What is the problem with nursing documentation? Perspective of Indonesian nurses

Abstract

BackgroundNursing documentation reflects the quality in patient care. It promotes effective communication between caregivers. However, although its significance has been discussed in numerous articles, nursing documentation remains problematic in Indonesia. ObjectiveThis research was the first of its kind in Indonesia which aim to identify issues with nursing documentation. MethodA qualitative approach through focus group discussions (FGD) with head nurses and staff was conducted to identify problems that hinder nurses’ abilities to follow proper documentation procedure in an urban hospital in Indonesia. The nurses who have more than one year work experience were recruited through simple random technique. There were 35 participants involved. The open-ended questions regarding the nursing documentation process were administered. The group discussions were held two times on each teams and conducted separately between the head nurses and their staff. The data for this descriptive qualitative study were recognized through content analysis methods. ResultsThe results of the study were captured in three themes: (1) Inadequate supervision for nurses on nursing documentation; (2) Competency issues in documentation; (3) Lack of confidence and motivation on documentation. ConclusionEducation is amongst the top listed contributing factors for quality nursing documentation. This is confirmed with this research. The findings of the study suggest the need for continuous support and educational intervention to ensure adherence to the nursing documentation procedure.