
Nool, I., Tupits, M., Parm, L., Raudsepp, V., & Peralaan, M. (2024). Nursing Diagnoses and Impact of Training on the Quality of Nursing Documentation in Nursing Care Clinic. Biomedical Journal of Scientific & Technical Research, 54(3), 45909–45917. https://doi.org/10.26717/BJSTR.2024.54.008553
Nurhilalahi. (2010). Pengaruh pelatihan proses keperawatan terhadap pendokumentasian proses keperawatan di ruang perawatan interna rsud prof. H. M. Anwar makkatutu bantaeng [Skripsi]. Universitas Islam Negeri Alauddin Makassar.
Purwandari, R., Kurniawan, D. E., & Kotimah, S. K. (2022). Nursing Documentation in Accredited Hospital. Jurnal Keperawatan Indonesia, 25(1), 42–51. https://doi.org/10.7454/jki.v25i1.1139
Rahman, A. I. A. El, Ibrahim, M. M., & Diab, G. M. (2021). Quality of nursing documentation and its effect on continuity of patients’ care. Menoufia Nursing Journal, 6(2), 1–18. https://menj.journals.ekb.eg
Rendana, A., & Muharni, S. (2023). Pengaruh pelatihan 3s (sdki, siki, slki) terhadap pengetahuan perawat dalam pendokumentasian asuhan keperawatan di UPTD Puskesmas Mantang. Jurnal Nursing Update, 14(2), 34–45.
Risnawati, Herman, A., Kurniawan, F., Shafwan, A., & Hermanto. (2023). Dokumentasi Keperawatan. Eureka Media Aksara.
Saputra, M. A. (2018). The Influence of Nursing Care Documenting Behavior to the Completeness of Nursing Care Documentation at Hospital X. Jurnal Medicoeticolegal Dan Manajemen Rumah Sakit, 7(2), 170–177. https://doi.org/10.18196/jmmr.7270
Sege, M., Dedi, B., & Tukayo, I. J. H. (2022). The influence of the design of nursing care documentation design sdki, slki, siki (3s) in hospital management information systems on nurse satisfaction at dian harapan jayapura hospital. Journal of Social Science, 3(6), 2073–2080. https://doi.org/10.46799/jss.v3i6.436
Siokal, B. (2021). Effectiveness of computer-based nursing documentation in nursing care in hospital-a literature review. Journal of Muslim Community Health, 2(2), 15–22.
Sugiyono. (2013). Metode penelitian kuantitatif, kualitatif dan r&d (19th ed.). Alfabeta.
Supratti, & Ashriady. (2018). Pendokumentasian standar asuhan keperawatan di rumah sakit umum daerah mamuju. Jurnal Kesehatan Manarang, 2(1), 44. https://doi.org/10.33490/JKM.V2I1.13
Tamir, T., Geda, B., & Mengistie, B. (2021). Documentation practice and associated factors among nurses in harari regional state and dire dawa administration governmental hospitals, eastern ethiopia. Advances in Medical Education and Practice, 12, 453–462. https://doi.org/10.2147/AMEP.S298675
Tasew, H., Mariye, T., & Teklay, G. (2019). Nursing documentation practice and associated factors among nurses in public hospitals, Tigray, Ethiopia. BMC Research Notes, 12(1). https://doi.org/10.1186/s13104-019-4661-x
Washilah, W., Suhartini, T., & Hadi, W. N. (2023). Analisis faktor yang mempengaruhi kualitas dokumentasi keperawatan. Media Husada Journal of Nursing Science, 4(1), 36–42. https://mhjns.widyagamahusada.ac.id
Widiastuti, E., Zuryati, M., Asep Sunandar, M., & Setiyono, E. (2024). Determinan mutu pelayanan keperawatan terhadap kepuasan pasien di rumah sakit islam jakarta cempaka putih. Jurnal Ilmiah Keperawatan, 10(1), 47–63.