Affiliations 

  • 1 Universiti Malaysia Sarawak (UNIMAS), Kota Samarahan, Sarawak
  • 2 Griffith University
  • 3 University of Huddersfield
MyJurnal

Abstract

Introduction: Nursing documentation is the key to nursing care in hospitals. Nursing documentation contains ev- idences which demonstrate a significant association between the comprehensive level of nursing care and nurses’ professional practice. Therefore, nurses in Malaysia are trained to abide with the code of professional practice (1998) which required them to contrive a complete and comprehensive nursing documentation. Despite the importance of nursing documentation in the nursing professional practice, such study almost non-existent in Malaysia. Hence, there is a need to explore nurses understanding about existence of professionalism within their documentation, from a Malaysian context. Methods: The study utilized a qualitative approach which aimed to explore the perceptions among nurses in Malaysia on their documentation with relation to professionalism in nursing. Forty semi structured interviews were conducted in order to obtain an understanding of nurses’ views on their documentation and its influ- ence on their ways of preparing and completing their documentation. Thematic analysis was used to identify catego- ries and themes in nurses’ accounts of their documentation with relation to professionalism in nursing. Results: One of many profound findings from the study is the fear among nurses of “blaming culture” in that occurs their clinical setting. The nurses perceive “blaming culture” do not tolerate mistakes and they are more likely to be blamed for poor patient safety and insufficient quality of care. This is because nurses are directly involved in delivering care to patient or client in the hospital. “Blaming culture” however motivates nurses to ensure their documentation is com- plete, comprehensive and contemporaneous. Conclusion: Interestingly, the nurses perceive their documentation as an important evidence if there are possible future medical legal issues that they might have to involve with.