EFFECT OF NANDA-I, NIC, AND NOC DOCUMENTATION SYSTEM TRAINING ON QUALITY OF NURSING CARE DOCUMENTATION IN THE PERINATAL WARD OF YOGYAKARTA REGIONAL PUBLIC HOSPITAL

Enny Eko Setyaningrum, Intansari Nurjannah, Anik Rustiyaningsih


DOI: https://doi.org/10.33546/bnj.770

Abstract


Background: The existing standard of nursing language consists of NANDA-I for diagnostic language standard, Nursing Intervention Classification (NIC) for nursing intervention, and Nursing Outcome Classification (NOC) for nursing outcomes. One way to improve the quality of nursing care documentation is to provide training in the documentation system.

Objectives: To determine the effect of providing NANDA-I, NIC, and NOC (NNN) nursing care documentation systems training on the quality of nursing documentation.

Methods: This was a pre-experimental study with pretest posttest design without a control group.  Twenty-one nurses and eighty-six Medical Records (MR) of patients who were treated in the perinatal ward of Yogyakarta Regional Public Hospital were used as samples selected using purposive sampling. Those nurses were trained in the nursing care documentation system. The quality of nursing care documentation was measured using modified Quality of Diagnoses, Interventions and Outcomes (Q-DIO) instrument. Data were analyzed using Independent samples t-test with a confidence level of 95%.

Results: The average of the scores of the quality of nursing documentation before training was lower (1.91) than the average after training (2.78). There was a significant difference in the quality of nursing documentation before and after training (p < 0.001).

Conclusion: Training of NNN nursing documentation system could improve the quality of nursing documentation in the perinatal ward of Yogyakarta Regional Public Hospital.


Keywords


Training; nursing documentation; documentation

Full Text:

PDF

References


Adubi, Iyanuoluwa O., Olaogun, Adenike A., & Adejumo, Prisca O. (2017). Effect of standardized nursing language continuing education programme on nurses' documentation of care at University College Hospital, Ibadan. Nursing Open, 5(1), 37-44. https://doi.org/10.1002/nop2.108

Aprisunadi. (2011). Hubungan antara berpikir kritis perawat dengan kualitas asuhan keperawatan di unit perawatan ortopedi Rumah Sakit Umum Pusat Fatmawati Jakarta [The relationship between nurse critical thinking and the quality of nursing care in the orthopedic care unit of Fatmawati Central General Hospital Jakarta]. (Thesis), Faculty of Nursing, Universitas Indonesia, Jakarta.

Aris, A. (2014). Gambaran kinerja perawat dalam dokumentasi asuhan keperawatan [Overview of Nurse's performance in nursing care documentation]. Jurnal Ilmiah Permas: Jurnal Ilmiah STIKES Kendal, 4(1), 16–21.

Bujang, M. A., & Baharum, N. (2017). Guidelines of the minimum sample size requirements for Cohen’s Kappa. Epidemiology Biostatistics and Public Health, 14(2), e12267-12261-e12267-12210. https://doi.org/10.2427/12267

Cartwright-Vanzant, Rachel C. (2010). Medical record documentation: Legal aspects in neonatal nursing. Newborn and Infant Nursing Reviews, 10(3), 134-137. https://doi.org/10.1053/j.nainr.2010.06.008

Chaghari, M., Saffari, M., Ebadi, A., & Ameryoun, A. . (2017). Empowering education: A new model for in-service training of nursing staff. Journal of Advances in Medical Education & Professionalism, 5(1), 26.

Donsu, J. D. T. (2017). Metodologi penelitian keperawatan [Nursing research methodology]. Yogyakarta: Pustaka Baru Press

Efendy, M. A., & Purwandari, R. (2012). Perbedaan tingkat kualitas dokumentasi proses keperawatan sebelum dan sesudah penerapan NANDA-I, Nic, dan NOC [Differences in the quality level of nursing process documentation before and after implementation of NANDA-I, Nic, and NOC]. Jurnal Keperawatan Soedirman, 7(2), 17–23.

Fortney, Christine A., & Steward, Deborah K. (2015). Medical record documentation and symptom management at the end of life in the NICU. Advances in Neonatal Care, 15(1), 48-55. https://doi.org/10.1097/ANC.0000000000000132

Grohmann, Anna, & Kauffeld, Simone. (2013). Evaluating training programs: development and correlates of the Questionnaire for Professional Training Evaluation. International Journal of Training and Development, 17(2), 135-155. https://doi.org/10.1111/ijtd.12005

Jefferies, D., Johnson, M., Nicholls, D., & Lad, S. (2012). A ward-based writing coach program to improve the quality of nursing documentation. Nurse Education Today, 32(6), 647-651. https://doi.org/10.1016/j.nedt.2011.08.017

Kamil, Hajjul, Rachmah, R., & Wardani, Elly. (2018). What is the problem with nursing documentation? Perspective of Indonesian nurses. International Journal of Africa Nursing Sciences, 9, 111-114. https://doi.org/10.1016/j.ijans.2018.09.002

Kaplan, Sena, & Komurcu, Nuran. (2017). Evaluation of effectiveness of health services training given with different methods in combating of intimate partner violence against women: A pilot study. Journal of Family Violence, 32(1), 69-77. https://doi.org/10.1007/s10896-016-9834-y

Karaca, T., & Aslan, S. (2018). Effect of 'nursing terminologies and classifications' course on nursing students' perception of nursing diagnosis. Nurse Education Today, 67, 114-117. https://doi.org/10.1016/j.nedt.2018.05.011

Kim, J., Park, J. H., & Shin, S. (2016). Effectiveness of simulation-based nursing education depending on fidelity: a meta-analysis. BMC Medical Education, 16, 152. https://doi.org/10.1186/s12909-016-0672-7

Lees, L. (2010). Improving the quality of nursing documentation on an acute medicine unit. Nursing Times, 106(37), 22-26.

Li, Alice ML. (2016). Simulation-based clinical skill training to promote effective clinical learning with simulation evaluation rubrics in nursing education. International Journal of Information and Education Technology, 6(3), 237. https://doi.org/10.7763/IJIET.2016.V6.692

Linch, Graciele Fernanda da Costa, Lima, Ana Amélia Antunes, Souza, Emiliane Nogueira de, Nauderer, Tais Maria, Paz, Adriana Aparecida, & da Costa, Cíntia. (2017). An educational intervention impact on the quality of nursing records. Revista latino-americana de enfermagem, 25. https://doi.org/10.1590/1518-8345.1986.2938

McHugh, M. L. (2012). Interrater reliability: the kappa statistic. Biochemia Medica, 22(3), 276-282.

Muller-Staub, M., Lunney, M., Odenbreit, M., Needham, I., Lavin, M. A., & van Achterberg, T. (2009). Development of an instrument to measure the quality of documented nursing diagnoses, interventions and outcomes: the Q-DIO. Journal of Clinical Nursing, 18(7), 1027-1037. https://doi.org/10.1111/j.1365-2702.2008.02603.x

Muller-Staub, M., Needham, I., Odenbreit, M., Lavin, M. A., & van Achterberg, T. (2007). Improved quality of nursing documentation: results of a nursing diagnoses, interventions, and outcomes implementation study. International Journal of Nursing Terminologies and Classifications : , 18(1), 5-17. https://doi.org/10.1111/j.1744-618X.2007.00043.x

Müller‐Staub, Maria, Lunney, Margaret, Odenbreit, Matthias, Needham, Ian, Lavin, Mary Ann, & Van Achterberg, Theo. (2009). Development of an instrument to measure the quality of documented nursing diagnoses, interventions and outcomes: The Q‐DIO. Journal of Clinical Nursing, 18(7), 1027-1037. https://doi.org/10.1111/j.1365-2702.2008.02603.x

Noor, J. . (2011). Metodologi penelitian: Skripsi, tesis, disertasi, dan karya ilmiah [Research methodology: Thesis, thesis, dissertation, and scientific work] (1st ed.). Kharisma Putra Utama: Jakarta.

Nøst, Torunn Hatlen, Frigstad, Sigrun Aasen, & André, Beate. (2017). Impact of an education intervention on nursing diagnoses in free-text format in electronic health records: A pretest–posttest study in a medical department at a university hospital. Nordic Journal of Nursing Research, 37(2), 100-108. https://doi.org/10.1177/2057158516668081

Nursalam. (2011). Manajemen keperawatan : Aplikasi dalam praktik keperawatan profesional (Tiga) [Nursing management: Application in professional nursing practice (Three)]. Salemba Medika: Jakarta.

Rav-Marathe, K., Wan, T. T. H., & Marathe, S. (2016). A systematic review on the KAP-O framework for diabetes ducation and research. Medical Research Archives, 4(1). https://doi.org/10.1097/RCT.0b013e3182a0d05f

Sapyta, Ying Ying, & Eiger, Carmel. (2017). Improving pediatric nurses' knowledge, accuracy, and confidence through code documentation simulation. Clinical Simulation in Nursing, 13(6), 278-283. https://doi.org/10.1016/j.ecns.2017.02.003

Sastroasmoro, S. (2014). Dasar-dasar metodologi penelitian klinis [Basics of clinical research methodology] (5th ed.). Jakarta: Sagung Seto.

Siswanto, L. M. H, Hariyati, R. T. S., & Sukihananto. (2013). Hubungan pengetahuan perawat dalam dokumentasi keperawatan dengan pelaksanaanya di rawat inap RSI Kendal [Relationship between nurses' knowledge in nursing documentation and implementation was hospitalized at RSI Kendal]. Jurnal Keperawatan Indonesia, 16(2), 77–84.

Wang, Ning, Hailey, David, & Yu, Ping. (2011). Quality of nursing documentation and approaches to its evaluation: a mixed‐method systematic review. Journal of Advanced Nursing, 67(9), 1858-1875. https://doi.org/10.1111/j.1365-2648.2011.05634.x

Wilson, S., Hauck, Y., Bremner, A., & Finn, J. (2012). Quality nursing care in Australian paediatric hospitals: a Delphi approach to identifying indicators. Journal of Clinical Nursing, 21(11-12), 1594-1605. https://doi.org/10.1111/j.1365-2702.2011.04004.x

Yeni, F. . (2014). Pengaruh pelatihan proses keperawatan terhadap dokumentasi asuhan keperawatan di Puskesmas Kabupaten Agam Propinsi Sumatera Barat [Effect of nursing process training on nursing care documentation in Agam District Health Center, West Sumatra Province]. Ners Jurnal Keperawatan, 10(1).


Refbacks

  • There are currently no refbacks.




Copyright (c) 2019 Enny Eko Setyaningrum, Intansari Nurjannah, Anik Rustiyaningsih

Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 International License.