Hrev_master Healthcare in Low-resource Settings 2023; volume 11:11756 Relationship between nurses knowledge level and workload about implementation of patient identification Hilda Hilda,1 Arsyawina Arsyawina,1 Supriadi Supriadi,1 Hesti Prawita Widiastuti,1 Annisa Syaputri,1 Joko Sapto Pramono2 1Nursing Study Program, Poltekkes Kemenkes Kaltim, Samarinda; 2Health Promotion Program, Poltekkes Kemenkes Kaltim, Samarinda, Indonesia Abstract Patient safety incidents can originate from patient identifica- tion errors. From the preliminary study, it was found that there were 3 cases of patient identification errors in the year 2022. The objective of this research was to determine the relationship between nurses knowledge level and workload with patient iden- tification implementation. This study employed a quantitative method with a cross-sectional research design. This research aims to analyze the relationship between variables where the indepen- dent variable and dependent variable are identified at one unit of time. In this case, to determine the relationship between the level of knowledge and workload of nurses with the implementation of patient identification. The sample consisted of 93 individuals dis- tributed across the inpatient wards. The research sample was selected used random sampling. The knowledge level and work- load of nurses were independent variables, while the implementa- tion of patient identification was the dependent variable. Data col- lected was used of a level of knowledge, workload, and applica- tion of identification questionnaire. Data analyzed used were with Chi-square test. The obtained p-value for the relationship between nurses knowledge level and the implementation of patient identi- fication is p=0.018 (p<0.05). Therefore, there is a significant rela- tionship between nurses knowledge level and the implementation of patient identification. P-value for the relationship between nurs- es workload and the implementation of patient identification is p=0.564 (p>0.05). This explains that there is no significant rela- tionship between nurses workload and the implementation of patient identification. There is a significant relationship between nurses knowledge level and the implementation of patient identi- fication. The majority of nurses demonstrated a good implementa- tion of patient identification. It is recommended for the hospital management to make efforts to improve nurses knowledge, espe- cially in the area of patient safety. Introduction Patient safety has become a global issue in various countries1 with an estimated 10-25% of inpatients experiencing patient safety incidents.2 Patient Safety is the provision of nursing care that min- imizes risks and ensures safer care, with the aim of minimizing the occurrence of errors (Minister of Health Regulation No. 11, 2017). Based on the number of unexpected events in hospitals in various countries, namely America, England, Denmark and Australia, the incidence was 3.2-16.6%, while in New Zealand the incidence was reported at 12.9%, in England 10.8%, Canada 7.5%, United Kingdom 10% and Australia 16.6%. This is caused mostly by errors in patient identification (WHO, 2018). Patient identification is one of the crucial aspects in implementing patient safety sys- tems.3 Accurate patient identification is an international patient safety goal. Patient safety incidents can arise from incorrect patient identification procedures. Errors in patient identification can be caused by unsafe actions, such as human errors, lapses, and mis- takes.4 Factors such as lack of organized systems, unclear standard Correspondence: Arsyawina Arsyawina, Nursing Study Program, Poltekkes Kemenkes Kaltim, Samarinda, Indonesia. E-mail: winarispi@gmail.com Key word: knowledge level; workload; patient identication implementaion. Contributions: HH: methodology, data analysis, manuscript writing, overview; AA: manuscript writing and overview; SS, HP, JS: manu- script writing; AS: data collection, data analysis and manuscript writing. Conflict of interest: the authors declare no conflict of interest. Ethics approval and consent to participate: the research has received ethical approval from the Health Research Ethics Commission, East Kalimantan Ministry of Health Polytechnic, based on ethical certifi- cate DP.04.03/7.1/07744/2023. During the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. Patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. Funding: this research did not receive external funding. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Acknowledgement: we would like to thankful to AM. Parikesit Hospital Tenggarong for their valuable insights and contributions to this study. Received: 11 September 2023. Accepted: 5 October 2023. Early access: 12 October 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2023; 11:11756 doi:10.4081/hls.2023.11756 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affili- ated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 6] [Healthcare in Low-resource Settings 2023; 11:11756] Non -co mmerc ial us e o nly operating procedures (SOPs), ambiguous spatial arrangements, and inadequate resources contribute to the likelihood of human errors.5 There are several factors that can influence patient identifica- tion, including policies or regulations, standard operating proce- dures (SOPs), nurse knowledge, nurse skills, and patient educa- tion.6,7 One important factor that can affect patient safety is the knowledge level of nurses.8 When nurses have good knowledge about the identification process and understand when and how to perform patient identification, it is crucial for successful patient identification.9 Therefore, nurses should have a good level of knowledge, as all actions must be based on knowledge.10 Data obtained from WHO (2017)11 showed that 13% of surgi- cal errors and 68% of blood transfusion errors were due to patient identification mistakes. Among the 68% of blood transfusion errors, 11 patients died. These findings indicate that identification errors still occur frequently and can result in patient mortality. According to the Patient Safety report from the South Australian Government, common types of patient identification errors report- ed between 2014 and 2015 include 273 cases of patient identifica- tion errors, 272 cases of specimen labeling errors, 211 cases of wrong patient errors, 59 cases of incorrect medical record status, and 28 cases of examination result errors. A study conducted in Saudi Arabia in 2019 showed that 82% of respondents had good knowledge but lacked proper implemen- tation of patient identification. Only a small percentage, less than 20% or around 30 healthcare professionals, followed the SOPs for patient identification. This could be due to a lack of socialization or training on the implementation of patient identification. Despite having good knowledge, the application of proper patient identifi- cation was still not optimal and not in line with guidelines.12 In contrast, a study by Mualimah et al., (2021) at East Lampung found that 71.4% of nurses had good knowledge and implemented patient identification effectively. This finding is consistent with the study by Andriyanti et al., which reported that 41 nurses (77.4%) had good knowledge and performed patient identification with a good rating. However, when patient identification is not imple- mented correctly, it can lead to unintended incidents, such as med- ication errors, which can result in patient harm or even death. This has negative implications for healthcare institutions.9 Identification errors can also occur due to excessive nursing workload.14 For example, when the number of nurses does not match the number of inpatients in a hospital or hospital ward, it can lead to increased workload for nurses. This, in turn, affects the implementation of patient safety. The longer a patient is hospital- ized, the more procedures and treatments they require, which increases the workload for nurses. Data obtained from Luo et al., (2020) research on the psychological and mental impact of COVID- 19 on medical staff and the general population revealed that out of 9,207 studies, 62 studies involving 162,639 participants from 17 countries focused on healthcare workers experiencing anxiety (32%), depression (28%), with the highest prevalence observed among healthcare workers directly involved in patient care (55%). Another study by Yudi et al., found that 33.3%, or 10 nurses, were categorized as having inadequate patient safety practices due to high physical workloads. When the number of incoming patients exceeds the available nursing staff in a particular area, nurses per- ceive an increased workload. Although patient identification pro- cesses are consistently carried out, they become more susceptible to risks due to the administration of multiple medications and the greater number of procedures performed by nurses on patients. Analysis of the data obtained from A.M. Parikesit Hospital in 2022 revealed three instances of patient identification errors. Additionally, data from the hospital’s quality and patient safety com- mittee indicated an increase in patient safety incidents from 2020 to 2021. Specifically, incidents classified as Unexpected Events increased from 15 to 34, Non-injury Events increased from 14 to 29, Near Miss Incident increased from 9 to 13, and Potential Injury decreased from 1 to 0 in 2021. The number of sentinel events also decreased from 2 to 0. These findings suggest an upward trend in patient safety incidents at A.M Parikesit Hospital during the period of 2020 to 2021. Efforts to implement patient identification proce- dures require collaborative teamwork to prevent errors in the patient identification process. Nursing and other healthcare personnel need to recognize their roles in the hospital to minimize the risk of patient safety incidents. However, achieving continuous and permanent patient safety practices necessitates long-term commitment. Based on the comprehensive review of the existing literature and the afore- mentioned explanations, the purpose of this study was examine the relationship between the level of knowledge and workload of nurses with the implementation of patient identification. Materials and Methods This research is designed as a quantitative study using a cross- sectional design. The sampling technique employed in this study is random sampling. The population of this study consists of nurses working in the in inpatient wards totaling 122 individuals. The sam- ple size was determined using the Slovin’s formula, resulting in a sample of 93 individuals. The results of the research sample selec- tion were selected according to the inclusion and exclusion criteria. The inclusion criteria are nurses are willing to be respondents, the nurse has worked for more than 1 year. The exclusion criteria for this research are nurses are not willing to be respondents, nurses who are on leave, nurse who is sick. The knowledge level and workload of nurses were independent variables, while the implementation of patient identification was the dependent variable. Data collected was used of a level of knowledge, workload, and application of identifi- cation questionnaire. The first questionnaire used was about the level of knowledge, consisting of 20 questions using the Guttman scale through respondents’ answers to the available statements regarding patient identification with 2 answer choices, namely true and false. The second questionnaire used was about nurses workload, consist- ing of 13 questions using a Likert scale through respondents answers to the available statements about nurses workload with 4 answer choices, namely not a workload with a score of 4, light workload with a score of 3, moderate workload with a score of 2, heavy work- load with a score of 1. The third questionnaire used was about the implementation of patient identification, consisting of 15 questions using a Likert scale based on respondents’ answers to the statements that were available regarding the implementation of patient identifi- cation with 4 options The answer is never with a score of 1, some- times with a score of 2, often with a score of 3, always with a score of 4. Before conducting research, an ethical test will be carried out first. Ethical clearance will be published from the campus of the Health Polytechnic of the Ministry of Health of East Kalimantan. After that, ethics was published in June 2023 with the ethical certifi- cate number DP.04.03/7.1/07744/2023. And then the data will be analyzed used with chi-square test. If the probability value <0.05 then the hypothesis Ha is accepted, which means that there is a sig- nificant relationship between the independent and dependent vari- ables. If the probability value is > 0.05 then the hypothesis Ha is rejected, which means that there is no significant relationship between the independent variables and the dependent variable. [Healthcare in Low-resource Settings 2023; 11:11756] [page 7] Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Non -co mmerc ial us e o nly Results Based on Table 1, it indicates that the majority of respondents are female, totaling 58 individuals (62.4%), while the remaining respondents are male, totaling 16 individuals (37.6%). The major- ity of respondents, comprising 48 individuals (51.6%), fall within the age group of 26-30 years. On the other hand, a small proportion of respondents, totaling 6 individuals (6.5%), belong to the age group of 36-40 years. The majority of respondent is graduate of from Diploma III Nursing that is amounted to 54 people (58.1%), meanwhile graduate of from Nurse amount 39 person (39.7%). The majority of respondent based on from group long Work nurse in AM Parikesit Hospital obtained that partly big nurse own old groups work with ranges long Work during > 1 to 5 year a total of 56 people (60.2%). Whereas part small nurse own group length of work during < 1 year is 10 people (10.8%). The majority of respon- dent based on marriage status are as follows 58 individuals (62.4%) are married, while 35 individuals (37.6%) are unmarried. Based on from Table 2, show that distribution respondent based on level knowledge nurse about application identification patient, obtained that most nurses have level good knowledge as much 73 people (78.5%) and enough knowledge as much 20 per- son (21.5%). Distribution respondent based on workload nurse, obtained that part big nurse own workload heavy as many as 66 people (71.0%). Whereas a small proportion of nurses have a workload light a number 27 people (29.0%). Based on from Table 3, show that distribution respondent based on application identifi- cation patient, obtained that part big nurse own application identi- fication Good that is as many as 87 people (93.5%). Whereas part small nurse own application of medium identification a number 6 person (6.5%). Based on Table 4 on the level knowledge variable, it can be observed that there are 71 individuals (97.3%) who are classified as having good knowledge and implementing good patient identification practices. Additionally, there are 2 individu- als (2.7%) who have good knowledge but only implement patient identification practices at a moderate level. On the other hand, there are 16 individuals (80%) who are classified as having suffi- cient knowledge and implementing good patient identification practices, while 4 individuals (20%) have sufficient knowledge but only implement patient identification practices at a moderate level. The analysis using the Chi-square test, specifically the Fischer exact test, the result is p-value of 0.018. Since the obtained p-value is less than the significance level of 0.05 (α < 0.05). Therefore, it can be concluded that there is a significant relationship between the level of knowledge and the implementation of patient identifi- cation. The odds ratio (OR) obtained from the analysis is 8.875 (1.494- 52.729), indicating that nurses with good knowledge are 8.875 times more likely to have better implementation of patient [page 8] [Healthcare in Low-resource Settings 2023; 11:11756] Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 1. Characteristics respondents. Respondent characteristics Frequency Percentage (n) (%) Type sex Man 35 37,6 Women 58 62.4 Amount 93 100 Age respondent 20-25 23 24.7 26-30 48 51.6 31-35 15 16,1 36-40 6 6.5 >40 1 1.1 Amount 93 100 Level education respondents Diploma III 54 58.1 Ners 39 41.9 Amount 93 100 Long work respondents < 1 year 10 10.8 > 1 until 5 year 56 60.2 > 5 year 27 29.0 Amount 93 100 Marriage status Marry 58 62.4 Not married yet 35 37.6 Amount 93 100 Source: Analysis Data Primary, 2023. Table 2. Distribution respondents based on level knowledge. Level Frequency Percentage (n) (%) Knowledge nurse Good knowledge 73 78.5 Enough knowledge 20 21,5 Workload nurse Heavy 66 71.0 Light 27 29.0 Amount 93 100 Source: Analysis Data Primary, 2023. Table 3. Distribution Respondents based on application of identi- fication patient in patient ward. Application of identification Frequency Percentage patient (n) (%) Good application of identification patient 87 93,5 Enough application of identification patient 6 6,5 Total 93 100 Source: Analysis Data Primary, 2023. Table 4. Level knowledge and workload of nurse with application identification patient in inpatient ward. Variabel Application identification patient Amount p OR (95% CI) Level knowledge Good Moderate n % n % n % Good 71 97.3 2 2.7 73 100 0.018 8.875 Enough 16 80 4 20 20 100 (1.494-2.729) Workload Good Moderate n % n % n % Heavy 62 93.9 4 6.1 66 100 0.564 Light 25 92.6 2 7.4 27 100 Source: Analysis Data Primary, 2023. Non -co mmerc ial us e o nly identification. Based on Table 4 on the workload variable, the results can be seen that nurse which own category workload heavy with the implementation of good identification there as much 62 person (93.9%), nurse Which own category workload heavy with application identification currently there is 4 person (6.1%). Nurse Which own category workload light with the implementa- tion of good identification there as much 25 person (92.6%), nurse Which own category workload light with application identification while there were 2 people (7.4%). From the results Chi-square test analysis seen from mark Fisher exact obtained results that mark p- values = 0.564. With thus the result of the p-value is more than alpha value 0.05 (α>0.05). Canconcluded that No there is mean- ingful relationship between Expenses Work with Application Identification Patient. Discussion Relationship level knowledge with the application of patient identification in inpatient ward Results study show that there is relationship which meaning between level knowledge nurse with application identification patient. So that there is a relationship between the level of knowl- edge of nurses with the implementation of patient identification. This can be seen from the results of filling out the questionnaire where the results of filling out the questionnaire regarding the level of knowledge of most nurses have a percentage value of 80- 95%, which is in the good category. And for the application of patient identification, most of the nurses have a good identifica- tion application as well. This can be seen from the results of filling out the questionnaire where most of the nurses are in a good cate- gory in implementing patient identification. So, it can be conclud- ed that the implementation of good identification is influenced by the nurse’s knowledge or understanding of SPO or work proce- dures regarding identification in patient safety.17 Results study this is in line with Mualimah et al., (2021) obtained exists level relationship nurse knowledge to identification patient safety in Permata Hospital inpatient room Heart of East Lampung 2021, from the results of bivariate analysis, it was found that nurses who have a good level of knowledge with the applica- tion of good identification (100%). This is also in line with research conducted by Eliwarti, (2021) from the results of bivari- ate analysis, it was found that nurses who have a high level of knowledge are more obedient in implementing patient identifica- tion, namely there are as many as (60.9%) of nurses. According to Notoatmodjo (2012), the taller level knowledge someone else will be even better knowledge which owned person. The more lots of information which obtain by that person thenthere will be more and more knowledge. Knowledge is the result of human sensing or the result of knowing someone about an object through their five senses such as eyes, nose, ears, and so on, so knowledge is something that is obtained from a person through the five senses where most of the five senses come from the senses of sight and hearing.19,20 Researcher argue that a nurse which has level knowledge Which tall so application identification which held will the more good also. Where as nurse which own level knowledge Which Enough or more low level knowledge somebody, so application identification patient in Hospital will No done with maximum And No in accordance with existing standards and regulations. This matter caused by any action will done related with behavior that every behavior Which based on knowledge then it will character- istic more permanent or long lasting . Relationship workload nurse with the application of patient identification in inpatient ward Results study show that There is no relationship which mean- ing between workload of nurse with application identification patient. This explains that there is no relationship between the workload of nurses and the application of patient identification. This can also be seen from the results of the bivariate analysis, as many as 62 nurses out of 93 nurses have a heavy workload howev- er have good patient identification. This can be seen too from fill- ing out the patient identification implementation questionnaire in statement number one which contains implementing the rules made by the hospital to always identify patients where most nurses answer with the statement “often” and always. This shows that nurses always comply with SPO regulations to implement patient identification in hospitals. Results this study is in line with research Noormailida Astuti et al., (2022) .It means No There is Relationtship Which signifi- cant (means) between variable workload to identification patient, from the results of bivariate analysis it was found that nurses with a high workload had a fairly good identification application (60%). Results study This in line Also withresearch conducted by Yudi et al., (2019) Which It means No There is Relationtship between workload mentally nurse with application patient safety, from the results of the bivariate analysis it was found that nurses with a high workload had a good identification application (36.7%). According to Winarti (2015)22 ideally the workload of nurses in hospitals is 1:2, it can be said that the workload is not ideal. According to the Marquis and Hounston (2010) workload nurse is activity or activity which done by a nurse while on duty insome- thing units service health, workload or workload is also interpreted as patient days which has meaning on amount procedure, inspec- tion visit on client or patient. The researchers believe that despite the high workload, the implementation of patient identification in the hospital is mostly categorized as good. the researcher assumes that, even though nurses have a heavy workload, nurses at Parikesit Hospital are always obedient in identifying patients. This is because patient identification is a regulation or standard operating procedure that must be carried out by a nurse in every hospital for patients in order to avoid the risk of patient safety incidents occurring due to patient identification errors. This research design uses a cross-sec- tional approach which is only carried out at the same time so that research regarding the relationship between the level of knowledge and workload of nurses and the implementation of patient identifi- cation can only be known within one time period. The location of this research was only in VIP, I, II and III class inpatient rooms at AM Hospital. Tenggarong Parikesit only. This research did not examine all nursing staff such as intensive care rooms, emergency rooms, and other treatment rooms. Conclusions From the research results it can be concluded that distribution of nurses knowledge levels in inpatient wards shows that the majority have a good level of knowledge. Distribution of nurses workload inpatient wards shows that the majority have a heavy workload. Distribution of patient identification implementation in [Healthcare in Low-resource Settings 2023; 11:11756] [page 9] Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Non -co mmerc ial us e o nly inpatient wards shows that the majority have good patient identifi- cation implementation. There is Relationship between level knowledge with application identification patient in Inpatient Ward . There is no Relationship between workload nurse with application identification patient in Inpatient Ward. It is hoped that the results of this research can become a strong basis or reference for future research. Suggestions from researchers are expected to not only examine the level of knowledge and workload but also to research factors that can influence the implementation of patient identification and other patient safety targets. Suggestions The results of this study are expected to be a strong basis or reference for future research. Suggestions from researchers are expected to not only examine the level of knowledge and workload but also be able to research the factors that can affect the applica- tion of patient identification and other patient safety goals. The results of this study are expected to be information and data mate- rials for hospitals to be able to further improve programs regarding patient safety to improve nurse knowledge. It is hoped that the results of this research can become a strong basis or reference for future research. References 1. WHO. Patient Safety and Risk Management Service Delivery and Safety. 2019. 2. Indrayadi I, Oktavia NA, Agustini M. Perawat dan Keselamatan Pasien: Studi Tinjauan Literatur. J Kepemimp dan Manaj Keperawatan 2022;5:62-75. 3. Dewi YS, Wahyuni ED, Arifin H, et al. Health Literacy of ICU Patients’ Family: A Review. Malaysian J Med Heal Sci 2022;18:302-6. 4. Kusnanto K, Arifin H, Pradipta RO, et al. 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