EFFECTIVENESS OF SUPERVISION WITH COMPLIANCE WITH NURSING
ROUND DOCUMENTATION IN THE CHILD CARE ROOM
Tri Ratnaningsih.
Ita Bagus Argentina .
Aris Suprianto Universitas Bina Sehat PPNI Kabupaten Mojokerto.
Jawa Timur Indonesia
Corresponding author*: Tri Ratnaningsih / 085648631672
ABSTRACT
Keywords Nursing rounding is conducted every two hours, which includes monitoring patient complaints, monitoring IV line complaints, positioning the patient comfortably, meeting personal needs, meeting elimination needs, and maintaining privacy.
In-service conditions, nurses' compliance with nursing rounding documentation remains low.
Compliance with nursing rounding documentation can be improved through nurse supervision.
This study aims to analyze the relationship between supervision and compliance with nursing rounding documentation.
This study used a correlational analytical approach with a cross-sectional method.
A sample of 84 nurses was selected using purposive sampling from a population of 90 nurses.
The instruments used included a nursing rounding documentation observation questionnaire.
GROW-ME coaching, and a compliance observation sheet.
Data analysis was performed using the Spearman Rho correlation test.
Most nurses received good supervision .
%).
Eighty percent of nurses demonstrated compliance with nursing rounding documentation.
There was a significant relationship between supervision and nursing rounding documentation .
=0.
Nurse supervision significantly increased compliance with nursing rounding It is recommended that institutions strengthen coaching, training, and motivation programs to improve the quality of documentation and overall nursing care.
INTRODUCTION
Nurses comprehensive, high-quality nursing care.
High-quality nursing care can be demonstrated through the quality of nursing If nursing activities are not objectively, and completely, and in Supervisio Nursing Rounding Document Complianc accordance with nursing care standards, it is difficult to prove that nursing actions have (Article 2.
(Kilminster and Jolly 2.
One type of nursing documentation that must be documented according to standards is nursing rounding documentation.
Nursing rounding documentation by nurses that does International Journal of Nursing and Midwifery Science (IJNMS).
Volume 9.
Issue 3.
December 2025 not comply with standard operating procedures (SOP.
has the potential for inter-team communication, duplication of nursing care actions, a decline in professional ethics, and a higher risk of errors in nursing care due to a lack of evidence of nurse accountability and responsibility (Documentation 2.
(Ajzen 1.
Poor nursing rounding documentation is caused by several factors, including inconsistent supervision, high workloads, the absence of a reward and punishment system, low nurse knowledge of nursing rounding, a lack of guidance and coaching in conducting nursing rounding procedures, and a lack of monitoring and evaluation after Nurses' low motivation for nursing rounding activities (Meade 2.
Research in Egypt showed that 9% of nurses at Benhill University Hospital had not received training on nursing rounding.
In Indonesia, the implementation of nursing rounding remains At R.
Manado General Hospital, only 64.
5% of nurses understood the implementation of nursing rounds (Bowers 2.
According to(Andika and Saputra 2.
, in their research conducted at several hospitals in Jakarta, approximately 60-75% of nurses had begun documenting nursing rounds regularly and according to The remaining 25-40% of nurses still faced challenges in documenting them completely or on time.
In regional hospitals, especially those outside major cities, nursing rounding documentation levels are generally lower, with only about 50-60% of nurses Research conducted by Lestari et al.
in several hospitals in East Java showed that 55% of nurses in these hospitals did not perform comprehensive documentation, which impacted the quality of service.
Research by (Andika and Saputra 2.
showed that more than 70% of nurses in hospitals in East Java did not consistently document nursing rounding, which impacted the quality of patient care.
Meanwhile, research by(Wahyuni.
Asmoro.
& Susiana 2.
showed that around 35% of nurses in Surabaya hospitals showed noncompliance with nursing documentation.
Based on a preliminary study conducted in August 2024 in the inpatient ward of Mitra Keluarga Waru Hospital, 60% of 30 nurses documented nursing rounds, while 40% did not.
Only 15% documented nursing rounds every 2 hours, and 85% were not completed on schedule.
The preliminary study also found that some nurses were not yet compliant with nursing round documentation due to other activities and not documenting them promptly, resulting in missed appointments.
According to(McDonald.
, &
McArthur 2.
the impact that occurs if nurses do not document nursing rounding properly, it has a negative impact on the quality of patient care, the nursing service system becomes unstructured and not optimal, there can be repetition of work which causes decreased patient satisfaction, decreased quality of patient care, medical errors, treatment and complaints are not handled properly, communication between nursing teams becomes poor and cannot be accounted for, the risk of infection / phlebitis increases and complications increase which causes decreased patient and family Implementation of nursing documentation that does not meet standards will reduce communication between teams and have a negative impact on the quality of nursing care (Negarandeh.
Mahmoodi, , & Haghani 2.
Nursing significantly facilitates communication between nursing teams and clients, including client decisions regarding treatment, evaluation of treatment outcomes, and feedback on treatment outcomes as considerations for subsequent actions.
Nursing care documentation is a crucial part of the nursing process after providing care to (Ede.
Nursing documentation plays a crucial role in the implementation of nursing services.
Nursing documentation serves as a non-verbal communication medium and the sharing of relevant information between nursing Efforts that can be made to improve nursing round documentation compliance International Journal of Nursing and Midwifery Science (IJNMS).
Volume 9.
Issue 3.
December 2025 include improving supervision, conducting coaching, and increasing nurses' work Supervision is very important in the implementation of nursing rounds, because it can change and direct a person's behavior in acting, one of which is nursing round documentation.
Nursing round documentation compliance can be carried out by nurses using the proctor method supervision technique, namely one-to-one performance-based, collaborative approach, and providing continuous feedback (Basalamah.
& AsAoad 2.
In addition, according to (Lufianti.
, supervision and coaching have an important role in improving nurse performance in various hospital contexts.
Another approach is the GROW ME coaching method, as it has a simple and easy-to-follow structure, focuses on achieving goals, increases self-awareness, and encourages creativity in problemsolving .
Another approach is nurse motivation provides emotional support for nurses in documenting nursing rounds according to procedures (Sudariani, 2.
Milgram .
stated that a person's compliance with a system is influenced by both individual and external factors.
Individual factors include work motivation, age, education level, work experience, skills and knowledge, and workload.
External factors include the status of the agency's location, personal responsibility, the legitimacy of the authority figure, the status of the authority figure, peer support, and proximity to the authority figure.
METHOD
This research is an associative quantitative study to examine the influence of two variables using a cross-sectional study approach (Arikunto 2.
The analytical correlation design was used because the researcher intended to analyze the influence between the independent and dependent variables in a single measurement using a questionnaire.
The population was all 90 nurses in the inpatient ward of Mitra Keluarga Waru Hospital.
The sample was taken from a portion of the nurses in the inpatient ward of Mitra Keluarga Waru Hospital who met the criteria.
The sampling technique used in this study is purposive sampling technique.
The instrument used is Nursing Rounding Supervision Observation Sheet from the SPO Nursing Rounding Supervision of Mitra Keluarga Waru Hospital which contains 36 statements using the Gutt Mann scale with yes and no answers, if done is given a value of 1, if not done then the value is 0 then interpreted as Good: X Ou M SD.
Sufficient: (M-SD) O X < (M SD).
Less: X < M Ae SD.
Nursing Rounding Documentation Compliance Sheet from the SPO Nursing Rounding of Mitra Keluarga Waru Hospital which contains 25 statements, consisting of 6 parts namely: Pain.
Peripher.
Position.
Personal care.
Personal item.
Privacy.
Using the Gutt Mann scale with yes and no answers, if done is given a value of 1, if not done then the value is 0.
The validity test of the supervision observation sheet obtained all valid, higher than the R table at a significance level of 5%.
The documentation compliance test is also 5%, meaning that both variables.
The bivariate data analysis technique used to determine the correlation between the independent and dependent variables uses the Spearman rho statistical ETHICS REVIEW Research Ethics Review by the Health Research Ethics Committee of the ICME Jombang Health Sciences College.
No.
287/KEPK/ITSKES-ICME/II/2025,
dated February 4, 2025
RESULT
Table 1 Frequency Distribution of Characteristic Data Based on Age.
Gender.
Education.
Length of Service and Career Level at Mitra Keluarga Waru Hospital International Journal of Nursing and Midwifery Science (IJNMS).
Volume 9.
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December 2025 Based on table 1 above, it can be seen that the age of the respondents is mostly 20-30 years old as many as 46 people .
%) and a few of the respondents are aged > 40 years as many as 10 people .
%).
For the gender of the respondents, almost all of them are women as many as 82 people .
%) and very few of the respondents are male as many as 2 people .
%), and in terms of education, almost all of the respondents are S1 Ners as many as 66 people .
%) and a few of the respondents have a D3 Nursing education level as many as 18 people .
%).
Data for the length of service of the respondents Most are 1-5 years as many as 49 people .
%) and very few of the respondents have a length of service of 5-10 years as many as 10 people .
%).
The career level of the respondents is a small part of the nurse PK 2 as many as 31 people .
%) and very few of the respondents are PK 4 as many as 4 people .
%).
Table 2 Frequency Distribution of Respondents Based on Nursing Rounding Documentation Compliance of Nurses in the Inpatient Ward of Mitra Keluarga Waru Hospital.
February 2025 Kepatuhan Dokumenta si Nursing Rounding Patuh Tidak Patuh Frekuen Persentase( Total Based on table 2 above, it can be seen that the compliance of nursing rounding documentation of nurses in the Inpatient Ward of Mitra Keluarga Waru Hospital is almost entirely compliant, namely 66 people .
%) and very few respondents are noncompliant, namely 18 people .
%).
Table 3 Frequency distribution of respondents based on the results of cross-tabulation Supervision with Nursing Rounding Documentation Compliance of Nurses in the Inpatient Ward of Variabel
Frekuensi Prosentase Usia
20-30 tahun 31-40 tahun > 40 tahun Jenis Kelamin
Laki-laki Perempuan Pendidikan Keperawatan S1 Ners Lama Kerja 1-5 Tahun 5-10 Tahun > 10 Tahun Jenjang Karir
PK 1
PK 2
PK 3
PK 4
Mitra Keluarga Waru Hospital.
February 2025 Superv Nursin Roundi Baik Cukup Kurang Kepatuhan Dokumentasi Nursing Rounding Patu % Tida % Juml Total Uji Statisik Rank Spearman's rho ( pvalu.
= 0,000 < 0,05 Correlation coefficient = 0,662 Based on Table 3 above, the cross-tabulation results show that 75 respondents received good nursing rounding supervision, with 66 respondents .
%) complying with nursing respondents .
%) did not comply with Meanwhile, 4 respondents received International Journal of Nursing and Midwifery Science (IJNMS).
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December 2025 inadequate nursing rounding supervision, with all 4 respondents .
%) complying with nursing rounding documentation.
The statistical test using Spearman's rho test showed a p-value of 0.
000 <0.
05, indicating a relationship between nursing rounding supervision and compliance with nursing rounding documentation in the inpatient ward at Mitra Keluarga Waru Hospital.
DISCUSSION
Based on the research results, a probability value (P-valu.
000 was This indicates a significant relationship between supervision and compliance at Mitra Keluarga Waru Hospital, as evidenced by a p-value <0.
These results align with research conducted by (Andika and Saputra 2.
, which stated that the implementation of a management approach in the form of supervision has a positive effect on correct documentation in Therefore, documentation implementation is an aspect that must be considered to ensure that what has been implemented is properly and correctly recorded.
This study agrees with research by (Farokhzadian.
Nayeri, and Borhani 2.
, which stated that the relationship between ward head supervision and the completeness of nursing care documentation in the inpatient wards of Ungaran Regional Hospital.
Most nursing care documentation is supported by good In addition, research (Wardani, 2.
stated that there was a significant relationship between the supervision of the head of the room and the documentation of nursing care at Ambarawa General Hospital .
-value 0.
According to the theory proposed by Brigid Proctor .
, clinical supervision provides support in the development of nurses' professional skills.
Supervision of nursing rounding documentation is an activity that needs to be carried out by the head of the ward for the implementing nurse.
Nurses need to be maintained, developed, and have a positive attitude towards their Nurse job satisfaction in nursing practice is achieved when nurses feel they have made a contribution, are considered important, receive support from existing resources, and many nursing outcomes are achieved (Bunting and Klerk n.
This theory is also in line with the Fair.
Feedback, and Follow-Up supervision theory proposed by (Bosch-capblanch and Garner 2.
This theory states that supervision is carried out in three stages: clarifying existing problems (Fai.
, providing feedback (Feedbac.
, and giving awards or following up on findings during supervision (FollowU.
This theory increases the responsibility, ability, and authority of nurses in carrying out nursing documentation.
The relationship between supervision and nursing rounding compliance has a moderate relationship and a positive relationship direction with a correlation coefficient of This means that the better the supervision carried out, the higher the documentation in the inpatient ward, and conversely, the lower or worse the nursing supervision, the lower the compliance of nursing rounding documentation.
According to the researcher's opinion, the implementation of a management approach aimed at monitoring nursing care documentation is a supervisory activity that can be carried out by the head of the ward.
The existence of supervisory activities is expected to influence the correct documentation of the nursing process, so that evidence can be professionally and legally accounted for.
Therefore, the implementation of documentation is an aspect that must be considered so that what has been implemented is recorded properly and correctly.
In its implementation, nursing rounding supervision is carried out based on existing standard operating procedures (SOP).
The head of each ward section supervises nursing rounding to all nurses in the ward.
Supervision is carried out routinely every day by the head of the ward as well as supervision, validation by the Head of Department and audit by the nursing corporate according to a predetermined schedule to ensure that each nurse performs nursing rounding documentation according to standards.
The implementation of nursing rounding documentation supervision at International Journal of Nursing and Midwifery Science (IJNMS).
Volume 9.
Issue 3.
December 2025 Mitra Keluarga Waru Hospital is considered to have been implemented well in each unit so that nurse compliance in nursing rounding documentation has increase (Farokhzadian.
Nayeri, and Borhani 2.
Based on the description above and the research conducted, it can be seen that good supervision activities carried out by the head of the ward have an impact on increasing the completeness of nursing care documentation carried out by nurses in the inpatient ward.
The completeness of nursing care documentation carried out by nurses is due to the control and supervision of the head of the ward over the documentation of nursing care carried out by nurses through supervision activities.
Supervision activities carried out can assist nurses in documenting nursing roundings.
Repeated supervision can reduce nurse errors in documenting and improve good habits in documentation.
CONCLUSION
Nursing Rounding supervision in the inpatient wards at Mitra Keluarga Waru Hospital was generally considered good.
This was true for 75 staff .
%), while a small percentage .
were found to be SUGGESTIONS For respondents Nurses and ward heads can collaborate to maximize compliance with nursing rounding documentation by supervising.
For Institutions Agencies can provide facilities for ward heads and nurses to supervise, coach, and increase nurse work motivation.
Institutions are expected to support compliance with nursing rounding For further researchers This study can serve as a reference or literature source for further researchers, allowing them to expand upon other factors that have not yet been studied.
REFERENCES