The Effect of Nursing Care Documentation Training Based on Indonesian Nursing Standards

Abstract

Background: Maintain accurate and full nursing documentation to meet patient safety criteria. Evidence links nurse documentation to the hospital setting. Nursing documentation is impacted by patient load, lack of time, and skill and training.Purpose: This study examines the effectiveness of nursing documentation training based on Indonesian Nursing Standards (Diagnosis, Outcome, and Intervention) on nurses' knowledge.Methods: The research method is quasi-experimental with a pre-test post-test design for a single group. Participants in this study are 150 nurses from state-owned hospitals in Jember Regency, East Java. Total sampling was employed as the sampling approach. Data were analyzed using univariate frequency distribution, and bivariate analysis using paired t-test.Results: The average pre-test knowledge was 37.95 and the average post-test knowledge was 66.51. The p-value for the t-test analysis of the data was 0.000 ( 0.05).Conclusions: Effective nursing documentation training enhances nurses' abilities to document nursing care in accordance with the Indonesian Nursing Standards (diagnosis, outcome, and intervention).