COACHING AS A STRATEGY TO ENHANCE NURSING CARE DOCUMENTATION QUALITY

Maria Tarisia Rini, Dheni Koerniawan, Srimiyati Srimiyati

Sari


Introduction: Nursing care documentation serves as the cornerstone of effective interprofessional communication, continuity of care, and patient safety, continuity of care, and defensible legal practice. Despite its important role, the quality of nursing care documentation remains a constant challenge in various clinical settings. While traditional methods for improving nursing documentation can result in some initial improvements, they often fail to achieve sustained and meaningful change.  Given these persistent problems, coaching became one of the innovative strategies to improve nursing documentation practices and foster a culture of continuous improvement in healthcare settings. Purpose: This study aims to explore the effectiveness of coaching as a strategy to improve the quality of nursing care documentation. Method: 16 nursing documentation measures used the Q-DIO before-after coaching implementation. Collected data in this study analyze using Wilcoxon test to find significance of the difference before-after measurements. Result: The study found that there was improvement in each dimension of nursing documentation quality as measured by the Q-DIO instrument, and that the dimensions significantly differed in overall quality (p<0.001). Discussion: Therefore, further implementation of the coaching method with longer and more intermittent sequences gives certain promise as an alternative strategy for enhancing the quality of nursing care documentation in the future.


Teks Lengkap:

PDF (English)

Referensi


Akhu-Zaheya, L., Al-Maaitah, R. and Bany Hani, S. (2018) ‘Quality of nursing documentation: Paper-based health records versus electronic-based health records’, Journal of Clinical Nursing, 27(3–4), pp. e578–e589. Available at: https://doi.org/10.1111/jocn.14097.

Anggariswa et al. (2024) ‘The Implementation of Nursing Diagnosis Based on Indonesian Nursing Diagnosis Standard: Retrospective Study’, Galore International Journal of Health Sciences and Research, 9(2), pp. 36–40. Available at: https://doi.org/10.52403/gijhsr.20240205.

Arthurs, K. et al. (2017) ‘A culture of nursing excellence: A community hospital’s journey from Pathway to Excellence® to Magnet® recognition’, Journal of Nursing Education and Practice, 8(5), p. 26. Available at: https://doi.org/10.5430/JNEP.V8N5P26.

Ballengee, L.A. et al. (2022) ‘Effectiveness of Quality Improvement Coaching on Process Outcomes in Health Care Settings: A Systematic Review’, Journal of General Internal Medicine, 37(4), pp. 885–899. Available at: https://doi.org/10.1007/S11606-021-07217-2.

Belal, G.A.E.-S., EL-Said, F.M. and Elkhawaga, D.S. (2024) ‘Effect of Structured Based Training on Nurses’ knowledge and practices regarding the Modern Contraceptive Methods’, Egyptian Journal of Health Care, 15(4), pp. 125–140. Available at: https://doi.org/10.21608/EJHC.2024.385328.

Elon, Y. et al. (2018) Teori dan Model Keperawatan. Medan: Yayasan Kita Menulis.

Foba, M., Liforter, K. and Atanga, M. (2024) ‘Nursing Documents and Documentation for Patients with Heart Diseases; Could Be Made Easier’, Global Journal of Critical Care and Emergency Medicine, 1(2). Available at: https://doi.org/10.33425/3065-5641.1007.

Frisca, S. et al. (2022) Penelitian Keperawatan. Medan: Yayasan Kita Menulis.

Harding, M., Troyer, S. and Bailey, M. (2014) ‘Using courtroom simulation to introduce documenting quality wound care to beginning nursing students’, Nurse Educator, 39(6), pp. 263–264. Available at: https://doi.org/10.1097/NNE.0000000000000078.

Hussain, M., Saddique, H. and Jabeen, R. (2024) ‘Knowledge Attitude and Practices of Nurses Regarding Nursing Documentation’, Biological and Clinical Sciences Research Journal, 5(1), p. 1393. Available at: https://doi.org/10.54112/BCSRJ.V2024I1.1393.

Jedwab, R.M. et al. (2022) ‘Improving the Quality of Electronic Medical Record Documentation: Development of a Compliance and Quality Program’, Applied Clinical Informatics, 13(4), pp. 836–844. Available at: https://doi.org/10.1055/s-0042-1756369.

Kelley, T.F., Brandon, D.H. and Docherty, S.L. (2011) ‘Electronic Nursing Documentation as a Strategy to Improve Quality of Patient Care’, Journal of Nursing Scholarship, 43(2), pp. 154–162. Available at: https://doi.org/10.1111/j.1547-5069.2011.01397.x.

Koerniawan, D., Daeli, N.E. and Srimiyati, S. (2020) ‘Aplikasi Standar Proses Keperawatan: Diagnosis, Outcome, dan Intervensi pada Asuhan Keperawatan’, Jurnal Keperawatan Silampari, 3(2), pp. 739–751. Available at: https://doi.org/10.31539/jks.v3i2.1198.

Koerniawan, D. and Frisca, S. (2023) ‘Factors Determining Commitment to Health-Promoting Behavior During COVID-19’, Jurnal Keperawatan Indonesia, 26(2), pp. 97–106. Available at: https://doi.org/10.7454/jki.v26i2.1130.

Marušić, J. et al. (2020) ‘Health Care Documentation Management in Hospital Conditions’, Journal of applied health sciences, 6(2), pp. 201–218. Available at: https://doi.org/10.24141/1/6/2/3.

Mawarti, H. et al. (2021) Pengantar Riset Keperawatan. Medan: Yayasan Kita Menulis.

McCarthy, B. et al. (2019) ‘Electronic nursing documentation interventions to promote or improve patient safety and quality care: A systematic review’, Journal of Nursing Management, 27(3), pp. 491–501. Available at: https://doi.org/10.1111/jonm.12727.

Müller-Staub, M. et al. (2008) ‘Testing the Q-DIO as an instrument to measure the documented quality of nursing diagnoses, interventions, and outcomes.’, International journal of nursing terminologies and classifications : the official journal of NANDA International, 19(1), pp. 20–27. Available at: https://doi.org/10.1111/J.1744-618X.2007.00075.X.

Müller-Staub, M. et al. (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), pp. 1027–1037. Available at: https://doi.org/10.1111/j.1365-2702.2008.02603.x.

Mykkänen, M., Miettinen, M. and Saranto, K. (2016) ‘Standardized nursing documentation supports evidence-based nursing management’, Studies in Health Technology and Informatics, 225, pp. 466–470. Available at: https://doi.org/10.3233/978-1-61499-658-3-466.

Okaisu, E.M. et al. (2014) ‘Improving the quality of nursing documentation: An action research project’, Curationis, 37(2), pp. E1–E11. Available at: https://doi.org/10.4102/curationis.v37i2.1251.

Purwoto, A. et al. (2023) Sistem Informasi Keperawatan. Padang: GET Press.

Selvi, S.T. (2017) ‘Documentation in Nursing Practice’, International Journal of Nursing Education, 9(4). Available at: https://doi.org/10.5958/0974-9357.2017.00108.8.

Simanjuntak, G.V. et al. (2021) ‘Mengelola Stres di Masa Pandemi Covid-19 Dengan Hipnotis Lima Jari’, Journal of Community Engagement in Health, 4(1), pp. 54–57. Available at: https://doi.org/10.30994/JCEH.V4I1.114.

Solehudin et al. (2024) ‘Analisis Penerapan Manajemen Dokumentasi Asuhan Keperawatan Elektronik’, Jurnal Riset Rumpun Ilmu Kesehatan, 3(1), pp. 235–245. Available at: https://doi.org/10.55606/jurrikes.v3i1.2761.

Tawfik, E.A.M., Mahfouz, H.H.E. and AbdAllah, N.A. (2024) ‘Factors Influencing Effective Documentation and its relation to Patients Safety as Perceived by Staff Nurses.’, Journal of Nursing Science Benha University, 5(2), pp. 168–184. Available at: https://doi.org/10.21608/jnsbu.2024.362188.




DOI: https://doi.org/10.31869/mm.v9i1.7454

Article Metrics

Sari view : 0 times
PDF (English) - 0 times

Refbacks

  • Saat ini tidak ada refbacks.


 Kunjungan Saat ini

Kunjungan Dari Negara

 Flag Counter

 

 

Creative Commons License
Menara Medika is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.