Improving documentation of patient progress note through role empowerment of head nurse by Orlando theory approach

Abstract

This study aimed to identify the effect of role empowerment of head nurse by Orlando theory approach on the implementation of progress note documentation. This study used pilot study approach in which the research process started from developing module of role empowerment of head nurse, implementing of role empowerment of head nurse on in patient ward and then followed by evaluating head nurse competencies through the use of observation sheet and patient progress note. Pre-experiment design with one group pretest-posttest without control was used to evaluate the effectiveness of the intervention, and 115 progress notes were selected through cluster sampling technique which then analyzed by Wilcoxon, Spearman and Kruskal-Wallis test. There was a significant quality improvement of the implementation of progress note recording following the intervention of head nurses' role empowerment by Orlando theory approach (p=0.0001; α=0.025). Nurse Staff competencies in documenting progress note were improved significantly through the role empowerment of head nurse by Orlando theory approach. Development of policy, supervision, evaluation, and monitoring by nurse manager are necessary, as well as organizing a workshop on the application of head nurse's role as manager and implementation of progress note documentation.