An Exploration of the Elements of Professionalism within Nursing Documentation in Malaysia

Nursing documentation is the key to nursing care in hospitals. According to Pirie (2011) and Wang et al. (2011), nursing documentation that contains evidence regarding the comprehensive level of nursing care has a strong correlation with nurses’ professional practice. Nurses in Malaysia are trained to abide by the Code of Professional Practice (1998); therefore, the purpose of this study is to explore how nurses demonstrate the elements of professionalism within their documentation from a Malaysian context. Despite the significance of nursing documentation in nursing practice, no study has been conducted and published on this crucial aspect of nursing practice in Malaysia. Hence, there is a need to explore how nurses demonstrate the elements of professionalism within their documentation.

This study utilises a mixed methods approach (triangulation - convergence model design) in exploring how nurses in Malaysia demonstrate the elements of professionalism within their nursing documentation. This mixed approach enables greater understanding of nurses’ views on their documentation and its influence on the way the documentation is prepared. A quantitative approach is employed to analyse retrospective nursing documentation, where a total of 655 case notes were selected from the five participating hospitals in Malaysia. An innovative data extraction tool based on the Registered Nurses’ Association of Ontario (RNAO, 2007) model of Professionalism in Nursing was used in the analysis. The RNAO (2007), proposed eight attributes of professionalism in nursing: i) accountability, ii) advocacy, iii) innovation and visionary, iv) ethics and values, v) autonomy, vi) knowledge, vii) spirit of inquiry and, viii) collegiality and collaboration. The presence of all these attributes was assessed in the 655 selected case notes. Simultaneously, a total of 40 semi-structured interviews were conducted with nurses involved in completing the 655 reviewed case notes. In this context, thematic analysis (Braun & Clarke, 2006) was used to identify categories and themes in nurses’ accounts of their documentation, in relation to the elements of professionalism in nursing.

In summary, the quantitative findings reveal that there is evidence of the elements of professionalism exhibited in the nursing documentation among the selected case notes. However, the qualitative findings prove that the nurses could not demonstrate their comprehension of the elements of professionalism in their documentation. Several factors and influences were identified, which could be detrimental to nurses’ understanding of the elements of professionalism in nursing documentation, such as the working culture and common cultural values, educational backgrounds, different workplace settings and recognition of the profession. Additionally, the findings of this study point towards the creation of an alternative approach to explore and understand the elements of professionalism in nursing within the scope of this study.

The findings of this study suggest that there is room for further, extensive development of nursing documentation and future studies in many other health settings in Malaysia. The findings of this study could inform responsible authorities in health care and nursing educators to focus or to re-emphasise the importance of ensuring the good quality of nursing documentation in Malaysia. Furthermore, the findings could be used as a baseline to guide the relevant nursing authorities and personnel in Malaysia when dealing with complicated documentation issues and to improve the standard of the nursing documentation from a professional perspective in relation to the nursing practice.