The Application of Electronic-based Nursing Care Documentation,

Ethics and Nurse Performance on the Quality of Services in Ibu Dan

Anak Hospital in Banda Aceh

Halimatussakdiah and Abdurrahman

Lecturer of Nursing Study Program of the Health Polytechnic of Health Ministry Aceh, 110 Tgk. Daud Beureueh Street,

Banda Aceh, Indonesia

Keywords: Documentation, Electronic, Ethics, Performance, Service.

Abstract: The use of computers and internet in nursing service is the latest issue. It can overcome service problems

and improve patient satisfaction. This research was a correlation study aimed to identify the effect of

electronic-based nursing care documentation, ethics and nurse performance on nursing services quality in

Ibu dan Anak Hospital Banda Aceh. The research design was a crossectional study. The samples were 200

post-surgical inpatients. Consecutive sampling was used (special criteria; conscious patient and post-surgery

day 3). The Pearson product-moment coefficient correlation (significance <5%) used to test instrument

validity and Cronbach Alpha (> 0.60) to measure instrument reability. Data collection was conducted from

August to 20

September 2018. The SEM test shown the Goodness of Fit Index 0.954, the feasibility test

of full SEM model using Chisquare (399.5), Significancy probability 0.00, RMSEA 0.056, AGFI 0.954,

CMIN / DF 1.624, TLI, 0.946, CFI 0.952. Those values were within Cut of Value. The results of this study

are meaningful; the hypothesis is accepted. Electronic application and nurse professional ethics influence on

nurse performance. The nurse performance also influence service quality. Electronic nursing care

documentation has effect on service quality. It is expected nurses can improve services quality by using

electronic-based nursing care documentation, ethics, good performance.

1 INTRODUCTION

The quality of services in hospitals is currently

getting more attention from the hospital

management team (Mitropoulos, Vasileiou &

Mitropoulos 2006). Patients who are hospitalized

need quality services because of their demands as

users of higher values in service (Kamaldeep, Warfa,

Edonya, Mc Kenzie, Bhugra, 2007). Patients who

are cared for not only experience physical problems

but also psychological and social complaints which

requires care services professionally (Hernández, et

al., 2015).

The quality of nursing services is determined by

several factors, including nurse performance, nurse

ethics and professional documentation (Hernández,

et al., 2015). Service quality is a crucial component

of hospital organization performance and also

become one of the indicators of the success of

hospital programs. Service documentation

performed by nurses to patients is currently being

developed using electronic or computer-based

media. The use of computers aims to improve

performance, control and evaluate the quality of

services for patients in hospitals continually (Koné

& Wodchis, 2013).

The documentation must be standard and reliable

in order it can be applied for ethical aspects and also

to measure performance in every service. The

leadership performance survey on the health system

(Hospital Consumer Assessment of Health Care

Providers and Systems / HCAHPS) on 314 hospitals

in the United States shows that 82.2% respondents

agree that service quality is the main promotor of

hospital organization (Hayes, Banner, & Pryor,

2006).

Explicitly patients express that good service is

the result of good performance from nurses.

Contrary, some hospitals in the United States that

perform inefficient services require special efforts to

increase the number of outpatient visits by (18%)

and inpatients (13%) and to achieve efficiency they

reduce labor by transferring 264 clinical staff and 39

Halimatussakdiah, . and Abdurrahman, .

The Application of Electronic-based Nursing Care Documentation, Ethics and Nurse Performance on the Quality of Services in Ibu dan Anak Hospital in Banda Aceh.

DOI: 10.5220/0008206501410147

In Proceedings of the 1st International Conference of Indonesian National Nurses Association (ICINNA 2018), pages 141-147

ISBN: 978-989-758-406-0

141

beds to the nearest health clinic (Tlotlego,

Nonvingnon, Sambo, Azbu & Kirigia, 2010).

The development of quality nursing services is

the latest issue with the use of computers. The

computer application can overcome the problem of

services (Bouamrane & Mair, 2014). The use of

technology is greatly needed because consumers are

increasingly different from the aspects of education,

demands, law and the increase of critical thought on

services (Chaturvedi, Upadhyay & De Costa,

2014). The documentation on health data using the

internet has been done by 74% to 85% in developed

countries and 80% of users are looking for

information about health. In general, patients seek

information through the internet related to the

decisions that will be taken against the disease. The

documented data is almost 80% done by nurses. It is

because 80% of the total professions in the hospital

are nurses. In addition, nurses provide services for

almost 90% of all services for 24 hours (Cunha &

Cunha, 2004).

A review of the literature from 1999-2017 found

that there were 164 papers which 137 were

telemedicine services. Most of the telemedicine

services based in the United States (n = 61, 44.5%),

2/3 of services (n = 86, 62.7%) are in the form of

real time telemedicine. From the study, 50% (n = 81,

49.3%) assessed services from three different

evaluation perspectives: clinical, economic and

satisfaction outcomes (Aldossary, Melinda &

Khana, 2017). Statistically some of the causes of

inefficiencies in care services are finance,

technology, time and autonomy change

(Koovakada, 2013). The United States Department

of Health and humanitarian services can save up to $

140 billion per year with the use of Electronic

Health Record Systems (HER) technology (Campos

& Gillard, 2010).

In Indonesia, hospitals that apply a computerized

nursing information system are still limited. This is

due to various management factors such as hospital

type, ownership status, sufficient budget and

hospital management awareness to develop the

hospital. Some hospitals in Aceh want to develop

services according to patient needs. However, there

are some problems faced by hospitals such as lack of

budget support, management problems, and limited

human resources.

In general, documentation of services carried out

in Ibu dan Anak Hospital in Banda Aceh is still

using manual documentation (handwriting). In other

words, the use of computer-assisted documentation

is still lacking. The results of observations of

researchers at Ibu dan Anak hospital, the

admistration staff carried out computer-assisted

documentation for registration, recording patient

data, medical check-up, diagnosis, medical

treatment, and length of day care, and also finance.

While nursing care is written manually in the

medical record book.

2 METHOD

This research was a correlation research. It aimed to

identify the effect of the application of electronic

documentation, on patient satisfaction by involving

nurse ethics and nurse performance. Exogenous

variables included the use of electronic

documentation (accessibility, efficiency and

standardization), nurse ethics (patient safety,

competence and caring culture), and nurse

performance (nursing assessment, nursing diagnosis,

implementation and evaluation). While the

endogeneous variable was patient satisfaction

(tangible, empathetic, reliability, responsiveness,

awareness). The instrument used was designed by

researchers who had tested reliability and validity.

Before the research was conducted, the results of the

ethics test from the Aceh Health polytechnic were

conducted.

This study was designed based on the non-

equivalent post-test approach. The study location in

the post-surgical inpatient ward. The study involved

200 people as sample. Sampling technique used was

consecutive sampling with criteria (conscious patient

and post-surgery day 3). The statistical analyses

used for validity test was Pearson product-moment

coefficient correlation (significance < 5%) and

reliability test was measured by Cronbach Alpha (>

0.60). Data collection was taken from August 6 to

September 20, 2018. Data were analysed by

Structural Equation modeling (SEM) using the

AMOS 22 program which aimed to form and to test

models. (Hair, Black, Babin, Anderson & Tatham,

2006; Ferdinand, 2006).

3 RESULTS

The research respondents were 200 people who were

treated in the post-surgical room, the level of

awareness was good, the third day of care, aged 17-

57 years. The results of the study were found mostly

between 30-39 years old (40%). The respondents

were all women (100%) because of the location in

the post-surgical care room of the Ibu dan Anak

ICINNA 2018 - The 1st International Conference of Indonesian National Nurses Association

142

hospital. The majority of respondents education is

high school (37.5%), and the marital status of

respondents mostly is married (82%) and the

average income per month is 1.350.000 – 2.999.999

rupiah (39.5%).

3.1 Confirmatory Factor Analysis

Latent variables or constructs used in this research

model consist of 2 exogenous variables and 2

endogenous variables with a total of 24 dimensions.

The purpose of confirmatory factor analysis was to

test the unidimensionality of the dimensions formed

each latent variable. The results of data processing

for confirmatory factor analysis constructs for

electronic documentation application variable, nurse

professional ethics, nurse performance and service

quality are shown in figure 1.

Figure 1: Measurment model with loading factor.

Based on Figure 1, all indicators have a good

number of loading factors which was greater than

0.5. The formation of these variables already has an

adequate contribution from all relevant indicators so

that it does not need to be eliminated from the

model.

Table 1: Criteria of goodness of fit measurement models.

Size Cut-off Value

Result

Analysis

Evaluatio

n Model

CMIN CMIN/DF >2 2,150 Good

Baseline

Compari-

sons

approtimate 1

up 0,5 for

NFI, IFI, TLI

and CFI

Relative

good

Parsymony

Adjusted

Measure

0-1

Pration,

PNFI, PDCFI

between 0-1

Good

RMSEA > 0,05 0,076 Good

AIC

Default Model

less than

Saturated

636,958<

600,000

Good

ECVI

Default Model

between

Saturated &

Independence

3,201< 3,015

17,603<

Good

3.2 Analysis of Structural Equation

Modelling (SEM)

Figure 2: Test results of Structural Equation Model

(SEM).

The next analysis is the analysis of the Structural

Equation Model (SEM) in full model. The analysis

of the level of uni dimensionality of the indicators

forming latent variables was tested by confirmatory

factor analysis. Analysis of the results of data

processing at the full stage of the SEM model is

carried out by conducting suitability tests and

statistical tests.

Based on figure 2, it can be explained that each

variable, the application of electronic health

documentation and nurse professional ethics, has

influence on nurse performance and also has indirect

effect on service quality through nurse performance.

3.3 Hypothesis Testing

The 5 research hypotheses above are based on the

Critical Ratio (CR) value of a causality relationship

from the results of SEM processing as in table 2.

The Application of Electronic-based Nursing Care Documentation, Ethics and Nurse Performance on the Quality of Services in Ibu dan

Anak Hospital in Banda Aceh

143

Table 2: Regression weight structural equational model 4.

Estimate S.E.

C.R.

Nurse_

Perfomance

<--

Doc_

lication

0,442 0,110 4,000 ***

Nurse-

Performance

<--

Profession_

Ethics

0,374 0,113 3,313 ***

Service_

Qualit

<--

Doc_

lication

0,115 0,025 4,000 ***

Service_

Qualit

<--

Profession_

Ethics

0,425 0,121 3,519 ***

Service_

Quality

<--

Nurse_

Perfo

mance

0,659 0,116 5,683 ***

4 DISCUSSION

4.1 The Influence of the Electronics

Application of Nursing Care

Documentation on Nurse

Performance

The electronics application of nursing care

documentation has an effect on the performance in

Ibu dan Anak Hospital Banda Aceh.

Research on the use of technology in nursing or

the use of the Internet of Things (IoT) which

connects objects to the internet and its networks is

still not maximized in hospital services. The use of

this sophisticated application in nursing aims to

improve data obtained from patients and service

providers (nurses). This technology can be used to

improve the quality of patient care and safety

services. The concept of the Internet of Things and

the use of nursing services is the science and art of

using technology for nursing care in hospitals. The

survey of 265 papers where 62 papers related to

Internet of Things-based innovations found that

Internet of Things technology provided innovation

for basic maintenance use even though existing

innovations were still in the early stages

(Mieronkoskia, et al. 2017).

Other related research is about the comparison of

manual documentation with electronic

documentation of trauma resuscitation patients in the

emergency unit. This study conducted toward

respondents (n = 200) trauma resuscitation groups

were electronically documented and respondents (n

= 200) used manual documentation. The results

showed that electronic documentation more often

recorded 5 data elements, those are: team activation

time (100% vs 85%, P b .00), primary assessment

(94% vs 88%, P b. 036), doctors’ arrival time (98%

vs 93.5%, Pb. 026), intravenous fluid volume in the

emergency unit (94% vs 88%, Pb. 036), and

disposition (100% vs 89.5%, Pb .00). In general, the

electronic documentation is better in recording

trauma resuscitation compared to the documentation

on paper or manual documentation (Coffey, et al.,

2015).

Performance is the core of organizational

functions. Good performance is one way to improve

quality services. The care performance measurement

report carried out by the Institute of Medicine (IOM)

found that there is a significant gap between the

level of patient care desired and the quality of

services reported. The quality of care services is

consistently correct where it is given to right people

in the right way at the right time. The characteristics

of good care are packaged in six goals for

improvement: safe care, effective, patient centered,

on time, efficient, and fair (Fosson, Jones & Yoder,

2016).

The results of hypothesis testing on this variable

can be stated that if nurses can use electronic

nursing care documentation in conducting nursing

services to patients according to patient

expectations, then the nurse's performance can be

increased by 0.442 or 44.2%. The electonic

documentation on nursing service is a nursing

facility that is based on the SOP (Standard

Operational Procedure) and can affect the

performance of nurses. This is shown when nurses

conduct studies, enforce nursing diagnoses, to

intervene, or implement and also to do evaluation.

The actions of nurses in providing nursing care are

carried out systematically and professionally and can

be accessed by the head of the management room,

nursing staff and also finance staff.

4.2 The Influence of Nurse Professional

Ethics on Nurse Performance

Nurse professional ethics influences the performance

of nurses in providing nursing services to patients.

The results of other studies on 33 articles in the

journal Pubmed since 1990 which relate to patient

safety, ethics, audit and quality of care, found that

there are some factors that influence the quality of

care servicesmsuch as ethics, individual profiles,

administrative structures and team-based services.

The survey results found that influencing team work

on nurses included; self-awareness, work

environment, leadership, ethics, cooperation,

communication and competition. Monitoring the

leadership and management of the work team is very

important to achieve efficient team work. The results

of the study explain that manager's responsibility is

the main factor in creating and maintaining a work

climate in the team (Kossaif, Hleihel & Lahoud,

ICINNA 2018 - The 1st International Conference of Indonesian National Nurses Association

144

2017).

Team work is related to individual workloads

and is greatly influenced by the process of

maintaning risks to the consequences of nursing

services. The workload varies among nurses can put

patient safety on risks. This is because nurses also

carry out other tasks besides caring for patients.

Nurses apply strategies to manage procedures based

on patient safety oriented (Ross, Rogers & King,

2018).

The results of hypothesis testing can be

explained that if nurses at Ibu dan Anak Hospital can

improve their ethics in working and in performing

nursing services to patients according to the SOP,

then the nurse's performance can be increased by

42.5%. The good performance of nurses can be

demonstrated with the most basic things such as

being on time, being friendly with patients,

responsive to patient needs and being able to work

together on a team.

4.3 The Influence of Nurse

Performance on Service Quality

The results of the research on nurse performance

were found to influence the quality of care to

patients in Ibu dan Anak Hospital Banda Aceh.

The OECD (Organization for Economic

Corporation and Development) 2013, the

Organization for Economic Co-operation and

Development, explains that health care has now

begun to develop itself and focus on regulating

services with communication, disease prevention

and improvement in the quality of life and well-

being of patients. This is because current hospital

services require an approach that requires patience

dealing with patients who are curious about health

services for individuals, families and communities.

Experts argue that health services that use the

internet (e-health) are technological developments

that aim not only at program development, but also

on attention, thought, attitude and communication

become issues of health services both locally,

regionally and globally (Chen, Wenn, & Yang,

2014).

From hypothesis testing, it can be explained that

the performance performed by nurses with the use of

electronic Nursing Documentation (e-ND) nursing

documentation can improve the performance of

nurses in carrying out nursing care documentation in

inpatients. The results of this test explain that if

nurses at Ibu dan Anak Hospital are able to do

service with computer-based nursing documentation,

then it can improve nurse performance by 65.9%.

Services carried out by nurse for 3 shifts were

recorded by a system that can be used to see various

aspects of the nurse including discipline,

performance, calculation of medical service, career

services and at the same time malpractice that may

occur in patients. In addition, the performance

record that was recorded on the e-ND system can be

used for guidance, such as knowledge, skills and

attitudes.

4.4 The Influence of Electronic Nursing

Care Documentation on Service

Quality

The electronic nursing care documentation

application has an effect on the quality of services at

Ibu dan Anak Hospital in Banda Aceh. The results

of a similar study conducted in the capital city of

Australian towards empowerment and satisfaction of

patients who received nursing care from September

2013 to March 2014 on 678 nurses and patients at

the nurse's practice site, found that patients who

consulted with nurses longer were more satisfied

(OR = 2. 50, 95% CI: 1.43-4.35) and more active

(OR = 2.55, 95% CI: 1.45–4.50) than those with

shorter time. Patients who had continuity of care

with the same nurses were more satisfied (OR =

2.31, 95% CI: 1.33-4.00) than those who consulted

nurses whom they had never met before. It also

found that patients who consulted in practices where

nurses worked with a wide range of practice and

high levels of autonomy felt more satisfied (OR =

1.76, 95% CI: 1.09-2.82) and more active (OR =

2.56 , 95% CI: 1.40–4.68) compared to patients

attending a practice where nurses worked with a

small scope of practice and low levels of autonomy

(Desborougha, Bagheria, Banfield, Mills, Phillips &

Kordae, 2016).

A holistic perspective on harmony and

evaluation of interactions between computers and

humans has been carried out in Taiwan. This study

aims to evaluate the implementation of effective

information systems and their positive impact on

nurses' performance and and also to examine the

impact of harmony between nurses' perceptions of

Nursing Information System (NIS) and

technological capabilities of NIS to achieve success

and performance in nursing care and data storage.

The study was conducted on 531 registered nurses.

The result shows that the performance of nurses

using NIS and NIS technology capabilities can

achieve success and have a positive impact on nurse

satisfaction. As a result, nurse satisfaction will

increase. The use of Nursing Information System

The Application of Electronic-based Nursing Care Documentation, Ethics and Nurse Performance on the Quality of Services in Ibu dan

Anak Hospital in Banda Aceh

145

(NIS) can help nurses work and meet the patient's

needs in service optimally (Lin, Chiou, Chen &

Yang. 2016).

In this time, computer-based information

technology is a device to improve efficiency and

effectiveness in care organizations. Previous studies

have shown about success factors in health care

information systems. The majority of these studies

adapted well-known theories about the information

systems success model (ISSM), developed by

DeLone and McLean in 1992.

The success factors

using technology information systems adopted by

nurses in clinical practice have six dimensions:

system quality, information quality, service quality,

intention to use, user satisfaction and benefits.

System quality, information quality and service

quality are three antecedent variables that are

important and affect individuals in the use of

information system (Lin, Chiou, Chen & Yang.

2016).

The results of this hypothesis test indicate that

the better the electronic nursing care documentation

application will have better effect on improving

service quality by 11.5%. Nurses work using tools to

achieve the goal of quality service on patients.

Standard documentation tools have important value

because they can affect the performance of nurses as

a whole.

4.5 The Influence of Nursing Ethic on

Service Quality

The results of this study indicate that professional

ethics nurses have an influence on improving service

quality.

The results of other studies on the priority of

nursing care and intensification of the work of

nurses found that nurses can cause emotional fatigue

and emotional dissonance to experience physical and

emotional fatigue. Ethical regulation in nursing is an

important problem because it has an impact on

professional development, quality of care and patient

satisfaction. In addition, working in a state of fatigue

creates feelings of guilt, inability to act, frustration

and helplessness, illness, retention and lack of

service due to retention or illness (Suhonen et al.

2018).

International consensus on professional ethics,

nurses need support to manage ethical issues in daily

practice. One type of service in the form of clinical

ethics support in the form of Moral Case

Deliberation (MCD). The MCD is led by a facilitator

from a group of health care workers who discusses

ethics in difficult situations that are found in daily

patient care (Heidenreich, Bremer, Materstvedt,

Tidefelt & Svantesson, 2017).

Nurses must be able to adapt to different

patients, different problems and different needs.

Lack of time in the act of meeting the needs of

patients and the demands of the organization to

provide better services can cause problem. Thus, the

treatment need to be intensified (compacted)

because the number of nurses is not comparable to

the needs of patients. In the code of ethics of nurses,

nurses are always expected to serve patients in good

manner, do not differentiate patient status, nurses

speak politely, show professional attitude, are

responsible with values respecting culture and trust.

However, this condition is sometimes not fully

implemented because nurses experience fatigue and

disproportionate in doing work and it can put a risk

on creating ethical dilemmas.

5 CONCLUSION

This study concluded that there is correlation

between the use of electronic documentation, nurse

ethics and also nurse performance on the service

quality of Ibu dan Anak Hospital Banda Aceh. The

use of electronic documentation has influence on

service quality. There is the influence of nurse ethics

on service quality. Nurse ethics has direct influence

on professional development, quality of care and

patient satisfaction. Nurse performance also has

influence on service quality. In addition, there is also

influence of computer use, professional ethics,

through nurses' performance on service quality

partially and simultaneously (although simultaneous

values are smaller than partial).

The results of this study imply that the

application of electronic documentation and the

ethics of nurses have an influence in improving

nurse performance and have an impact on improving

the quality of care for patients. The direct effect of

the value is greater compared to the indirect

influence. There are some factors needed to obtain

service quality, those are electronic nursing care

documentation, professional ethics and nurse

performance are needed in providing services. The

results of the study show that the influence of these

variables has directly and indirect influence on

nursing performance. Post-surgery patient

satisfaction treated in an inpatient ward requires

services that include in each dimension and

indicator. The biggest influence is the nurse's

performance 65.9%, professional ethics 42.5%, and

for applications 44.2%.

ICINNA 2018 - The 1st International Conference of Indonesian National Nurses Association

146

Nurses should use mechanisms related to the

indicators in carrying out care for patients including

standardization, accessibility, efficiency and quality.

Furthermore, the facilities that are used properly can

improve nurse performance and service quality.

Several dimensions can be carried out to improve

nurse ethics in hospitals such as applying a culture

of caring, prioritizing patient safety and working

with competence.

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The Application of Electronic-based Nursing Care Documentation, Ethics and Nurse Performance on the Quality of Services in Ibu dan

Anak Hospital in Banda Aceh

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