436 | pISSN: 1858-3598  eISSN: 2502-5791 Jurnal Ners Vol. 15, No. 2, Special Issue 2020 http://dx.doi.org/10.20473/jn.v15i2.19784 This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License Original Research Analysis of Accuracy Nursing Care Process Implementation Tejo Trisno, Nursalam Nursalam, Mira Triharini Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia ABSTRACT Introduction: Implementation of the nursing care process is still a problem in nursing services. The problem found in the nursing process is the accuracy of nurses in applying the nursing care process. The aim of this study to analyze the accuracy of the implementation of the nursing care process. Methods: This study was as a descriptive analytics design with 100 respondents. Samples were selected using cluster sampling. Data were collected using a questionnaire that has been tested for validity and reliability. The variables included assessment, nursing diagnosis, nursing plan, nursing implementation, evaluation, and nursing documentation. Data were analyzed in a descriptive form consisting of good, sufficient and fewer categories. The standard for implementing the accuracy of the nursing process is 100%. Results: The result showed the accuracy of implementation nursing care, namely 64% assessments are sufficient, 69% of nursing diagnosis is sufficient, 59% of nursing plans are sufficient, 66% of nursing implementation is sufficient (), along with 60% of nursing care evaluation and 62% of nursing care documentation. Conclusion: The accuracy of the nursing care process describes the quality and patient safety and is useful for patients, nurses, and the health team. Further studies must be conducted to analyze factors related to accuracy of the implementation of the nursing care process. ARTICLE HISTORY Received: Feb 27, 2020 Accepted: April 1, 2020 KEYWORDS nursing care process; accuracy; implementation CONTACT Nursalam Nursalam  nursalam@fkp.unair.ac.id  Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia Cite this as: Trisno, I.,Nursalam, N., & Triharini, M. (2020). Analysis of Accuracy Nursing Care Process Implementation. Jurnal Ners, Special Issues, 436-439. doi: http://dx.doi.org/10.20473/jn.v15i2.19784 INTRODUCTION Nursing documentation is the record of nursing care that is planned and delivered to individual patients by qualified nurses or other caregivers under the direction of a qualified nurse (Tasew, Mariye and Teklay, 2019). Documentation is an authentic record in the application of management of professional nursing care. Professional nurses are expected to be able to face the demands of responsibility and accountability for all actions taken. Public awareness of the law is increasing so that complete and clear documentation is needed (Nursalam, 2014). Nursing documentation is the principal clinical information source to meet legal and professional requirements. Nursing documentation is evidence of recording and reporting of nurses is useful for the benefit of clients, nurses and healthcare team in providing health services with accurate and complete data written as a nurse's responsibility (Pakudek, Robot and Hamel, 2017). Nursing documentation is on the priority list in conducting quality nursing care. Nurses in Indonesia have been taught to prepare appropriate nursing records during their education. This is reemphasized again during their clinical training. On the other hand, despite the availability of evidence on the impact of insufficient documentation of patient care, nursing documentation problems in this context exist. Recent national publications have clearly stated that nursing documentation in a number of hospitals in Indonesia is far from ideal (Kamil, Rachmah and Wardani, 2018). Hence, the quality of nursing documentation in Indonesia is still questionable. It can be seen from previous research conducted by Sabila (2009) that, of 300 samples of medical records of nursing documentation, 69.3% were in the incomplete category as well as only 41.3% of nursing https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:nursalam@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v15i2.19784 JURNAL NERS http://e-journal.unair.ac.id/JNERS | 437 documentation in emergency ward were in good category. In addition, Purwanti (2012) found that the percentage of complete nursing documentation was only 63% as well as the diagnosis and nursing care plan was only complete for 61%, and implementation and evaluation was only 75% (Ahsan* and , Ardhiles Wahyu, Elvira Sari Dewi, 2018). Incomplete nursing documentation indicates that the nursing care process is not working properly and continuously. Nursing documentation according to the standard of nursing language (Standardized Nursing Language) is still a problem in the nursing profession, especially the uniformity in the use of diagnostic languages and nursing interventions. An instrument is needed to produce good diagnosis and intervention documentation (Diana Rachmania*, Nursalam*, no date). The use of standardized nursing languages helps nurses understand patients’ needs with precision and speed. This study assesses the knowledge of standardized nursing languages (SNL); how nurses perceive and utilize SNL. MATERIALS AND METHODS The study used descriptive research designs in order to systematically describe events and emphasize factual data rather than conclusions. This research was conducted from January to March 2020 in a private hospital in East Java. This research was conducted by observing and interviewing 100 primary nurses in documenting nursing care in the medical record sheets obtained in total sampling. The inclusion criteria in this study were: 1) Primary nurses who worked for more than two (2) years, 2) worked in the inpatient room, 3) nurse education. Meanwhile, the exclusion criterion in this study was primary nurses who did not work in the inpatient unit. Participants were recruited using cluster sampling technique. Data was collected using 5- sectioned self- structured questionnaires whose validity and reliability had been previously ascertained (Olatubi et al., 2018). The study assessed the documentation of nursing care before, during and after the Standardized Nursing Language Continuing Education Program (SNLCEP). It evaluated the differences in documentation of nursing care in different nursing specialty areas and assessed the influence of work experience on the quality of documentation of nursing care with a view to provide information on documentation of nursing care. The instrument used was an adapted scoring guide for nursing diagnosis, nursing intervention and nursing outcome (Q-DIO) (Adubi, Olaogun and Adejumo, 2018). Statistical tests inform the results of validity and reliability by Cronbach's alpha on the appropriateness of nursing care assessments, nursing Table 1. Distribution of variables in the personal analysis of accuracy nursing care process implementation (n=100) Characteristics of respondents n % Gender Male 33 33 Female 67 67 Age 21-25 years old 27 27 26-30 years old 64 64 31-35 year old 8 8 36-40 year old 1 1 Education Bachelor in nursing 100 100 Length of working 2-5 years 79 79 6-10 years 19 19 11-15 years 1 1 > 15 years old 1 1 Quality and safety training Ever 77 77 Never 23 23 Table 2. Distribution of variables in the personal analysis of accuracy of nursing care process implementation (n = 100) Indicator Categories Total Good Enough Less Assessment 10 64 26 100 Nursing diagnoses 6 69 25 100 Planning/intervention 14 59 27 100 Implementation 10 66 24 100 Evaluation 10 60 30 100 Nursing documentation 10 62 28 100 T. TRISNO ET AL. 438 | pISSN: 1858-3598  eISSN: 2502-5791 diagnoses, interventions, implementation, evaluation and documentation of nursing averaged results of 0.727 and results on the implementation of the highest values of 0.863, interventions of 0.784, and evaluations of 0.736. Data obtained through observation sheets were carried out by researchers on the sheet of nursing care instruments in the patient's medical record. This observation sheet to evaluate nursing care instruments includes nursing assessment, nursing diagnosis, nursing planning/intervention, implementing nursing actions, nursing evaluation and nursing documentation. This research protocol was declared to have passed an ethics test by the Health Research Ethics Commission of the Faculty of Nursing, Universitas Airlangga with certificate number No: 19922-KEKP on February 24, 2020 RESULTS Table 1 informs about the characteristics of respondents in terms of age, sex, length of work, and education of nurses who work in inpatients in private hospitals. It is shown that the majority of nurses are aged 26-30 years (64%), most were women (67%), most had been working for 2-5 years (79%), and all nurses had educational background as bachelor in nursing (100%). Table 2 shows the evaluation of implementation of nursing assessment, diagnosis, nursing care plan, implementation, evaluation and documentation. Poor performance is shown in the less category, which are in the top three and including nursing evaluation (30%), then followed by nursing documentation (28%) and nursing care plan/intervention (27%). DISCUSSION Evaluation of the implementation of the accuracy of nursing care standards in private hospitals in East Java was measured using an observation sheet based on diagnosis standards, outcome standards and intervention standards as well as implementation and evaluation that have been determined by The Indonesian National Nurses Association (INNA or known as PPNI). The accuracy of nursing care based on the standard of PPNI is mostly moderate (69%), with 59% adequate nursing plan, 66% adequate nursing implementation and 60% evaluation of nursing care and 62% documentation of nursing care. The standard for applying accuracy to the nursing process is 100%. Law No. 38 of 2014 concerning nursing emphasizes that nursing practice must be based on a code of ethics, service standards, professional standards, and operational procedure standards. On 29 December, 2016, PPNI established nursing care standards by publishing the Indonesian Nursing Diagnosis Standards book (SDKI), then continuing with the issuance of the Indonesian Nursing Output Standards (SLKI) and the Indonesian Nursing Intervention Standards (SIKI). Standardization of nurse care is very important in improving the quality of nursing services in the current health era and the use of standardized standards is very necessary to improve services to patients. Nursing care standards developed by the Indonesian nurse profession organization (PPNI) include Indonesian Nursing Diagnosis Standards, Indonesian Nursing Intervention Standards, and Indonesian Nursing Output Standards. CONCLUSION Based on the results of research and discussion, it can be concluded that the accuracy of nursing care is the competence of nurses in providing quality services. In implementing the nursing care standards for the IDHS, SIKI and SLKI, they must comply with the guidelines for nursing care. CONFLICT OF INTEREST No conflict of interest has been declared. ACKNOWLEDGEMENT Acknowledgments to all research respondents and nursing leaders who were willing to take the time, energy, and provide information support to complete this research data. REFERENCES Adubi, I. O., Olaogun, A. A. and Adejumo, P. O. (2018) ‘Effect of standardized nursing language continuing education programme on nurses’ documentation of care at University College Hospital, Ibadan’, Nursing Open, 5(1), pp. 37–44. doi: 10.1002/nop2.108. Ahsan* and , Ardhiles Wahyu, Elvira Sari Dewi, S. (2018) ‘Analysis of Nursing Behavior Factors in Documentation of Nursing Care in Emergency Unit Using Theory of Planned Behavior’, International Journal of Indonesian National Nurses Association (IJINNA), 1(1), pp. 64–79. doi: 10.32944/ijinna.v1i1.20. Diana Rachmania*, Nursalam*, E. Y. 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