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Asian Journal of Healthy and Science
p-ISSN: 2980-4302
e-ISSN: 2980-4310
Vol. 2 No. 5 May 2023
THE KNOWLEDGE OF THE NURSE AND THE HEAD OF ROOM
SUPERVISION INFLUENCES THE IMPLEMENTATION OF NURSING
CARE DOCUMENTATION
Kori Limbong, Yulianti Kristiani Banhae, Fransiskus S. Onggang, Thomas Laga
Boro
Poltekkes Kemenkes Kupang, Kupang, Indonesia
Email: cor_limb@yahoo.com, yulianti.banhae@gmail.com,
lagathomas784@gmail.com, fransiskussalesiusonggang@gmail.com
Abstract
Nursing care documentation is a very important part of nursing services because
documentation has responsibilities and responsibilities that are very important for
nurses in carrying out nursing care. Knowing the influence of the knowledge of
nurses and supervise of the head of the room on the implementation of nursing care
documentation at the National Police Hospital, Drs. Titus Uly Kupang. This
research is a quantitative research with a cross sectional approach. The population
is all nurses in the inpatient room of Drs. Titus Uly Kupang Police Hospital totaling
48 people with the sample being the total population. The analysis used for univariate
analysis is frequency distribution analysis in the form of tables and for bivariate
analysis using the Chi Square test to see the relationship between nurse knowledge
and the supervision of the head of the room with the implementation of nursing care
documentation in the inpatient room of the Drs. Titus Uly Kupang Police Hospital.
The results of the univariate analysis showed that most of the documentation of
nursing care in the inpatient room of Drs. Titus Uly Kupang Police Hospital was in
the good category, only for 100% of nurses did not perform. Bivariate analysis shows
that there is a relationship between knowledge and the implementation of nursing
care documentation (p value 0.037), there is a relationship between the supervision
of the head of the room and the implementation of nursing care documentation (p
value 0.031) in the inpatient room of the Drs. Titus Uly Kupan Police Hospital
Knowledge and supervision of the head of the room affect the implementation of
nursing care documentation, so this is a concern for management to improve nursing
care documentation.
Keywords: Knowledge; Head of Room Supervision; Nursing Care Documentation;
Nurse
INTRODUCTION
Nursing care documentation is a description and result of all nursing actions
performed by nurses during providing nursing care to patients (Nurhidayah, 2014).
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This documentation describes the client's condition from admission to discharge
from the hospital, starting from assessment, diagnosis, planning, implementation to
evaluation (Umar, 2021). Nursing documentation is also a record that can be used as
evidence in legal matters because documentation aims to identify the client's health
status, record assessments, problems, action planning and evaluation (Nursalam,
2014)
The implementation of incomplete nursing documentation will have a negative
impact on nurses as service providers to patients who receive services. Nurses can
face the law if they make mistakes in providing care, and one of the authentic
evidences is the documentation of nursing care itself. Some mistakes/omissions that
nurses often make in nursing actions such as errors in administering blood
transfusions, errors in administering drugs: wrong drugs, wrong doses, and wrong
patients that can endanger the patient's life and also bring nurses to deal with the law
(Amir & Purnama, 2021; Mustikaningsih et al., 2020)
The implementation of nursing care documentation is influenced by several
factors such as the knowledge and supervision of the head of the room (Putra, 2013).
Research by ISWARA,(2020) and Nuryani & Susanti, (2014) said that the knowledge
of nurses affects the implementation of nursing care documentation in hospitals. In
addition to knowledge of other factors that influence the implementation of
documentation of nursing care characteristics
individuals such as education, age, gender, length of service. Nurul recommended to
the management to continue to conduct training, education and socialization to
nurses about nursing care documentation. The results of an initial survey conducted
by researchers at Drs. Titus Uly Hospital Kupang showed that 100 percent of nurses
did not intervene and were asked there were 2 nurses who said that they did not
intervene as long as the implementation was carried out, did not answer correctly
about nursing care procedures, and also 2 nurses said the head of the room rarely
supervised the doquemnation of nursing care. From the background mentioned
above, it became my reference in carrying out research on the relationship between.
The purpose of this study was to determine the relationship between knowledge and
supervision of the head of the room with the implementation of nursing care
documentation in the inpatient room of the National Police Hospital Drs. Titus Uly
Kupang.
RESEARCH METHODS
This type of research is quantitative research with a cross sectional approach Abduh
et al., (2023), namely to analyze the factors that affect the implementation of nursing care
documentation in the inpatient room of the Drs. Titus Uly Kupang Police Hospital, The
population of this study is all nurses in the inpatient room, which is 58 people, with the
sample being the total population. The research was conducted in June – October 2019.
There are 2 independent variables in this study: the learning and vision of the head of the
room and the dependent variable is the implementation of nursing care documentation.
Data collection was carried out using questionnaires for variables that were
distributed directly to respondents for independent variables, while for dependent
variables, researchers made observations from nursing records on patient status.
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Univariate analysis was done with percentage data while bivariate using chi square.
Before the bivariate test is carried out, the analysis begins with a data normality test to
determine the distribution of data. If the data is normally distributed, then the Cut Of Point
used is the mean. Bivariate analysis is used to see the relationship between the dependent
variable and each independent variable. Bivariate analysis using the Chi Square test. If
the Chi Square test results p value < 0.05, Ho is rejected which means there is a
relationship or association between the independent variable and the dependent variable.
Furthermore, independent variables that have a meaningful relationship are included in
the multivariate analysis.
RESULT AND DISCUSSION
Univariate Analysis
a. Distribution of respondents by gender, education level and employment status
Distribution
Table .1
Frequency Distribution of Respondent B characteristics based on age, Jenis
Kelamin, Education Level, Working Period at Drs. Titus Uly Kupang Police
Hospital October 201 9 (n=48)
Variable
Frequency
Percentage
a. Age
< 25 years
25 - 35 yrs
> 35
Total
7
36
5
14,6
75,0
10,4
48
100
b. Gender
Male
Woman
Total
20
28
41,7
58.3
48
100
Education
DIII
Ners
Total
35
13
72,9
27,1
48
100
Period of Service
< 5 yrs
≥ 5 yrs
Total
21
27
43,8
56,2
48
100
Table 1 above shows that most respondents were between 25 – 35 years
old, namely 36 people (75%), the remaining 5 people (10.4%) were aged between
35 years.
Gender data shows that most of the respondents are female, namely 28
respondents (58.3%), the remaining 20 respondents (41.7%) are male.
Based on education level , most of the respondents en DIII were 35
respondents (72.9%), the remaining 13 respondents (27.1%) with Ners education
level.
Last seen from the working period of most respondents, namely 27 (56.2%)
working period more than 35 years and the remaining 21 (43.8 %) working
period less than 5 years.
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b. Descriptive Description of Respondents' Knowledge of Nursing Care
Documentation at Drs. Titus Uly Kupang Police Hospital
Table 2.
Frequency Distribution of Answers Respondent regarding Knowledge and
Documentation of Nursing Care at Drs. Titus Uly Police Hospital Kupang
October 2019 (n=48)
Variable
Frequency
Percentage
Less
Good
Total
20
28
41,6
58,3
48
100
Table 2 above shows that most have good knowledge of nursing care
documentation, i.e. 28 people (58.3%) the remaining 20 people (41.6%) have
knowledge not good.
c. Descriptive Description of Respondents' Answers about the Supervision of the
Head of the Room on Nursing Care Documentation at the National Police
Hospital Drs. Titus Uly Kupang.
Table 3
Descriptive Description of Respondents' Answers about the Supervision of the
Head of the Room on Nursing Care Documentation at the National Police
Hospital Drs. Titus Uly Kupang
Variable
Percentage
Less
Good
Total
54,2
45,8
100
Table 3 above shows that most have fewer attitudes about nursing care
documentation, namely 26 people (54.2%) the remaining 22 people (45.8%) have
good attitudes.
d. Descriptive Description of Mean, Median, Minimum Value, and Maximum
Value of Nursing Care Documentation at Drs. Titus Uly Kupang Police Hospital
Table 4
Description of Respondent’s Answer on Nursing Documentation at Drs. Titus
Uly Police Hospital Kupang October 2019 (n=48)
Assessment
Diagnosis
Planning
Implementation
Evaluation
Dokumaskep
Mean
25.36
11,13
7,02
13,3
7,2
64,04
Median
25,00
11,00
7,00
13,00
7,00
65,00
Min
20,00
9,00
4,00
11,00
5,00
56,00
Max
28,00
13,00
8,00
15,00
8,00
71,00
Primary data sources, 2015
The median documentation score tonurses as a whole was 65.00 with the
minimum score being 56.00 and the maximum score being 71.00 . If the score
is < from the median, it is categorized as poor documentation, otherwise if the
total score is > median, it is categorized as good documentation.
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e. Overview of the Implementation of Nursing Care Documentation
Table 5
Frequency Distribution of Answers Respondent about Nursing Care
Documentation at RSUD S.K. Kupang October 2018 (n=45)
Frequency
Percent
Not Good
19
39,6
Good
29
60,4
Total
45
100
Table 5 above shows that most of the respondents namely 29 (60.4%) did
well in nursing documentation and the remaining 19 respondents (39.6%) were
not good.
Nursing documentation is a record that contains all data needed to
determine nursing diagnosis, nursing planning, nursing actions, and nursing
assessments that are compiled systematically, validly, and morally and legally
accountable (Sebayang, 2020). According to Asmadi, (2020), documentation is a
statement about authentic events or activities by making written records. Nursing
documentation contains the results of nursing activities carried out by nurses on
clients, from assessment to evaluation.
The results of this study showed that most of the respondents, namely 25
(55.6%) did well in nursing documentation and the remaining 20 respondents
(44.4%) were not good.
The results of this study are supported by Sitinjak, (2016) which shows that
most of the nursing care documentation is in the good category, namely 92.65%,
Solawati et al., (2014) research 73.2% complete documentation. However, it is
not in line with Nellisa et al., (2022) which says that 76.3% of care documentation
is in the sufficient category.
The quality of nursing care documentation at the National Police Hospital
Drs. Titus Uly Kupang is mostly in the good category because of the
commitment of the management of the National Police Hospital Drs. Titus Uly
Kupang to improve the quality of nursing care to improve quality nursing
services. This commitment is evidenced by the implementation of a workshop
on the preparation of Nursing Care Standards in early 2018.
Bivariate Analysis
a. The Relationship Between Knowledge and the Implementation of Nursing Care
Documentation
Table 6
The Relationship between Knowledge and Implementation of Nursing Care
Documentation at Drs.Titus Uli Kupang Police Hospital October 2019 (n=48)
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Nursing
Documentation
Total
Sig
less
good
0.037
Lack of Knowledge
Good
21
22
43
0
5
5
Total
21
27
48
The table 6 above shows the results of the analysis obtained p value: 0.037
which means that there is a relationship between nurse knowledge and the
implementation of nursing care documentation.
This research is in line with the results of ISWARA, (2020) research saying
that nurses' knowledge affects the implementation of nursing care documentation
in hospitals. In addition to knowledge of other factors that affect the
implementation of nursing care documentation, individual characteristics such as
education, age, gender, length of service. This research is also in line with
research entitled the Nuryani & Susanti, (2014) relationship between nurse
knowledge and completeness of filling out nursing care documentation with the
results P = 0.001. Nurul recommended to the management to continue to conduct
training, education and socialization to nurses about nursing care documentation.
Table 7
The Relationship between Supervision and Implementation of Nursing Care
Documentation at Drs.Titus Uly Kupang Police Hospital October 2019 (n=48)
Nursing
Documentation
Total
Sig
less
good
0.031
Less Supervision
Good
16
11
27
5
16
21
Total
21
27
48
The table 7 above shows the results of the analysis obtained p value: 0.031
which means that there is a relationship between the supervision of the head of the
room and the implementation of nursing care documentation.
Supervision of the head of the room is one of the factors that greatly affects
the quality of management in the treatment room because the supervision of the
head of the room is one of the directing functions that cannot be separated from
nursing management. The results of this study are in line with the research entitled
The Nurhayati (2022) Relationship between Nurse Characteristics and the
Implementation of Head of Room Supervision with Nursing Documentation in
the Inpatient Room of Raden Mattaher Hospital, Jambi Province. Nurhayati,
(2022) gave recommendations to management so that management facilitates the
provision of guidance and training gradually for nurses who still have a new
working period in the implementation of askep documentation, as well as
increasing supervision to the implementation of nursing care.
CONCLUSION
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There is a relationship between the knowledge and supervision of the head of
the room with the implementation of nursing care documentation in the inpatient
room of the Drs Police Hospital . Titus Uly Kupang.
BIBLIOGRAPHY
Abduh, M., Alawiyah, T., Apriansyah, G., Sirodj, R. A., & Afgani, M. W. (2023).
Survey Design: Cross Sectional Dalam Penelitian Kualitatif. Jurnal Pendidikan
Sains Dan Komputer, 3(01), 31–39.
Amir, N., & Purnama, D. (2021). Perbuatan Perawat Yang Melakukan Kesalahan
Dalam Tindakan Medis. Kertha Wicaksana, 15(1), 26–36.
Asmadi, A. (2020). Konsep Dasar Keperawatan (108). Stikes Perintis Padang.
Iswara, A. (2020). Hubungan Pengetahuan Perawat Dalam Dokumentasi Asuhan
Keperawatan Dengan Pelaksanaan Di Rumah Sakit.
Mustikaningsih, D. A., Fatmawati, A., & Suniati, N. (2020). Pelaksanaan
Perencanaan Pulang Oleh Perawat. Jurnal Kepemimpinan Dan Manajemen
Keperawatan, 3(2), 45–53.
Nellisa, D., Rachmah, R., & Mahdarsari, M. (2022). Pendokumentasian
Keperawatan Di Ruang Rawat Inap Rumah Sakit. Jurnal Ilmiah Mahasiswa
Fakultas Keperawatan, 1(4).
Nurhayati, C. (2022). Hubungan Tingkat Pengetahuan Tentang Diabetes Melitus,
Self Management Dengan Kualitas Hidup Pada Pasien Diabetes Melitus Tipe
2. Journal Of Nursing And Health Science, 1(2), 58–65.
Nurhidayah, N. (2014). Manajemen Model Asuhan Keperawatan Profesional
(Makp) Tim Dalam Peningkatan Kepuasan Pasien Di Rumah Sakit. Jurnal
Kesehatan Uin Alauddin, 7(2), 137579.
Nursalam, D. (2014). Manajemen Keperawatan" Aplikasi Dalam Praktik
Keperawatan Profesional. Salemba Medika.
Nuryani, N., & Susanti, D. D. (2014). Hubungan Pengetahuan Perawat Dengan
Kelengkapan Dokumentasi Asuhan Keperawatan Di Rsud Dr. Soekardjo Kota
Tasikmalaya. Jurnal Manajemen Informasi Kesehatan Indonesia (Jmiki), 2(2).
Putra, O. (2013). Faktor-Faktor Yang Berpengaruh Terhadap Pelaksanaan
Pemberantasan Sarang Nyamuk (Psn) Di Kelurahan Sawojajar Dalam
Pencegahan Demam Berdarah Dengue. Universitas Brawijaya.
Sebayang, I. D. B. (2020). Pengantar Keperawatan Keluarga.
Sitinjak, C. (2016). Envious Increasing Student’s Academic Performance.
Proceeding From The Asean Conference: 2nd Psychology &
Humanity,“Optimalizing Human Strenght For Productivity And Well Being,
716–722.
Solawati, T., Aeni, Q., & Sulistiyowati, D. (2014). Gambaran Kinerja Perawat
Dalam Dokumentasi Asuhan Keperawatan. Jurnal Ilmiah Permas: Jurnal
Ilmiah Stikes Kendal, 4(1), 16–21.
Umar, Y. (2021). Gambaran Kelengkapan Dokumentasi Keperawatan Di Ruang
Rawat Inap Rumah Sakit Umum Daerah Otanaha Kota Gorontalo=
Description Of Completeness Of Nursing Documentation In Inpatient Room
Of General Hospital, Otanaha Region, Gorontalo City. Universitas
Hasanuddin.
https://ajhsjournal.ph/index.php/gp 239
Copyright holders:
Kori Limbong, Yulianti Kristiani Banhae, Fransiskus S. Onggang, Thomas Laga
Boro (2023)
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AJHS - Asian Journal of Healthy and Science
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