Analysis of Standardized Nursing Languages Application in the Context of Nursing Diagnosis in Hospital in Indonesia
Keywords:Nursing, Standardized nursing languages, Nursing languages, Nursing diagnosis
Background. Documentation of nursing care is important in applying care to patients, in terms of their workload coming into the context of indirect nursing care. The focus of his study is to assess the application of nursing diagnoses in hospitals. The phenomenon that occurs in the order of nursing services was found that nurses only focused on documenting nursing assessments, but formulating nursing diagnoses was not clearly illustrated and there are still different perceptions in relation to writing a nursing diagnosis phrase. Objective. The purpose of this study is to identify the application of Standardized Nursing Languages in the context of nursing diagnoses in hospitals in Indonesia.
Method. This study uses a descriptive correlation design using simple random sampling and obtained 132 nurse respondents. Closed questions (with answer choices prepared by the researcher) and open questions (in the form of frequently used diagnostic questions) were used. The instrument was first tested for validity and content validity with a CVI (0.9) and CVR (0.85) value, which means that the instrument is relevant and important to use.
Results. It was found that almost half of the respondents (48.49%) nurses did not use a standard diagnosis. Only the level of education has a relationship with the application of the use of standard language nursing in Indonesia (p-value = 0.006) where the higher the education of nursing will have an impact on accuracy in diagnosing. Whereas for other variables such as gender, career ladder level and position in nursing were found no relationship with the ability in the accuracy of writing diagnoses.
Conclussion. As the results shows that the use of the standard language of nursing is not fully used by nurses in Indonesia. Standardization and equalization of perception by nursing professional organizations are needed to be a guide for all nurses in carrying out documentation of nursing care
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