NURSER'S PERSPECTIVE ON INDONESIAN NURSING DIAGNOSIS STANDARDS: ANALYSIS STUDY OF NURSES COMPETENCE IN DOCUMENTING NURSING DIAGNOSES

Abstract

Documentation that is not done properly can reduce the quality of nursing services because it
cannot identify the extent of the success rate of nursing care that has been given. The competence of nurses
in documenting nursing diagnoses according to the Indonesian nursing diagnosis standards (IDHS) shows
the accountability of nurses. The purpose of this study was to determine the competence of nurses in
documenting nursing diagnoses based on the IDHS in the hospital ward.
This research is an analytical study with the nurse competency variable in documenting nursing diagnoses
according to the IDHS. The sample was 84 respondents by total sampling according to the inclusion criteria.
Data collection tools use observation sheets and questionnaires.
The results showed that the majority of nurses had good and sufficient competence in documenting nursing
diagnoses according to the IDHS on the knowledge aspect, namely an average of 50.3% and 31.8%,
especially in the diagnostic component (56.0%), a component in the principle of documentation. and ethics
in the legality of nursing documentation 56.0%, respectively. While the affective and psychomotor aspects
were mostly good and sufficient, namely an average of 51.6% and 39.3%, especially in the diagnosis
component of 65.5%, the principal component in the documentation was 55.9% and partly sufficient in the
nursing diagnosis component. 56.0%. The lack of knowledge competence in the ethical aspects of the
legality of nursing documentation was 33.3%, while the effective and psychomotor competencies were still
lacking in the aspects of the diagnosis component by 11.9% and the type of nursing diagnosis by 10.7%.
The competence of nurses in documenting nursing diagnoses by the IDHS, which is mostly sufficient in the
knowledge aspect and both on the affective and psychomotor aspects, is inseparable from their backgrounds
whose majority work period is> 8 years, amounting to 66.67% and also the policies in the room that have
provided the format The diagnosis is selected by checking the appropriate diagnosis from the results of the
assessment so that it makes it easier to remember or make decisions.
Efforts to improve nurse competence require a nurse's commitment to lifelong learning, be diligent in
attending conferences and seminars related to IDHS, passing competency tests and having competency
certificates, as well as the role of superiors in this field of nursing and hospital directors to provide
continuous education and training.