The Effect of Case
Reflection Discussions (DRK) on Improving Nursing Care Documentation According
to 3S Standards (SDKI, SLKI, SIKI): a literature review
Andina
Desiani Ekawaty1,
Blacius Dedi2
STIK
Sint Carolus Jakarta, Indonesia1*
STIK
Sint Carolus Postgraduate Program Jakarta, Indonesia2
Email:
[email protected]
ABSTRACT
Nursing documentation is a means
of communication between medical personnel aimed at restoring patient health. Documentation
is nursing work that can facilitate nursing management, improve continuity of
care, coordinate care, and evaluate patient interventions. DThe completeness
and suitability of nursing care documentation in accordance with the 3S nursing
care process standards (SDKI, SLIKI, SIKI) in several hospitals is still low.
Implementing case reflection discussions can help improve a nurse's ability to
carry out good and effective planning in improving the quality of nursing. This
research is to determine the influence of case reflection discussions (drk) on
improving nursing care documentation according to 3s standards (SDKI, SLKI,
SIKI). This article was written using a literature study method which was
analyzed from several journals related to the topic taken, journals were
searched through Proquest, Pubmed, Google Scholar, Garuda, Sinta, which were
then selected according to the topic, literature searches were carried out
within the publication period journal from 2018 to 2024. The results of the
discussion of the analysis of 20 literature reviews with hypothesis testing for
each journal show that there is an influence of DRK on the quality of nursing
care. DRK has the benefits of increasing knowledge, solving service problems,
increasing awareness of quality practices and critical thinking. Nurses'
knowledge influences the documentation of nursing care according to 3S
standards (SDKI, SLKI, SIKI). One way to increase nurses' knowledge is with
Case Reflection Discussions (DRK).
Keywords: DRK, Nursing Care, Documentation,
SDKI, SLKI, SIKI
INTRODUCTION
A hospital is an organization
that provides comprehensive individual health services through health
promotion, preventive, curative, rehabilitative, and/or palliative, and
includes inpatient, outpatient, and emergency unit services (Indonesian
People's Representative Council, 2023). Regulation of the Minister of Health of
the Republic of Indonesia No.17 of 2023 (House of Representatives of the
Republic of Indonesia, 2023) regulates that Health Workers must have a
professional attitude, knowledge and skills through higher education for
certain types that require authority to carry out health efforts.
Regulation of
the Minister of Health of the Republic of Indonesia Number 26 of 2019
(Permenkes RI, 2019) states that nursing practice is a service provided by
nurses in the form of nursing. Nursing services provided by nurses to patients
must be carried out systematically, on time, precisely and accurately according
to needs so that their health condition can be optimal (Lucyani, 2009).
��������� Nursing documentation is the result of
work or proof of a nurse's professional work. Nursing documentation has the
benefit of being legal evidence and is used as a means of accountability for
nurses, if legal problems arise in carrying out nursing services. This is one
of the reasons for the importance of writing, recording and compiling nursing
documentation clearly, well and correctly. Writing nursing documentation
according to standards is an obligation as a nurse in carrying out nursing
services in order to improve and create quality services (Jaya et al., 2019)
��������� Nursing services and activities must be guided by the code
of ethics, service standards, professional standards and standard operating
procedures developed by the PPNI organization. The standards in question
include the Indonesian Nursing Diagnostic Standards (SDKI), Indonesian Nursing
Outcome Standards (SLKI) and Indonesian Nursing Intervention Standards (SIKI)
(PPNI, 2017; PPNI, 2018; PPNI, 2019).
��������� Case Reflection
Discussion (DRK) is a method or activity to reflect on nurses' clinical
experience in providing care
��������� According to Alrabadi et al (2021), inappropriate
documentation will affect the quality of nursing services. Nursing
documentation is a series of activities carried out by a nurse starting from
assessment, diagnosis, action planning, nursing actions, to evaluation which
contains data about the patient's condition. Nursing documentation is the act
of documenting important and valuable service delivery activities. Nurses
should write nursing material that is complete, clear, accurate and easy for
others to understand to avoid human error (Risdianty & Wijayanti, 2019).
RESEARCH
METHODS
The method used is a literature
review study. Literature Review is a writing plan that examines several
journals/articles that have been published. The search is related to the title
The Influence of Special Reflective Discussion (DRK) on improving nursing
documentation. Journals were searched via Pubmed, Google Scholar, Garuda, Sinta
with the search keyword, namely Reflective Discussion. specifically,
documentation of nursing care and SDKI, SLKI, SIKI.Journal analysis using PICOT
(Population, Intervention, Comparison, Outcome, Time).
The
following presents a summary of various studies regarding improving nursing
documentation skills. The first study by (Sudaryati,
S., Afriani, T., Hariyati, RT, Herawati, R., & Yunita, 2022) showed that Case Reflection
Discussions (DRK) significantly improved nurses' abilities in nursing
documentation according to SDKI, SLKI and SIKI standards at Hospital X Jakarta,
with an increase of 40% for diagnosis and 24% for intervention.
(Yuwanto
& Prasetyo, 2023) reported an increase of 54.35%
in the implementation of 3S at RSUD M. Natsir Solok after knowledge
dissemination and role play. (Amir et
al., 2022) found that DRK was effective
in increasing nurses' knowledge, motivation and professionalism.
(Afriani,
T., Yetti, K., Mashudi, D., & Nasri, 2023) reported an increase in
writing nursing diagnoses according to SAK by 62.3% at Hospital X through
strengthening the Directing function and media innovation. Research by (Mukhtar
& Risnah, 2023) shows that training in the
SDKI, SLKI and SIKI books has a significant impact on nurses' knowledge, with a
p-value < 0.05.
(Manuhutu,
F., Novita, RV, & Supardi, 2020) found that head of ward
supervision training significantly increased nursing care documentation scores.
Fatiyah et al. (2022) revealed the benefits of DRK in developing nurses'
knowledge and professionalism.
(Hartopo
et al., 2024) noted an increase in the
quality of nursing service SOPs after DRK training. (Irianto,
G., Dedi, B., & Rohayani, 2024) showed that supervision by the
head of the room increased documentation compliance by 25.2% at Pameungpeuk
Garut Regional Hospital.
(Wati et
al., 2023) found a significant
relationship between nurse motivation and completeness of documentation. (Jeanifer
et al., 2023) emphasizes the strategy of
implementing training and discussing case studies in increasing nurses'
knowledge and skills.
(Herwawan
et al., 2023) reported a significant
relationship between nurses' knowledge and the use of 3S in nursing care.
Pranatha and Nugraha (2023) show that the implementation of nursing language
standards improves the quality of documentation at Juanda Kuningan Hospital.
(Yuwanto
& Prasetyo, 2023) noted that training in the use
of SDKI, SLKI and SIKI books improved nursing documentation. Wahyuningsih and
Herlianita (2024) found that the documentation format in the ER was being
refined for 10 priority diagnoses.
(Fatmawati
et al., 2024) shows that socialization is
the most influential factor on the quality of nursing care documentation.
DeGroot et al. (2022) reported that the high workload associated with clinical
documentation was comparable to organizational documentation workload.
(Shafiee
et al., 2022) emphasize the need for further
training in the use of electronic documentation systems. Finally, research by (Rosnawati
et al., 2023) shows a significant
relationship between length of service, workload, and education and nurses'
performance in documenting nursing care in inpatient rooms.
Discussion
This
literature review has examined 20 journal articles on influencediscussion of case reflections on
improving nurse documentation. Analysis of journal discussions uses several
different research designs such asquantitative description with a cross
sectional design, using fishbone chi square, andQuasi experimental.
Research from (Sudaryati,
S., Afriani, T., Hariyati, RT, Herawati, R., & Yunita, 2022), said that the case reflection
discussion method was effective in improving nursing documentation skills at
Hospital X Jakarta. There has been an increase in nurses' abilities in the
appropriateness of preparing nursing diagnoses in accordance with IDHS
standards, preparing implementation and output of nursing documentation in
accordance with SIKI and SLKI standards. There is an influence by carrying out
the Case Reflection Discussion Method (DRK) on increasing nurses' abilities in
documenting according to 3S standards (SDKI. SIKI. SLKI). There will be an
increase in 2022.
The research results of
Fitrianola Rezkiki, et al, 2022, stated that 3S (SDKI, SIKI, SLKI) are the 3
main components in nursing care as standards for preparing and recording
nursing care documentation. However, in reality, the results of the evaluation
of the ability of the process of writing and recording nursing care
documentation according to 3S standards (SDKI, SIKI, SLKI) have not run
optimally. There are many things that can be done to improve the ability of
nurses to optimize the 3S in nursing care, including increasing the supervision
of medical assistants' recaps by the head of the room which is carried out
every day.
Fitrianola Rezkiki, et al,
2022, also stated that Supervise increases control and supervision from the
head of the room regarding nursing care documentation and reduces nurse errors
in documenting nursing care stating that case reflection discussions are
effective in increasing nurses' ability to carry out nursing documentation
according to 3S standards (SDKI, SIKI , SLKI). Direct case reflection
discussions can make it easier to carry out strategies for developing nurses'
knowledge, especially in carrying out nursing documentation.
CONCLUSION
DRK has the benefit of
increasing knowledge, solving service problems, increasing awareness of quality
practices and critical thinking. Nurses' knowledge influences the documentation
of nursing care according to 3S standards (SDKI, SLKI, SIKI).One way to increase nurses'
knowledge is with Case Reflection Discussions (DRK).
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Copyright holder: Andina
Desiani Ekawaty1, Blacius Dedi2 (2024) |
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