Proceeding of Mayapada International Nursing Conference.
Vol.
No.
ISSN:x https://jurnal.
id/index.
php/minc CORRELATION BETWEEN NURSESAo PERCEPTION OF NURSING LEADERSHIP ROUNDS AND DOCUMENTATION
COMPLIANCE IN MEDICAL RECORDS
Azmi Sulintya Syahwa.
Hadianingsih Dini.
Handayani Trisni.
Manggala M.
Karmila Siti.
Khanifurosyid Nursing Department.
Mayapada Hospital Bogor.
Bogor.
Indonesia Corresponding Author: dini.
hadianingsih@mayapadahospital.
ABSTRACT
Background: The completeness and accuracy of nursing documentation reflect the professionalism and quality of hospital services.
One effective approach to improve documentation compliance is the Nursing Leadership Round (NLR), a form of direct clinical supervision conducted by nursing leaders to provide guidance and feedback to staff nurses.
Objective: This study aimed to determine the correlation between nursesAo perceptions of Nursing Leadership Rounds and their compliance with nursing documentation at Mayapada Hospital Bogor.
Indonesia.
Methods: This research employed a quantitative descriptiveAecorrelational design with a total of 55 inpatient nurses selected through total sampling.
Data were collected using validated and reliable questionnaires measuring perceptions of NLR and documentation compliance (CronbachAos = 0.
Data analysis used PearsonAos correlation test with a significance level of p < 0.
Results: Most respondents had moderate perceptions of NLR .
6%) and moderate documentation compliance .
2%).
PearsonAos correlation analysis showed a significant positive correlation between nursesAo perceptions of NLR and documentation compliance .
= 0.
Conclusion: There is a significant relationship between nursesAo perceptions of Nursing Leadership Rounds and compliance with medical record documentation.
Regular and structured implementation of NLR can enhance nursesAo motivation, awareness, and accountability in improving the quality of nursing documentation.
Keywords: Nursing Leadership Round.
Compliance.
Nursing Documentation.
Nurse Perception Introduction Nursing documentation in medical records is an integral part of professional nursing practice, serving as evidence of care delivery, a foundation for clinical decision-making, and legal protection for both healthcare professionals and patients.
The completeness and accuracy of nursing documentation not only reflect nursesAo professionalism but also serve as key indicators of hospital service quality, as assessed in national accreditation standards (Potter & Perry, 2.
modern healthcare settings, accurate documentation is a cornerstone of patient safety and continuity of nursing care.
Globally, compliance with nursing documentation remains a persistent challenge.
A meta-analysis conducted by McCarthy et al.
reported that the average international compliance rate for Proceeding of Mayapada International Nursing Conference nursing documentation was only 50.
01%, with a range between 37.
4% and 84.
Contributing factors include workload, the documentation system used, training, and managerial support.
Other studies highlight that the implementation of electronic documentation systems, such as Electronic Health Records (EHR), can increase the quality and compliance of nursing documentation to over 70% (JPTCP, 2.
In Indonesia, compliance with nursing documentation has not yet reached optimal levels.
A study by Ni Kadek et al.
found that only 73.
9% of nurses adhered to nursing documentation standards, even though most demonstrated high self-efficacy.
Similarly, a study conducted at Dr.
Hasan Sadikin General Hospital Bandung revealed that compliance with electronic medical record documentation reached only 56.
67%, influenced by factors such as motivation and internal socialization within the hospital (STIKes DHB, 2.
At the provincial level in West Java.
Asih and Indrayadi .
found that the completeness of nursing documentation at Sumber Waras Hospital Cirebon was significantly influenced by the design of the electronic medical record format .
= 0.
However, other factors such as knowledge, motivation, and ward supervision showed no significant relationship with documentation completeness.
In Bogor City, a study at Bogor City General Hospital .
reported that the completeness of outpatient medical records reached 93.
Nevertheless, several obstacles were identified in input components, such as the number of staff and overtime work systems, which affected documentation effectiveness.
Another study conducted in a private hospital in Bogor found that 5% of medical record summaries were incomplete, emphasizing the need for strengthened Standard Operating Procedures (SOP.
and a rewardAepunishment system to improve compliance (STIKes YRSDS, 2.
One approach increasingly implemented to address this issue is the Nursing Leadership Round (NLR).
NLR is a form of direct clinical supervision by nursing leaders aimed at providing feedback, guidance, and role modeling in nursing practice.
Research conducted by Moi.
Nursalam, and Asmoro .
demonstrated that NLR positively impacts communication, compliance, and the completeness of nursing documentation.
In this context, the present study was conducted to evaluate the relationship between nursesAo perceptions of NLR and their compliance in medical record documentation among staff nurses in inpatient units.
The instruments used in this study underwent validity and reliability testing, yielding excellent resultsAiall items were valid .
Ou 0.
p < 0.
with a CronbachAos alpha of 9418, indicating very high internal consistency.
This study is expected to contribute to the development of leadership-based clinical supervision models that enhance the quality of nursing documentation in a sustainable manner.
Methods Research Design This study employed a quantitative descriptiveAecorrelational design to identify the relationship between nursesAo perceptions of Nursing Leadership Rounds (NLR) and their compliance with medical record documentation.
This approach allows researchers to objectively describe and measure the correlation between variables using numerical data obtained from respondents.
Population and Sample The study population consisted of all staff nurses working in inpatient units at Mayapada Hospital Bogor, totaling 55 nurses.
The sampling technique used was total sampling, as the population size was relatively small and all members met the inclusion criteria.
Therefore, the final sample comprised 55 staff nurses.
To test the validity and reliability of the research instruments, a pilot test was conducted with 30 nurses from other units not included in the main sample.
This number meets the minimum requirement for instrument testing, as recommended by Sugiyono .
, which suggests at least 30 respondents.
The decision to use total sampling was made to ensure a high level of representativeness of the actual conditions in the field and to minimize sampling bias.
Research Instruments The instruments used in this study were structured questionnaires employing a four-point Likert scale .
Ae.
The questionnaire consisted of two main parts:
Perceptions of Nursing Leadership Rounds (NLR) NursesAo Compliance in Medical Record Documentation The instruments were tested for validity using the Pearson correlation analysis and for reliability using CronbachAos Alpha.
The results indicated that all items were valid .
Ou 0.
p < 0.
and reliable ( = 0.
, showing a very high level of internal consistency.
Data Collection Procedure Data collection was conducted by distributing the questionnaires directly to respondents who met the inclusion criteria, after obtaining their informed consent.
The researcher also carried out observations on the implementation of NLR and documentation activities as supporting data to strengthen the analysis.
Data Analysis Data analysis was performed using SPSS version 25.
The following analytical steps were applied:
Normality Test Ae The KolmogorovAeSmirnov test was used to determine the data distribution.
Correlation Test Ae PearsonAos correlation test was applied to identify the relationship between nursesAo perceptions of NLR and compliance in medical record documentation.
Interpretation of results was based on a significance level of p < 0.
05 and the correlation coefficient .
, with reference to standard statistical classifications for interpreting the strength of the Results and Discussion A total of 55 nurses participated in this study, all of whom were staff nurses working in inpatient The demographic characteristics of respondents are presented in Table 1.
Table 1.
Distribution of Respondents by Demographic Characteristics .
= .
Characteristics Gender - Male - Female Age .
- 20-25
- 26-35
Characteristics .
Ou 45 Table 1.
Distribution of Respondents by Demographic Characteristics .
Karakteristik Educational Background - Diploma in Nursing (D.
- Bachelor/Ners Length of Service .
- O1
- 1-5
- 6-10
- E 10
Position - Team Leader - Staff Nurse .
29,09 70,09 Table 1 presents the distribution of sociodemographic characteristics of the study, which involved 55 respondents consisting of nursing staff from inpatient care units.
Based on gender, the majority of respondents were female .
= 46.
6%), while male respondents totaled 9 .
4%).
In terms of age distribution, most respondents were between 26Ae35 years old .
= 27.
1%),
followed by those aged 20Ae25 years .
= 15.
3%).
Respondents aged 36Ae45 years accounted for 12 individuals .
8%), and only one respondent .
8%) was aged 45 years or older.
Regarding educational background, 29 respondents .
7%) held a Bachelor of Nursing/Ners degree, while 26 respondents .
3%) were Diploma (D.
Based on the length of service, 31 respondents .
4%) had worked in their current units for 1Ae5 years, 11 respondents .
0%) for O 1 year, 7 respondents .
7%) for 6Ae10 years, and 6 respondents .
9%) for more than 10 years.
In terms of job position, the majority of respondents were staff nurses .
= 39.
91%), while 16 respondents .
09%) held the position of team leader.
Table 2.
Distribution of NursesAo Perceptions of Nursing Leadership Rounds .
= .
Perception Category Low (O 29,.
Moderate .
,31-35,.
High (Ou 35,.
Total Mean .
32,47 A 3,17 Table 2 illustrates the distribution of nursesAo perceptions regarding the implementation of Nursing Leadership Rounds (NLR).
The mean perception score among respondents was 32.
47 A 3.
17, with scores ranging from 22 to 39.
The majority of nurses had a moderate perception .
= 35.
6%),
followed by those with high perception .
= 15.
3%) and low perception .
= 5.
1%).
These findings indicate that, in general, nurses perceived the implementation of NLR as fairly effective.
However, there remains room for improvement, particularly in aspects related to communication, feedback, and leadership engagement during the rounding process.
Table 3.
Distribution of Compliance with Medical Record Documentation .
= .
Compliance Category Low (O 38,.
Moderate .
,15-46,.
High (Ou 46,.
Total Mean .
42,51 A 4,37 Table 3 presents the distribution of nursesAo compliance with medical record documentation.
The mean compliance score was 42.
51 A 4.
37, with a minimum score of 34 and a maximum score of Most respondents demonstrated moderate compliance .
= 32.
2%), followed by those with high compliance .
= 15.
3%), and a smaller proportion with low compliance .
= 8.
5%).
These results suggest that, overall, documentation compliance among nurses in inpatient units was adequate but not yet optimal across all respondents.
This pattern indicates that while the majority of nurses are committed to performing documentation in accordance with established standards, there are still variations in consistency and accuracy that may be influenced by factors such as workload, time constraints, or feedback from supervisors.
Table 4.
Correlation Between NursesAo Perception of NLR and Documentation Compliance .
= .
Variabels p-value Description NLR Perception Ae Documentation Compliance 0,452 0,001 Significant correlation Table 4 shows that the results of the correlation test revealed a statistically significant relationship between nursesAo perceptions of Nursing Leadership Rounds (NLR) and their compliance with medical record documentation, with a correlation coefficient of r = 0.
452 and a significance value of p = 0.
< 0.
This positive correlation indicates that the more favorable nursesAo perceptions of NLR are, the higher their level of compliance in completing nursing documentation.
These findings suggest that Nursing Leadership Rounds play an important role in enhancing nursesAo awareness, sense of responsibility, and commitment toward maintaining the quality and accuracy of nursing documentation.
Discussion The findings of this study revealed a significant positive correlation between nursesAo perceptions of Nursing Leadership Rounds (NLR) and their compliance with medical record documentation .
= 0.
p = 0.
This indicates that the more positive the nursesAo perception of NLR, the higher their compliance in performing documentation.
The positive correlation suggests that NLR serves as an effective leadership approach that enhances nursesAo awareness, responsibility, and accountability regarding documentation quality and patient safety.
The implementation of Nursing Leadership Rounds represents a tangible form of transformational leadership in nursing, where leaders do not merely conduct administrative supervision but also engage directly in care areas to provide guidance, serve as role models, and actively listen to staff This leadership model fosters both emotional and professional engagement between leaders and staff, developing a sense of ownership toward their organization and practice (Northouse, 2.
Within the context of nursing documentation, the involvement of nursing leaders during NLR allows for real-time feedback, helping nurses recognize documentation errors and immediately correct them (Stanley, 2.
The results of this study are consistent with previous findings by Moi.
Nursalam, and Asmoro .
, who reported that consistent implementation of NLR improved communication, adherence to Standard Operating Procedures (SOP.
, and the completeness of nursing documentation.
Similarly.
Rahmawati et al.
found that leadership rounding increased nursesAo motivation and work discipline in performing documentation.
Frequent interaction between head nurses and staff during NLR strengthens working relationships, enhances feelings of appreciation, and fosters greater commitment to maintaining nursing care quality.
From a theoretical perspective, these findings can be explained by AjzenAos .
Theory of Planned Behavior, which posits that an individualAos perceptions and attitudes toward a behavior influence their intentions and actual actions.
In this context, positive perceptions of NLR shape the belief that the activity benefits professional and performance improvement, thereby motivating nurses to comply more consistently with documentation standards.
The stronger the nursesAo perception of NLRAos benefits, the more likely they are to demonstrate compliant documentation Apart from leadership factors, documentation compliance is also affected by individual and environmental characteristics.
In this study, the majority of respondents were female nurses aged 26Ae35 years with 1Ae5 years of work experience.
This aligns with findings by Setiawan et al.
which indicated that nurses with over two years of experience exhibit higher documentation compliance due to greater familiarity with hospital systems and policies.
Additionally, nurses with Bachelor of Nursing/Ners degrees tend to possess a better understanding of documentation as both an ethical and legal professional responsibility.
Although most nurses in this study demonstrated moderate to high perceptions of NLR, a small proportion had low perceptions.
This could be influenced by variations in leadership style, frequency of NLR implementation, and workload in certain units.
According to Wahyuni et al.
, the effectiveness of NLR depends largely on the consistency of its implementation, management support, and the preparedness of head nurses to exercise clinical leadership.
If NLR is carried out inconsistently or merely as a formality, it becomes difficult for staff to develop positive perceptions of the process.
Regarding documentation compliance, most respondents were categorized as moderate .
and high .
3%), while 14.
5% showed low compliance.
This aligns with Ni Kadek et al.
who reported that average compliance among Indonesian nurses remains below 80%, even when their understanding of documentation standards is adequate.
Common barriers include time constraints, insufficient supervision, and suboptimal electronic documentation systems.
Internationally.
McCarthy et al.
also identified workload and lack of managerial support as key determinants of poor documentation compliance.
Noncompliance in nursing documentation has direct implications for service quality and patient Incomplete documentation may result in communication errors among healthcare professionals, duplication of interventions, and even legal risks for healthcare facilities (Potter & Perry, 2.
Therefore, leadership strategies like NLR which promote two-way communication and continuous coaching are vital to strengthening a culture of quality and safety in healthcare This study also reinforces the idea that clinical leadership requires not only technical expertise but also interpersonal competence.
Nursing leaders who actively engage in NLR serve as role models for their staff, fostering trust and enhancing organizational citizenship behavior (OCB) voluntary behaviors that support organizational goals (Permana et al.
, 2.
Thus, successful NLR implementation contributes not only to improving documentation compliance but also to building healthy interprofessional relationships within nursing teams.
Practically, the results of this study have important implications for hospital management.
NLR
should be institutionalized as a regular and structured supervisory activity, accompanied by clear guidelines, evaluation indicators, and follow-up mechanisms for findings identified during the Ward managers and supervisors should receive coaching leadership training to ensure that NLR functions not merely as an inspection tool, but as a platform for professional learning and reinforcing a culture of safety.
Furthermore, the integration of electronic documentation systems can enhance the success of NLR by enabling real-time monitoring of compliance.
Asih and Indrayadi .
reported that userfriendly electronic medical record formats could improve documentation completeness by up to Integrating technology with leadership practices like NLR can therefore strengthen the overall effectiveness of clinical supervision and quality improvement efforts.
Conclusion This study confirms that positive perceptions of Nursing Leadership Rounds (NLR) are significantly associated with higher levels of compliance in medical record documentation among NLR serves as an effective clinical leadership strategy that fosters intrinsic motivation, strengthens communication, and enhances the culture of quality and accountability within nursing Consistent and structured implementation of NLR can improve nursesAo awareness and responsibility toward documentation standards, contributing to better patient safety outcomes and overall healthcare quality.
To optimize its impact.
NLR should be supported by leadership training programs and integrated with technology-based documentation systems.
Recommendations For Hospital Management Nursing Leadership Rounds (NLR) should be established as a routine, structured, and welldocumented supervisory activity within the hospital.
The process should include standardized guidelines, evaluation indicators, and follow-up mechanisms.
In addition, leadership development and coaching training for ward managers are essential to ensure that NLR implementation is effective and sustainable.
For Staff Nurses Nurses are encouraged to actively participate in NLR sessions and use them as opportunities for self-reflection, professional development, and quality improvement.
Compliance with documentation standards should be viewed as both a professional duty and a core component of patient safety.
For Future Researchers Future studies are recommended to employ a quasi-experimental design to measure the direct impact of NLR more objectively.
Further research could also explore additional factors influencing documentation compliance, such as leadership style, organizational culture, and managerial support systems.
References