Hrev_master Healthcare in Low-resource Settings 2024; volume 12:11949 Application of family nursing documentation in Tarakan City, Indonesia Sulidah Sulidah,1 Windhandini Listya Hananti2 1Faculty of Health Sciences, Universitas Borneo Tarakan, Tarakan; 2Sebengkok Community Health Center, The Health Office of Tarakan City, Tarakan, Indonesia Abstract Documentation of nursing care is authentic proof of nursing service activities, serving as the basis for fulfilling nurses’ respon- sibilities and accountabilities. Family nursing documentation holds distinct characteristics compared to other nursing practice settings. The Indonesian nursing professional organization has established three standards for nursing care: diagnosis, interven- tion, and outcome. This research aimed to understand how the implementation of family nursing care documentation is conduct- ed by community nurses in Tarakan City. The research was a cor- relational study with a cross-sectional approach. The study popu- lation consisted of all the nurses working in Community Health Centers in Tarakan City, totaling 80 individuals. The sample was selected using total sampling. The research variables included demographic factors, nurses’ knowledge about the documentation concept, and the application of family nursing documentation; these were measured using a modified researcher-made question- naire and declared valid and reliable. The analysis of research data used descriptive analysis and the Spearman Rank correlation test. This research identified that the majority of community nurses in Tarakan City did not implement family nursing documentation, and the level of knowledge regarding nursing documentation con- cepts was low. The Spearman’s rank correlation test yielded a p- value of 0.874, indicating no significant correlation between the level of knowledge and the implementation of family nursing doc- umentation. The inhibiting factors for the implementation of fam- ily nursing care documentation primarily included a high work- load, a limited number of health center nurses, motivation, and the lack of clear and uniform documentation guidelines. Introduction Nurses who work full-time require religious support in patient care and professional documentation tools.1,2 Documentation is one of the most important responsibilities of healthcare providers, including nurses.3 Nursing documentation is a fundamental aspect that nurses must undertake in the nursing process, including fam- ily nursing. Nursing documentation is the report done by nurses during nursing care, which is important for the patients and nurs- es.4 Documentation serves as evidence of nursing service activi- ties performed by nurses.5 Good and correct documentation is an indicator of a nurse’s professionalism.6 Factors that affect the quality of nursing documentation include the use of terminology and documentation instruments according to standards.7 Community nurses' performance can be assessed by implementing family nursing care, which is transformed into a healthcare document for patients and their families. The absence of documentation does not imply that family nurses did not provide care; however, nurses need authentic evidence of having carried out nursing care without documentation. Moreover, the quality of family nursing care is reflected in the comprehensive management of family nursing care plans, aiming to identify successful achieve- ments in family care as clients. Fully documented family nursing care serves as a legal aspect in cases of client dissatisfaction with the provided services. Effective family nursing care is fact-based, goal-oriented, comprehensive, concise, structured, timely, and eas- Correspondence:Sulidah Sulidah, Faculty of Health Sciences, Universitas Borneo Tarakan, Tarakan, Indonesia. E-mail: sulidah06@gmail.com Key word: family nursing; nursing documentation; nursing standards Contributions: SS conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; WLH conceptualization, investigation, validation, and writing – original draft. Conflict of interest: the authors declare no conflict of interest. Ethics approval and consent to participate: the research has received eth- ical approval from the Health Research Ethics Commission, Faculty of Health Science, Universitas Borneo Tarakan, based on ethical certificate number 002/KEPK-FIKES UBT/V/2023. During the research, the researcher pays attention to the ethical principles of information to con- sent, 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 was supported by a research grant from Research and Community Service Institution, Universitas Borneo Tarakan, with contract number 140/UN51.9/KONTRAK-LT/2021. 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 Research and Community Service Institution (LPPM), Universitas Borneo Tarakan and Head of the Tarakan City Health Office for their valuable insights and contributions to this study. Received: 21 October 2023. Accepted: 18 March 2024. Early access: 7 May 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:11949 doi:10.4081/hls.2024.11949 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, 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. [Healthcare in Low-resource Settings 2024;12:11949] [page 501] Non -co mmerc ial us e o nly ily comprehensible.8 Family nursing documentation is recognized as a critical element in ensuring care continuity and facilitating informative decision-making in the future. In providing nursing care, standardization of care is needed, which includes diagnostic standards, outcome standards, clear intervention standards, and standardized terminology, so that nursing care can be uniform, accurate, and unambiguous to guarantee continuity and quality of service.9 Several studies indicate that the implementation of family nursing documentation still faces challenges in terms of under- standing concepts, standardizing formats, and utilizing information technology. This can impact the quality of documented information and consequently influence informed decision-making in family care. The nursing department often encounters problems regarding the performance of nurses in providing nursing care at the hospi- tal.10 This analysis underscores the need to enhance nurses' knowl- edge and skills in family nursing documentation while formulating clear, standardized practice guidelines to ensure information integrity and optimal care quality. Currently, some standards can be applied in nursing documen- tation, including the Indonesian Nursing Diagnosis Standards, Indonesian Nursing Outcome Standards, and Indonesian Nursing Intervention Standards issued by the Indonesian nursing profes- sional organization, namely the Indonesian National Nurses Association.11 The Indonesian Nursing Diagnosis Standards were first published in December 2016, while the Indonesian Nursing Outcome Standards and Indonesian Nursing Intervention Standards were issued in 2018. These three standards are some- thing new for Indonesian nursing and are essential elements that can make it easier for nurses to document nursing care. However, nursing documentation has become an urgent problem almost worldwide in the past few years. The implementation of nursing care documentation in clinical settings is still very low,12 at only 47.8%. Similar results were found in research,13 which proved that nurses who carried out nursing documentation with good criteria were still low at 47.5%. Obstacles to the application of family nursing care documenta- tion by nurses are influenced by many factors, with the low knowl- edge of nurses being the main factor.14 The lower the level of knowledge about family nursing documentation standards, the lower the application of family nursing care.15 A study succeeded in identifying 13 out of 30 nurses with insufficient knowledge of nursing care documentation, which greatly affected the application of nursing documentation.16 This condition often occurs in various regions, including the City of Tarakan. Tarakan City is the most developed area in North Kalimantan Province, with superior human resources and health service facili- ties. Unfortunately, these conditions are not directly proportional to the implementation of family nursing documentation. Based on the experience and observations of researchers on the implementa- tion of family nursing care documentation in Tarakan City, it could be more optimal. This is indicated by incomplete documentation of family nursing care, non-standard diagnosis formulations, use of different formats, and even the need for evidence of family nursing care. Some nurses admitted that they needed to learn about the Indonesian Nursing Diagnosis Standards, Indonesian Nursing Outcome Standards, and Indonesian Nursing Intervention Standards, even though they had attended related seminars or out- reach programs. It is strongly suspected that this condition also occurs in other community health centers (puskesmas). Therefore, this study aimed to identify the implementation of family nursing care documentation at the community health center in Tarakan City according to applicable standards. Therefore, this study aimed to identify the implementation of family nursing care documentation at the community health center in Tarakan City according to applicable standards Materials and Methods Research design This research was a correlational study using quantitative methods with a cross-sectional approach. The type of research con- ducted aims to identify the implementation of family nursing doc- umentation by community nurses and analyze the influencing fac- tors. This study examines the influence of demographic factors, the level of knowledge about the concept of nursing documentation, nurses' experience, and years of service on the implementation of family nursing documentation. Study participants The research population consisted of all nurses working in the community setting at the Community Health Center in Tarakan City. The population size was 80, comprising 80 nurses. This study utilized the entire population as the sample (total sampling). Variable, instrument and data collection The independent variables consist of two variables: demo- graphic factors, which include age ranges of 17-25 years, 26-35 years, 36-45 years, 46-55 years, and 56-65 years; gender (male and female); education in the form of Diploma 3 and nursing profes- sion; and years of experience comprising 0-5 years, 6-10 years, and more than 10 years. The second variable is the level of knowl- edge about nursing documentation concepts, categorized into three levels: good, enough, and not enough. The dependent variable is the implementation of family nursing documentation. The research instruments used were questionnaires and observation sheets, which were previously tested for validity and reliability and were deemed valid and reliable. This research questionnaire was adopt- ed and modified from Kurniawati (2019) with a Guttman scale consisting of 5 questions about Indonesian Nursing Diagnosis Standards, 5 questions about Indonesian Nursing Intervention Standards, and 5 questions about Indonesian Nursing Outcome Standards. Observation sheets were used to identify the implemen- tation of nursing documentation, which covers the 5 steps of the nursing process: assessment, diagnosis, intervention, implementa- tion, and evaluation of nursing. Nursing documentation is consid- ered to be implemented if more than 64% of the answers are yes. Data analysis The data were analyzed using the Spearman Rank correlation test. This type of test was chosen based on the categorical data type of the research variables. Both variables were considered to have a correlation if the p<0.05. Ethical clearance The research has received ethical approval from the Health Research Ethics Commission, Faculty of Health Sciences, Universitas Borneo Tarakan, based on ethical certificate number 002/KEPK-FIKES UBT/V/2023. During the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-malefi- cence. Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions [page 502] [Healthcare in Low-resource Settings 2024;12:11949] Non -co mmerc ial us e o nly Results The research took place from April to June 2023 and involved all nurses working in community settings at the community health center in Tarakan City. There are 6 community health centers in Tarakan City, namely Karang Rejo Community Health Center with 24 nurses, Gunung Lingkas with 12 nurses, Sebengkok with 11 nurses, Juata with 15 nurses, Mamburungan with 12 nurses, and Pantai Amal with 6 nurses. The characteristics of the respondents are described in the table below. Based on Table 1, it was shown that the characteristics of com- munity nurses in Tarakan City who are respondents in this study are mostly females within the age range of 26-35 years and 36-45 years, which falls within the productive age group. They generally have a diploma 3 level of education, with a significant portion hav- ing more than 10 years of work experience. Based on the table above, it is also apparent that only a small portion of the research respondents have a good level of knowl- edge about nursing documentation. This has an impact on the implementation of family nursing care documentation, where the majority of respondents do not document family nursing care in their practice. Based on the data processing results in Table 2, an evaluation of the structural model (inner model) was conducted to determine the model's validity. The test results show that the T-statistics value is ≥ T-table (1.96) or the p-value is < significant alpha 5% or 0.05, indicating a significant influence of the independent variables on the dependent variable. The correlation analysis in this study, as shown in the table above, yielded a p-value of 0.847, which is greater than alpha = 0.05. This indicates that there is no significant relationship between knowledge and the utilization of family nursing care doc- umentation. This finding contradicts several widely accepted notions that suggest a strong influence of knowledge on one's actions. Typically, a higher level of knowledge is expected to lead to improved actions or behaviors. Discussion The research results indicate that community nurses in Tarakan City have not yet implemented family nursing care documentation.17 Low levels of knowledge are the primary inhibit- ing factor, while demographic factors have various effects. More women than men occupy the nursing profession. This was proven in this study, which succeeded in identifying nurses working in community settings in Tarakan City, most of whom were women. This can be explained through several historical, social, and cultur- al factors. In many cultures, grooming and caring roles are consid- ered traditional characteristics of women. This is reflected in social norms linking women to caring roles and men to more powerful or technical roles. In addition, gender stereotypes also play a role in influencing career choices. The nursing profession is often per- ceived as a job requiring gentleness, empathy, and attention to detail, which are characteristics often associated with female stereotypes.18 Gender differences are not something that needs to be debated because nursing professional organizations have regu- lated the rights and obligations of nurses regardless of gender dif- ferences. Even in the career development of nurses in Tarakan City, gender factors are also not considered but instead based on performance. Nurses who work in community settings in Tarakan City are generally in the productive age range, reflecting a time when indi- viduals have sufficient energy and physical stamina to handle diverse job demands. This demographic group has significant advantages in providing health services to the community, maxi- mizing the efficiency and effectiveness of community health ser- vices. Nurses in productive age ranges often have broader work experience and good interpersonal skills,19 which help them deal with the many challenges that may arise in community nursing care, including complex and diverse health problems. Their mature interpersonal skills enable effective communication, empathy with the communities they serve, building trusting relationships, and providing the support individuals and families need. This study found that most nurses in community settings in Tarakan City have a Diploma 3 education, which is the lowest for- mal nursing qualification, unlike those in clinical settings, where various undergraduate levels are evenly distributed. Challenges arise in ensuring community nurses understand community health, disease prevention, and health promotion concepts. Hence, enhancing competence through continuous education and compre- hensive training is essential for them to deliver optimal service. Collaborative efforts among the government, professional organi- zations, and healthcare institutions are crucial in developing edu- cational programs and professional development tailored to public health needs. Ong work experience is crucial in shaping nurses' skills in pro- Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions Table 1. Characteristics of research respondents. Indicator n % Age Age 17-25 year 8 10 Age 26-35 year 31 38.8 Age 36-45 year 38 47.5 Age 46-55 year 2 2.5 Age 56-65 year 1 1.2 Gender Man 16 20 Woman 64 80 Education Diploma 78 97.5 Bachelor 2 2.5 Years of experience 0-5 years 26 32.5 6-10 years 3 3.8 >10 years 51 63.7 Knowledge level Good 7 8.8 Enough 39 48.7 Not enough 34 42.5 Family nursing documentation Applied 10 12.5 Not applied 70 87.5 Table 2. Knowledge correlation analysis and application of nurs- ing documentation. Knowledge Nursing Documentation f p aplied not aplied Good 6 1 7 0.847 Enough 34 5 39 Not enough 30 4 34 [Healthcare in Low-resource Settings 2024;12:11949] [page 503] Non -co mmerc ial us e o nly viding nursing care. In Tarakan City, community nurses typically boast over ten years of experience. Such tenure brings benefits like refined clinical skills, extensive patient management know-how, and a profound grasp of practical nursing. They often excel in interpersonal relationships with patients and families. Nonetheless, prolonged tenure may lead to resistance to change and embracing new treatment practices, hindering adaptation to evolving health- care advancements.20 Fear of stepping out of their comfort zone may deter nurses from exploring new approaches or adhering to updated policies, impeding their willingness to enhance their knowledge, including in family nursing care documentation. The implementation of family nursing documentation that does not work can be seen, among other factors, in the documentation that needs to be uniform in format and conform to standards. This phenomenon may indicate a deficiency in training and understand- ing the importance of adequate documentation in nursing prac- tice.21 This can impact the quality of service and coordination between nurses, patients, and their families.22 Differences in the formats and documentation standards nurses use can also hinder proper monitoring and evaluation of the care provided and make it challenging to share the information needed to treat the patient as a whole. When community nurses lack adequate knowledge of family nursing documentation, it can hamper the program's ability to col- lect consistent and accurate data on public health.23 Low-quality documentation can also affect coordination between nurses, patients, and families in planning, implementing, and evaluating care. Therefore, efforts are needed to increase nurses' knowledge about family nursing documentation and ensure that documenta- tion practices follow applicable standards. This will support the implementation of a more effective and quality Community Health Program. A person's level of knowledge is influenced by factors such as age, gender, education, and years of service.24 Women often exhibit good knowledge absorption25 attributed to their cognitive style. Nurse knowledge tends to improve with years of service26 but this contrasts with findings showing low nursing documentation knowledge despite extensive tenures. Factors like inadequate train- ing, healthcare changes, and lack of professional support con- tribute to this discrepancy. Family nursing documentation, while similar to other care processes, differs due to care setting varia- tions. Nurses need a comprehensive understanding of family nurs- ing principles to effectively address family needs and dynamics.27 The biggest obstacle in documenting nursing care is the need for a greater understanding of the concept of documentation. This mis- understanding can result in errors in recording relevant and essen- tial information for the family. Additionally, the lack of technical skills in using the existing documentation system can be an obsta- cle, such as using software or digital platforms that nurses do not master well. This study highlights the ongoing need for the implementation of family nursing care documentation. Despite factors like age and years of service,28 which typically influence nursing practices, they do not positively impact the adoption of family nursing documen- tation by community nurses in Tarakan City. This aligns with pre- vious findings suggesting that age and tenure have minimal influ- ence on the quality of nursing documentation. Weaknesses in fam- ily nursing documentation include incomplete recording of the nurse's name, initials, and timestamps, crucial elements authenti- cating nursing actions. While most nurses are expected to adhere to proper documentation practices, some exhibit deficiencies. Various factors contributing to this issue in Tarakan City include high workload, limited nurse staffing, inadequate understanding of documentation standards, discrepancies between college education and practical experience, low interest in community nursing, inap- propriate documentation format changes, and insufficient habits and motivation among nurses. According to this study, extensive knowledge of procedures, formats, and purposes of documentation helps nurses identify rel- evant information that must be recorded and do so with accuracy.28 Good knowledge also allows nurses to avoid errors or discrepan- cies in data recording, which can improve documentation quality. Conversely, a lack of knowledge can lead to negligence in record- ing important data, reduce the quality and validity of records, and hinder collective understanding of the patient's or client's health.29 Variations in nursing documentation methods and formats across different institutions or health service units can hinder the imple- mentation of nursing care documentation. Transitioning from one method or format to another can cause confusion and data record- ing errors among nurses accustomed to a specific approach. Challenges in accessing, comprehending, or utilizing new docu- mentation systems may impede nurses from providing accurate and comprehensive information. Clear guidelines and sufficient training on the methods and documentation formats, along with considerations of their suitability and user-friendliness, are essen- tial for institutions or health service units to overcome barriers and effectively implement nursing care documentation. Nurses' interest in a particular service setting can influence their motivation and the quality of implementing nursing docu- mentation.30 When nurses work in settings where they are less interested, there may be a tendency to neglect or not pay full atten- tion to the documentation process. This can result in a lack of a sense of responsibility and suboptimal engagement in recording accurate and timely data. Health center nurses are often burdened with various tasks and functions, such as providing clinical ser- vices, health education, community mapping, cross-program, and cross-sector collaboration. Notably, some nurses are burdened with time-consuming administrative work and are responsible for man- aging health programs. On average, health center nurses oversee 2- 5 health center programs. To handle such a high workload, good management support is needed, including the allocation of ade- quate resources and relevant training31 to ensure that nursing ser- vices and documentation are carried out correctly and comply with applicable standards. The high workload for puskesmas nurses often stems from insufficient human resources. Effective workload distribution can alleviate nurses' burden. One proposed solution is forming a mul- tidisciplinary team where tasks are delegated based on members' expertise.32,33 Including doctors, nurses, nutritionists, and other health workers allows for task allocation according to competence. Flexible and fair work schedules are crucial to prevent nurse fatigue from extended hours. Puskesmas management should pri- oritize nurses' work welfare, work-life balance, and provide sup- port for training and skill development to ensure efficient duty ful- fillment without excessive workload. In order to ensure that nursing documentation can be adequate- ly implemented in puskesmas, nurses and policymakers need to take concrete steps involving various aspects. According to these studies, two things need to be developed.27,34 First, the develop- ment of clear guidelines or standards for nursing documentation that should be followed by all nurses in community health centers is necessary. These guidelines can include formats, types of infor- mation to be documented, as well as the frequency and proper doc- umentation methods. Second, collaboration between nurses and puskesmas stakeholders in monitoring and evaluating documenta- tion practices is crucial. Monitoring can be done through internal Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions [page 504] [Healthcare in Low-resource Settings 2024;12:11949] Non -co mmerc ial us e o nly audits or periodic supervision of documentation records. The results of this monitoring can be used as a basis for identifying areas that need improvement and further development. By involv- ing nurses in the evaluation process, they will feel more involved and have a responsibility to maintain the quality of the documen- tation. This research has limitations in terms of a relatively small pop- ulation size. Although it has covered all levels of community ser- vice, it does not consider differences in the workload of communi- ty nurses and the level of education of nurses, which is generally a Diploma 3. Some educational institutions do not include commu- nity nursing care in their curriculum, even though in reality, all community nurses have an obligation to provide and document community nursing care regardless of their educational back- ground. Conclusions This study found that most of the community nurses in Tarakan City needed to document family nursing care. Low knowledge about nursing documentation is one of many influencing factors. 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