Transformational leadership improves nursing documentation self-efficacy

Abstract

The quality of nursing services in hospitals can be improved with the quality of nursing documentation. Good nursing documentation can improve a problem, whereas bad documentation can lead to misunderstandings and noncompliance with standards. Nurses who have high self-efficacy in completing nursing documentation are more diligent when tending to their duties.1 Those with low self-efficacy regarding nursing documentation display low self-confidence, are pessimistic, and may skip important patient-care steps.2 According to Ngongo, over half (52%) of nurses with good performance have good self-efficacy.2 Self-efficacy is an individual behavior governed by each nurse; weak self-efficacy affects a nurse's ability to perform. However, a nurse's self-efficacy can't be entirely separated from nursing leadership style. Transformational leadership can identify a person's potential, as well as enhance employees' sense of satisfaction in their work.3 Nursing services require effective leadership to enact the changes required by nursing leadership and see an improvement in the quality of the nurses' performance. These goals demand, among other things, a change in the methods nurses use to problem solve while carrying out their duties. A transformational head nurse can influence the work environment in this way and provide positive support for staff.4 A transformational leadership style can also increase job satisfaction by rewarding nursing innovation. Part of a nursing supervisor's duties is to ensure the quality of their staff's work.5,6 The application of a transformational leadership style can improve the patient safety culture and lead to better management of nursing resources.7-9 Another factor related to self-efficacy is experience. The more mature an employee, the better their self-efficacy, because sufficient experience often means that they are better at solving problems.11 Some research shows that men may be more competitive than women when it comes to nursing documentation.12 The education and career levels of nurses also affect their competency. A nurse with a bachelor's degree may feel more confidence in their abilities compared with diploma-prepared nurses.13 However, more formal education or bachelor's degrees that aren't balanced with continuing education such as training can also affect self-efficacy. There's a strong relationship between work experience, a nurse's abilities, and skills in relation to completing nursing services.14 The results of a preliminary study of government hospitals in Indonesia showed that 8 of 10 nurses had low abilities in relation to completing nursing documentation up to current standards. Results of audits on nursing documentation showed that only 61% of nursing documentation was up to standard. Further findings confirmed that the role and leadership style of the head nurse regarding nursing documentation wasn't optimal. These results are similar to a study by Purwandi et al., which found that the quality of nursing documentation was poor, with an average achievement of 80.81%.15 Poor quality in nursing documentation was influenced by nurses' self-efficacy. Methods This study used a quantitative approach with a cross-sectional design. Sampling was done using the purposive sampling technique. The inclusion criteria: 1) nurse associates, with a minimum of a diploma degree, and 2) nurses had worked in the same service for at least 3 months. Nurses who were on annual and sick leave were excluded. This study was conducted in April 2022 in government hospitals in Indonesia. Data collection was completed with two questionnaires using a 5-point Likert-type scale for measurement. The first questionnaire included 16 statements to measure four tranformational leadership style dimensions: 1) idealized influence, 2) inspirational motivation, 3) intellectual stimulation, and 4) individualized consideration. The second questionnaire addressed self-efficacy on nursing documentation with 12 statements measuring four self-efficacy dimensions: 1) mastery experience, 2) models behavior, 3) persuasion from others, and 4) assessment of physical and emotional. This research collected information anonymously and required voluntary informed consent from the participants. A research ethics permit was obtained from the Ethics Committee Faculty of Nursing Universitas Indonesia with approval number Ket-07/UN2. F12D1.2.1/PPM.00.02/2022. Results Researchers achieved a total sample size of 159 nurses. The research questionnaires were tested using Cronbach alpha: the validity of the transformational leadership questionnaire was 0.961, and the validity of the nurse's self-efficacy on nursing documentation questionnaire was 0.945. Table 1 shows the distribution and frequency of nurses' demographic characteristics (age, gender, education level, clinical nurse level, experience, and certificate in nursing documentation). The majority of respondents were age 25 to 44 years (n = 133, 83.6%) and most were women (n = 111, 69.8%). Most respondents had a diploma degree (n = 68.6%) and worked as a novice nurse (n = 67, 42.2%). The majority had worked 2 or more years (n = 105, 66.0%) and didn't have a certificate in nursing documentation (n = 104, 65.4%). Table 1: - Respondent demographics at X Depok Hospital (N = 159) Variable Frequency (%) Age <25 Years 21 (13.2%) 25-44 Years 133 (83.6%) >44 Years 5 (3.1%) Total 159 (100.0%) Gender Male 48 (30.2%) Female 111 (69.8%) Total 159 (100.0%) Education Level Diploma 3 109 (68.6%) Bachelor/Professional degree 50 (31.4%) Total 159 (100.0%) Job Level Clinical Nurse 1 67 (42.1%) Clinical Nurse 2 46 (28.9%) Clinical Nurse 3 44 (27.7%) Clinical Nurse 4 2 (1.3%) Total 159 (100.0%) Experience ≤2 Years 54 (34.0%) >2 Years 105 (66.0%) Total 159 (100.0%) Documentation Training No 104 (65.4%) Yes 55 (34.6%) Total 159 (100.0%) Table 2 shows the distribution and frequency of the transformational leadership style; the majority of head nurses had a low transformational leadership style (n = 85, 53.5%) and high self-efficacy (n = 80, 50.3%). Table 2: - Transformational leadership style and self-efficacy of nurses on nursing documentation (N = 159) Variable Frequency (%) Transformational leadership style Low 85 (53.5%) High 74 (46.5%) Total 159 (100.0%) Self-efficacy on nursing documentation Low 80 (50.3%) High 79 (49.7%) Total 159 (100.0%) Table 3 shows the results of bivariate analysis (χ2), which indicates there's a relationship between gender (P = .043), certificate in nursing documentation (P = .015), the transformational leadership style of the head nurse (P = .000), and self-efficacy regarding nursing documentation. There was no relationship between age and self-efficacy of the nurse regarding nursing documentation (P = .385), education level and self-efficacy (P = .639), clinical path and self-efficacy (P = .975), or work experience and self-efficacy (P = .051). Table 3: - Results of bivariate analysis (N = 159) Self-efficacy of nurses in nursing documentation Variable Low High Total P Age <25 years 10 (47.6%) 11 (52.4%) 21 25-44 years 65 (48.9%) 68 (51.1%) 133 >44 years 4 (80.0%) 1 (20.0%) 5 Total 79 (49.7%) 80 (50.3%) 159 .385 Gender Male 18 (22.8%) 30 (37.5%) 49 Female 61 (55.0%) 50 (45.0%) 111 Total 79 (49.7%) 80 (50.3%) 159 .043∗ Level of Education Diploma 3 53 (48.6%) 56 (51.4%) 109 Bachelor/professional degree 26 (52.0 %) 24 (48.0%) 50 Total 79 (49.7%) 80 (50.3%) 159 .693 Clinical Nurse Clinical nurse 1 32 (47.8%) 35(52.5%) 67 Clinical nurse 2 24 (52.2%) 22 (47.8%) 46 Clinical nurse 3 22 (50.0%) 22 (50.0%) 44 Clinical nurse 4 1 (50.0%) 1 (50.0%) 2 Total 79 (49.7%) 80 (50.3%) 159 .975 Experience ≤2 years (new) 21 (38.9%) 33 (61.1%) 54 >2 years (experienced) 58 (55.2%) 47 (44.8%) 105 Total 79 (49.7%) 80 (50.3%) 159 .051 Documentation training No 59 (56.7%) 45 (43.3%) 104 Yes 20 (36.4%) 35 (63.6%) 55 Total 79 (49.7%) 80 (50.3%) 159 .015∗ Transformational leadership style Low 59 (69.4%) 26 (30.6%) 85 High 20 (27.0%) 54 (73.0%) 74 Total 79 (49.7%) 80 (50.3%) 159 .000∗ ∗P < .05. Table 4 shows the results of the multiple logistic regression model on the transformational leadership style analysis (P = .000). The most dominant variable is the variable with the largest odds ratio at the end of the modeling. It can thus be concluded that the transformational leadership style variable is the variable with the largest effect on nursing self-efficacy (OR, 6.156, beta = 1.817) after controlling for the other variables of gender, experience, and certificate in nursing documentation. Table 4: - Multivariate model Variable Early modeling Fit modeling P OR P OR Age .431 0.752 - - Gender .045∗ 0.492 .084 0.486 Level of education .693 1.145 - - Clinical nurse .937 1.013 - - Experience .052∗ 0.516 .460 0.733 Certificate in nursing documentation .016∗ 2.994 .129 1.497 Transformational leadership style .000∗ 6.127 .000 6.156 ∗P > .05 Discussion The results of this study show that there's no relationship between age and nurse self-efficacy regarding nursing documentation. This is contrary to the authors' hypothesis that the more mature a person is, the higher their self-efficacy. The more mature a person is in age, the more developed their thinking, the greater their ability to consider different perspectives, and the better their ability to solve problems when compared with adolescence.16 However, the results of this study indicate that there's a relationship between gender and the self-efficacy of nurses regarding nursing documentation. Female nurses tend to have better social interactions and higher self-efficacy when compared with male nurses. This is contrary to the research conducted by Handiyani, which stated that men have high self-efficacy.14,17 However, other research shows that men have good self-efficacy in conveying information or making decisions.12 Men may also be more competitive, thus supporting the idea that gender differences affect efficacy.18 The results also indicate that there's no relationship between the nurses' level of education and self-efficacy. Diploma degree nurses have good self-efficacy when compared with nurses with a professional nursing degree (bachelor's degree). This is again contrary to the authors' hypothesis that a person with a high degree of formal education (bachelor's degree) will feel more confident in doing their job than someone lacking advanced formal education. Subsequently, it appears continuing education is extremely important when it comes to gaining new knowledge or experience because it allows the practitioner to apply theory and practice in hospitals.19 The results also showed that there was no relationship between career path and self-efficacy; in fact, nurses with lower career levels have better abilities. This is contrary to other research, which states that the more advanced the nurse's career, the better their self-ability. Nurses in nursing services are required to have competence, professionalism, and good self-efficacy; high self-efficacy affects a nurse's professional identity.20,21 Most novice nurses reported high self-efficacy on nursing documentation. The researchers assume that high-level careers that aren't balanced with continuing education result in low self-efficacy, which affects the quality of nursing documentation.22 Furthermore, no relationship between experience and self-efficacy was found. Contrary to current research, nurses with long tenures didn't have a high self-efficacy compared with beginner nurses. This contradicts the research that states that the length of time nurses have worked leads to better caring provisions, higher service quality, and more knowledge that they can use to make appropriate decisions.23 Much can be done to improve self-efficacy. Mentoring can be provided, with a preceptorship program to increase a nurse's initiative and cognitive skills. As the results show, there's a correlation between the certificate in nursing documentation and self-efficacy. As such, nurses with good self-efficacy are more likely to collect relevant information and therefore make the right decisions.17 Nursing documentation training activities are one of the directive functions in the efforts made to improve self-efficacy.24 The activities of function briefing are under the control of the head nurse, which encompasses intellectual stimulation and inspirational motivation.6 As discussed, the results of this study compared with previous research found a relationship between the transformational leadership style and the self-efficacy of the nurses. A transformational head nurse should have the ability to consider their staff's needs, distribute tasks, manage resources well, and assign nurses tasks according to their abilities to reduce workload and turnover.25 Transformational leaders encourage their staff to be more committed to their roles. The head nurse has an important role in motivating, supervising, fostering a sense of optimism, providing guidance, and assessing abilities or evaluating performance. The appropriate facilities provide staff with the opportunity to produce ideas and be more creative, which in turn leads to nurses who feel more satisfied, and have loyalty and a sense of responsibility toward work. Nurse leaders should recognize that applying a transformational leadership style can lead to strong self-confidence and innovative behavior, ensuring the quality of staff work, motivation, and respect for the job, all of which lead to an improvement in the quality of the work.23 The transformational leadership style must be applied in a manner that is in line with the role of the head nurse, because it's not only an interpersonal role but also involves being a role model, inspiring staff, and liaising among departments. Finally, a head nurse who has properly implemented a transformational leadership style will create opportunities for nurses to increase their self-efficacy.24 Recommending transformational leadership This study indicates that there's no relationship between age, experience, education level, or career path and the self-efficacy of nurses in carrying out nursing documentation. In contrast, gender, certificate in nursing documentation, and the transformational leadership style of the head nurse do have a relationship with self-efficacy. The head nurse's transformational leadership style was the most dominant variable. It's therefore recommended that a transformational leadership style be implemented by all nursing service managers. Furthermore, nurses' career path or clinical level should be optimized by facilitating continuing nurse education. Future studies could investigate each variable individually and perhaps look at other research designs to improve the transformational leadership style in nursing services.