Pengaruh Faktor Internal Perawat dan Faktor Organisasi terhadap Penerapan Standar Dokumentasi Asuhan Keperawatan di Ruang Rawat Inap RSUD Bendan Kota Pekalongan

Universitas Diponegoro Fakultas Kesehatan Masyarakat Program Magister Ilmu Kesehatan Masyarakat Konsentrasi Administrasi Kebijakan Kesehatan 2014 ABSTRAK Teguh Irawan Pengaruh Faktor Internal Perawat dan Faktor Organisasi terhadap Penerapan Standar Dokumentasi Asuhan Keperawatan di Ruang Rawat Inap RSUD Bendan Kota Pekalongan 110 halaman + 30 tabel + 2 gambar + 15 lampiran Dokumentasi asuhan keperawatan sangat penting untuk mengetahui perkembangan status kesehatan pasien dan bukti tanggung jawab perawat dalam menjalankan tugasnya. Proses dokumentasi di ruang rawat inap RSUD Bendan belum berjalan dengan baik, terbukti 63,3% dokumentasi asuhan keperawatan tidak lengkap. Penelitian ini bertujuan menganalisis pengaruh faktor internal perawat dan faktor organisasi terhadap penerapan standar dokumentasi asuhan keperawatan di ruang rawat inap RSUD Bendan Kota Pekalongan. Jenis penelitian adalah observasional analitik dengan rancangan cross sectional. Variabel bebas yaitu pengetahuan, sikap, persepsi imbalan, persepsi sarana, persepsi supervisi, persepsi beban kerja dan persepsi kebijakan. Variabel terikat yaitu penerapan standar dokumentasi asuhan keperawatan. Sampelsemua perawat di ruang rawat inap (74 perawat). Pengumpulan data dengan cara observasi dan wawancara menggunakan kuesioner terstruktur. Analisis data dilakukan secara univariat (deskriptif), bivariat (Pearson product moment dan rank spearman) dan multivariat (regresi linier). Hasil penelitian menunjukkan sebagian besar responden memiliki pengetahuan kurang baik (67,6%), sikap baik (56,8%), persepsi imbalan kurang baik (54,1%), persepsi sarana baik (54,1%), persepsi supervisi baik (51,4%), persepsi beban kerja ringan (51,4%), persepsi kebijakan baik (52,7%). Responden yang mendokumentasikan asuhan keperawatan kurang lengkap sebanyak (56,8%). Variabel pengetahuan, sikap, persepsi imbalan, persepsi sarana, persepsi supervisi, persepsi beban kerja dan persepsi kebijakan berhubungan dengan penerapan standar dokumentasi asuhan keperawatan (nilai p ≤ 0,01). Variabel persepsi beban kerja (p=0,0001), pengetahuan (p=0,001) dan persepsi supervisi (p=0,003) berpengaruh secara bersama-sama terhadap penerapan standar dokumentasi asuhan keperawatan. Disarankan agar Manajemen RS mengadakan pelatihan tentang dokumentasi asuhan keperawatan, menyederhanakan format dokumentasi asuhan keperawatan. Melakukan bimbingan dan pengawasan secara rutin dalam pendokumentasian asuhan keperawatan. Kata Kunci : Penerapan Standar, Dokumentasi, Asuhan keperawatan Kepustakaan : 38 (1999-2013) Diponegoro University Faculty of Public Health Master’s Program in Public Health Majoring in Administration and Health Policy 2014 ABSTRACT Teguh Irawan The Influence of Internal Factors of Nurse and Organizational Factors towards the Implementation of Nursing Care Documentation Standard at Inpatient Unit of Bendan Public Hospital in Pekalongan City 110pages + 30tables + 2 figures + 15enclosures Documentation of nursing care is very important to recognize development of patient health status and as proof of nurses’ responsibility in accomplishing their tasks. The process of documentation at inpatient unit of Bendan Public Hospital had not been done well in which 63.3% of nursing care documents was incomplete. This research aimed to analyze the influence of internal factors of nurse and organizational factors towards the implementation of a nursing care documentation standard at inpatient unit of Bendan Public Hospital in Pekalongan City. This wasobservational-analytic research using cross-sectional approach. Independent variables encompassed knowledge, attitude, perception of reward, perception of means, perception of supervision, perception of workload, and perception of policy. On the other hand, implementation of nursing care documentation standard was as dependent variable. Samples were all nurses at inpatient unit (74 nurses). Data were collected by observing and interviewing using a structured questionnaire. Data were analyzed using the methods of univariate (descriptive), bivariate (pearson product moment and rank spearman), and multivariate (linear regression). The result of this research revealed that mostly respondents had bad knowledge (67.6%), good attitude (56.8%), bad perception of reward (54.1%), good perception of means (54.1%), good perception of supervision (51.4%), perception of light workload (51.4%), and good perception of policy (52.7%). In addition, most of them did not document nursing care well (56.8%). Variables of knowledge, attitude, perception of reward, perception of means, perception of supervision, perception of workload, and perception of policy significantly related to the implementation of the standard (p ≤ 0.01). Furthermore, variables of workload (p=0.0001), knowledge (p=0.001), and perception of supervision (p=0.003) jointly influenced the implementation of the standard. As a suggestion, the hospital management needs to conduct a training of nursing care documentation, simplify a form of nursing care documentation, guide and monitor the documentation process regularly. Key Words: Standard Implementation, Documentation, Nursing Care Bibliography: 38 (1999-2013