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Contents lists available at ScienceDirect

International Journal of Africa Nursing Sciences

journal homepage: www.elsevier.com/locate/ijans

What is the problem with nursing documentation? Perspective of Indonesian

nurses
Hajjul Kamil, R. Rachmah, Elly Wardani⁎
Nursing LEADERSHIP AND MANAGEMENT DEPARTMENT, FACULTY of Nursing, SYIAH KUALA University, JALAN Tengku TANOH Abee DARUSSALAM, 23111 BANDA Aceh, InDONESIA

ARTICLEINFO ABSTRACT

BACKGROUND: Nursing documentation reflects the quality in patient care. It promotes effective communication
Keywords:
Indonesia between caregivers. However, although its significance has been discussed in numerous articles, nursing doc-
Nursing documentation umentation remains problematic in Indonesia.
Nurses competency Objective: This research was the first of its kind in Indonesia which aim to identify issues with nursing doc-
Patient report umentation.
Quality Method: A qualitative approach through focus group discussions (FGD) with head nurses and staff was con-
ducted to identify problems that hinder nurses’ abilities to follow proper documentation procedure in an urban
hospital in Indonesia. The nurses who have more than one year work experience were recruited through simple
random technique. There were 35 participants involved. The open-ended questions regarding the nursing doc-
umentation process were administered. The group discussions were held two times on each teams and conducted
separately between the head nurses and their staff. The data for this descriptive qualitative study were re-
cognized through content analysis methods.
Results: The results of the study were captured in three themes: (1) Inadequate supervision for nurses on nursing
documentation; (2) Competency issues in documentation; (3) Lack of confidence and motivation on doc-
umentation.
Conclusion: Education is amongst the top listed contributing factors for quality nursing documentation. This is
confirmed with this research. The findings of the study suggest the need for continuous support and educational
intervention to ensure adherence to the nursing documentation procedure.

1. Introduction information provided in nursing documentation reflects the complete

As prominent care provider, nurses have continual direct contact
with patients. Such conditions place nurses in the critical position of
maintaining detailed documentation to ensure all health-care team
members are well-informed to any changes in a patient’s health status
(Mbabazi & Cassimjee, 2006). An array of literature has underlined the
importance of nursing documentation. For instance, accurate doc-
umentation promotes communication and collaboration, aids in the
legal aspect of the process and outcomes of care, facilitates patient care
decisions and safety, and fulfills professional and practice standards
(Blake-Mowatt, Lindo, & Bennett, 2013; Jefferies, Johnson, & Griffiths,
2010). The inclusion of documentation as a pertinent role of nurses’
professional practice started with Florence Nightingale (Iyer & Camp,
2004). Up to now, it is still recognized as one of the important core
competencies (Asamani, Amenorpe, Babanawo, & Ansah Ofei 2014;
Cheevakasemsook et al., 2006; Lindo et al., 2016). This is because
series of nursing processes ranging from nursing assessments and di-
agnosis, nursing interventions, nursing care implementation and eva-
luation, and, ultimately, patient response and outcomes (Austin, 2011;
Higginbotham & McCarthy, 2001).
Nonetheless, documentation is one of the most disputed and du-
bious nursing roles (Heartfield, 1996) because it is interpreted differ-
ently across settings or even summarily dismissed as a misrepresenta-
tion of nursing care. This could be true considering that attention on
nursing documentation is somewhat unpopular and often perceived not
as being important as hands on nursing care (Hoban, 2003). Hand-
written nursing report, in particular, historically seen as nurses ritual
and mostly provide inadequate information (Hager & Munden, 2008)
since it tends to be messy and hard to read. Despite the availability of
technology for accuracy in patient care documentation in some settings,
it does not necessarily uplifted problems that nurses’ encounter on
patient report (Whittaker, Aufdenkamp, & Tinley, 2009). Nurses’ major

⁎
Corresponding author.
E-MAIL ADDRESS: ellywardani@unsyiah.ac.id (E. Wardani).

https://doi.org/10.1016/j.ijans.2018.09.002
Received 8 December 2017; Received in revised form 26 September 2018; Accepted 27 September 2018
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H. KAMIL et AL.
barriers on proper report that extensively reported include time con-
straints, disproportion between staffing resources and workload, in-
sufficient guidelines for completing documentation, institutional po-
licies (Kärkkäinen & Eriksson, 2005; Laitinen, Kaunonen, & Åstedt-
Kurki, 2010), and discontinuity on education as underlying problem
related to documentation was also found (Blair & Smith, 2012); thus
education is amongst the top listed contributing factors to en-
sure quality nursing reports which is aimed at improving and main-
taining the standard of documentation (Noorkasiani, Gustina, &
Maryam, 2015).
Evidence on hurdles around patient care documentation is globally
identified. These, however, were mostly reported findings in developed
countries. Limited studies are available on nursing documentation in
developing countries compared to other issues such as inadequacy of
nurses or workplace facilities (Nakate, Dahl, Petrucka, Drake, &
Dunlap, 2015). Indonesia, as one of developing country in Asia is yet
struggling with this issue. Nursing as professional relatively new in the
country. In terms of nursing availability, Shields et al. found that there
were about 50 nurses per 100,000 people in Indonesia (Shields &
Hartati, 2003). Most of these nurses were educated at diploma level,
known as AKADEMI KEPERAWATAN, in both private and public institutions.
More recently, the nursing profession in Indonesia has been striving to
develop competency assessments and accreditation procedures. Each
level of nursing education has been standardized and accredited for
decades by referring to Presidential Act No. 8, 2012, regarding the
Indonesian National Qualification Framework. The aforementioned Act
is a general rule for all Indonesian professionals. After a significantly
long process, the Nursing Law (UNDANG-UNDANG KEPERAWATAN) was
passed by the country’s legislature under Bill No. 38/2014. The law
addresses several critical areas such as legal protection for nursing
professionals, the organization, and professional education for nurses.
In addition to this, nurses in Indonesia are expected to adhere to a code
of conduct standardized by the PERSATUAN PERAWAT NASIONAL INDONESIA
(PPNI) or Indonesian National Nurses Association (INNA). These pro-
fessional standards involve nurses’ responsibility for clients, nurses and
their best practice, community, colleagues, and their own profession
(PPNI, 2012). Nursing documentation is therefore on the priority list in
conducting quality nursing care. Nurses in Indonesia have been taught
to prepare appropriate nursing records during their education. This was
reemphasized again during their clinical training. On the other hand,
despite the availability of evidence on the impact of insufficient doc-
umentation of patient care, nursing documentation problems in this
context exist. Recent national publications have been clearly stated that
nursing documentation in a number of hospitals in Indonesia is far from
ideal. Studies report that most nurses only fulfill 50% or less of the total
target of 80% required documentation as mandated by the ministry of
health; this, unfortunately, indicates the low quality of nursing care
(Noorkasiani et al., 2015). Reflecting on this problem and the paucity of
research with regard to nursing documentation in the country, this
study sought to further identify problems faced by these nurses that
lead to inadequate documentation in nursing.
2. Methods
Ethics approval for the research was obtained from the Faculty of
Nursing, University of Syiah Kuala Ethics Committee with certificate
number: 113001180517, as well as permission from the Research and
Development Center of the hospital where the study took place. This
study adopted a qualitative approach by undertaking focus group dis-
cussion (FGD) with head nurses and staff nurses. After obtaining a list of
staff and head nurses in the hospital supplied by the Hospital’s Human
Resource Department, participants for the study were randomly re-
cruited. The inclusion criteria were nurses who have more than one
year experience. The selected participants were contacted to seek for
their consent to participate to this study. All the contacted head nurses
and staff were able and willing to have FGDs with the researchers. To
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Table 1
FGD guide.
Questions
1. What do you understand by nursing documentation?
2. What effort that has been done to ensure proper documentation?
3. What do you think about the quality of documentation you have now?
4. Is there any challenges you encounter for this?
5. What should we do to overcome such challenges?
protect the participants, permission obtained include consent for par-
ticipation in the study as well as for recording the FGDs. The FGDs were
conducted during the nurses’ lunch break. One of the researchers who is
experienced in the methodology, led the FGD discussions. Open-ended
questions were used as FGDs guide to ensure the discussion is on its
track (see Table 1). Each participant was allocated a random number to
ensure their anonymity. There were 35 participants involved including
14 head nurses (i.e., HN team) and 21 staff nurses (i.e., SN team). We
divided the selected head nurses and staff into two groups which make
four groups in total for the FGDs. Each of the HN teams consisted of
seven head nurses. For the staff nurses, the first group consisted of 10
nurses and the second one was 11 nurses. Separate FGDs were con-
ducted for head nurses and their staff. The intention to interview them
separately, was to provide comfort for nurses in expressing their opi-
nions and thoughts. It was also anticipated that participants may feel
pressurised if the leaders and staff are mixed together. The duration for
the FGDs was 40–50 min and took place at a large urban hospital in a
province in Indonesia. This hospital was purposefully selected because
it is the main health referral and education center in the province.
Content analysis was conducted after coding and categorizing data into
thematic areas. Three themes of nurse perspectives on obstacles hin-
dering them from proper nursing documentation were derived. We
checked the transcribed data verbatim for reliability of data. To escalate
the findings trustworthiness, we conducted peer debriefing. An ex-
perienced colleague was asked to check over the study for credibility
and determine if the results align with the data obtained from partici-
pants.
3. Results
3.1. DEMOGRAPHIC description
All participants involved in the research were the staff nurses and
head nurses in the hospital. They were all female nurses and their age
were between 29 and 52 years old. Educational backgrounds vary
amongst them, and range from the diploma level (n = 23 nurses), ba-
chelor in nursing (n = 10 nurses) to master degree (n = 2 nurses).
3.2. Problems with nursing DOCUMENTATION
Primary problems encountered by nurses in documentation from the
perspective of head nurses and their staff can be viewed within these
themes: (1) Inadequate supervision for nurses on nursing documenta-
tion; (2) Competency issues in documentation; (3) Lack of confidence
and motivation on documentation.
(1) INADEQUATE supervision for nurses on nursing DOCUMENTATION
The greatest problem encountered by the nurses is primarily caused
by inadequate supervision in the documentation process. The nurses
were asked to complete the documentation procedure but rarely as-
sessed on how they completed its process. One head nurse complained:
“We do know that documenting nursing process is important for a
patient during his time with us in the hospital, but, what I have seen
is that the staff do not know how to fill that in. They need more
H. KAMIL et AL.
supervision on that.” (Head nurse 5, Group 1)
A staff member also argued:
“The management only care about documentation when we get
closer to hospital accreditation.” (Staff nurse 4, Group 2)
These findings revealed the importance of regular support to de-
velop staff competency in documenting nursing care. The nurses con-
firmed that supervision was conducted at irregular intervals. The au-
diting gets much more intense when the hospital was due for
accreditation. However, once the hospital accreditation was achieved,
the documentation quality decreased.
Lack of supervision and auditing in nursing documentation puts the
nurses in a difficult position. On one side, they are expected to complete
documentation as a measurable tool for nursing care quality. On the
other side, they received minimal attention and support on how to
conduct effective yet efficient documentation.
(2) Competency issues in nursing DOCUMENTATION
The head nurses agreed that their staff have various levels of com-
petency. The staff’s mixed nursing education and training is a likely
reason for their variable ability to handle documentation.
A head nurse said:
“I don’t think that the staff nurses understand documentation. Some
nurses have bachelor degrees but some others have diplomas in
nursing. This makes it kind of hard to put them at the same level.”
(Head nurse 8, Group 2)
The head nurses felt that the staff members’ backgrounds influence
the way they see documentation. They realized that it is challenging to
have the same expectations for everyone since every nurse is unique
and has a different capabilities in learning. As one nurse explained:
“We have different phase on learning, so, it’s kind of hard.” (Staff
nurse 10, Group 1)
(3) LACK of confidence AND MOTIVATION on nursing DOCUMENTATION
The head nurses claimed that confidence is almost always a problem
with nurses, including in the documentation process. As the following
head nurse said:
“The documentation that my staff did mostly copied what others
had done before. It doesn’t really matter what they have written in
there.” (Head nurse 5, Group 1)
Another head nurse claimed:
“There is no adviser for the documentation they have done. I think
the nurses in ward just do documentation as a regular task. They
don’t take that seriously.” (Head nurse 10, Group 1)
Such low motivation was also described by the following staff nurse:
“We have so many things to do at once. We have to fulfill respon-
sibilities with patients and the paperwork. I don’t think we can
commit to having a good patient record in that condition.” (Staff
nurse 16, Group 2)
The aforementioned opinions confirm the inadequacy of confidence
and motivation in understanding the documentation process. There
seems to be a prominent feeling of insecurity about nursing doc-
umentation. Additionally, nurses lack the motivation to perform the
documentation process considering the burden of the other responsi-
bilities they have to carry out during their duty hours. There is op-
portunity, with these limitations in mind, for nurses’ to consider nursing
documentation as a less crucial component in the delivery of care.
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4. Discussions
This research has elucidated issues related to nursing documenta-
tion amongst nurses in Indonesia. While most available literature pro-
vides findings and recommendations on how to maximize the doc-
umentation procedure, this research has introduced the problems that
lead nurses to complete inadequate documentation of nursing care in
Indonesia.
Nursing documentation should reflect nurses’ critical thinking that
leads to decisions or intervention in care. Considering the first theme, it
reflected the importance of documentation. The nurses in the study
confirmed the significance of documentation for patient care. They
knew that there is a special tie between patients and nurses. This should
underline that these nurses may actually understand that proper doc-
umentation contributes to the quality of care they provide to their
patients. It builds a relationship between both parties to ensure the
continuity of care. This response is concurrent with Cheevakasemsook
et al. (2006) who describes the pertinence of documentation in the
nursing field.
The nurses are aware of the importance of documentation, however,
since supervision or auditing processes are irregular, they are not likely
to perform proper documentation. Nurses claimed that they lacked an
auditing or supervision process. The drawback of documentation due to
lack of supervision has been identified in earlier studies (Björvell et al.,
2003; Edelstein, 1990; Owen, 2005). It is clearly asserted that organi-
zational support is indeed a crucial link to improving the quality of
nursing documentation.
Furthermore, problems of competency were strongly articulated
amongst the nurses. Nurses competency has been linked with educa-
tional attainment. For the case of Indonesia, the educational entry level
for nurses in Indonesia ranged from Diploma III to the Bachelor’s stage
(Hennessy, Hicks, Hilan, & Kawonal, 2006). The development of nur-
sing education since 1999 has shown that about 1% of nurses are
educated at university level to the degree of Bachelor’s, Master’s and
Doctorates (Shields & Hartati, 2003). The applied concepts in nursing
education are influenced by the American nursing curriculum (Strength
& Cagle, 1999). Textbooks or other nursing reading materials are
mostly American-based resources providing a challenge for users in
understanding them, since the majority of teachers and students have
difficulty reading in English (Gillund, Rystedt, Wilde-Larsson,
Abubakar, & Kvigne, 2013). Moreover, Gillund et al. found that, due to
limited resources, most of the qualified nursing students receive an
offer of a teaching position following graduation from school, creating
nursing instructors who have an inadequate amount of clinical ex-
perience (Gillund et al., 2013; Lock, 2011; Shields & Hartati, 2003).
Referring to nursing education context in Indonesia, it clearly stated
that the nurses acknowledged that the diversity of nursing education
and training may determine their abilities in documentation. That
suggestion was supported through the observation and review of nur-
sing notes in patients’ records. Nurses’ competencies varied from the
diploma level to a bachelor’s degree in nursing. Thus, the range in
education created a spectrum in how they documented care. Research
has argued for educational processes for all nurses for quality assurance
improvement of nursing documentation. Therefore, it is recommended
to educate nurses at all levels on documentation rather than expecting a
few pioneer nurses to lead other nurses to reach the desired outcomes
(Darmer et al., 2004, 2006).
Last but not least, the final problem identified by nurses in de-
termining low documentation quality can be found under the lack of
confidence and motivation theme. The nurses seemed to expect
minimal time spent on the documentation procedure in order to bal-
ance it with their other duties. Similarly, workloads and its effect on
documentation has been spotted in other studies (Björvell et al., 2003;
Persenius, Hall-Lord, Bååth, & Larsson, 2008; Wang, Hailey, & Yu,
2011). The imbalanced workload of patient care and the expectation of
quality documentation is likely to hinder innovations in nursing
H. KAMIL et AL.
(Björvell et al., 2003). Furthermore, it often affects the nurses’ moti-
vation to complete proper nursing documentation. The theme poten-
tially introduced the role of nursing leadership and their commitment
to documentation. Head nurses, along with their staff, admitted that
there were an absence of leadership among them. All tasks and duties
were regarded simply as regular activities, likely leading to a deva-
luation of nursing documentation. Although nurses previously ac-
knowledged the significance of documentation in nursing care, there
must be an urgent call for hospital management and leadership to
strengthen nurses’ patient reporting and the quality of care (Müller-
Staub, Needham, Odenbreit, Ann Lavin, & Van Achterberg, 2007;
Thoroddsen & Ehnfors, 2007; Wardani, 2017).
5. Conclusion
Though the performance remains rudimentary, the nurses ac-
knowledged that nursing documentation is a crucial element that builds
positive linkage between nurses and their ability to provide high-
quality care to their patients. Lack of supervision, competency issues,
and problems of confidence and motivation affect the way they conduct
documentation. Increasing support and improvement of nursing skills
across nursing education at all levels are essential for the successful
adherence to proper nursing documentation. The study was an initial
attempt to identify the problems with documentation among nurses in
Indonesia. The mixed perspective of staff nurses and their proximal
leaders generated a larger view rather than single approach participant
(e.g., staff nurses only). The use of randomized selected participants has
helped to avoid bias during discussions. The results of this research,
however, remains somewhat limited. The data was generated from
hospital based nurses, therefore it is less likely generalizable across
Indonesia at large. Single approach of focus group discussion, time
constraints, and nurses as participants only did not allow the re-
searchers to fully engage in the organizational culture and may have
limited the study’s interpretations. Future research is therefore war-
ranted by incorporating hospitals’ supervisory board and leaders per-
spective to investigate further on institutional oversight which may
enhance the quality of future studies on nursing documentation in the
country of Indonesia.
6. Ethics
Ethics approval from the University of Syiah Kuala Ethics
Committee.
Conflict of interest
We confirmed that there is no conflict of interest to disclose in this
research.
Acknowledgements
The research is part from PENELITIAN UNGGULAN UNIVERSITAS (University
Excellent Research) funding scheme, grant number: 73/UN11.2/PP/
PNBP/SP3/2017, Syiah Kuala University, Indonesia. Our thanks to all
the nurses involved for their time and knowledge on this study.
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