Application of family nursing documentation in Tarakan City, Indonesia

Abstract

Documentation of nursing care is authentic proof of nursing service activities, serving as the basis for fulfilling nurses' responsibilities 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, intervention, and outcome. This research aimed to understand how the implementation of family nursing care documentation is conducted by community nurses in Tarakan City. The research was a correlational study with a cross-sectional approach. The study population 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 questionnaire 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 concepts 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 documentation. The inhibiting factors for the implementation of family nursing care documentation primarily included a high workload, a limited number of health center nurses, motivation, and the lack of clear and uniform documentation guidelines.