ETHICAL ASSESSMENT OF

NURSING CARE QUALITY IN EMR

Professor Dr. Nursalam, M. Nurs (Hons)

Professor in Nursing Sciences,
Universitas Airlangga
 Name : Prof. Dr. Nursalam, M. Nurs (Hons)-UoW
Phone : 081339650000
Address : Jl. Keputih Tegal Timur 62 Surabaya 60111
e-Mail : nursalam@fkp.unair.ac.id

HIGHER, EDUCATION:
1. Doctor, Medecine, Postgraduate Programme, Airlangga University, 2005
2. Honours Master of Nursing,, University of Wollongong, New South Wales, Australia, 1997
3. Master of Nursing (Coursework), Univ. Wollongong, NSW, Australia,1996
4. Med. Surgical Nursing, Lambton College, Sarnia Ontario Canada, 1991
5. Diploma III in Nursing, Sutoma Surabaya 1988

ORGANISATION AND WORKING EXPERIENCES :

1. Dean, Faculty of Nursing Universitas Airlangga (2008 – 2010) & (2015 – 2020)
2. Chaiman, AIPNI Regional JAWA TIMUR (2015-2017)
3. Chairman, PPNI Jawa Timur (2015-2020)
4. Head, Education and Training, Dewan Pengurus Pusat PPNI
5. Nursing Manager, Airlangga University Hospital (2011-2015)
6. Head, School of Nursing, Faculty of Medecine, UNAIR (2007 – 2008)
7. Vice Head, Educatin & Training, PPNI East Java Nursing Association (2000 – 2010)
PUBLICATION: 20 books; 150 articles
Disruption ERA?
 An era where many new products, with new logic, totally
different ideas, and can eliminate old products.
 An era in which the economic landscape is much
influenced by the development of technology (the most
dominant IT technology).
 The solution: Not opposed, but must collaborate
with competitors as soon as possible.
 It is

not the strongest

of the species that survive,

nor the most intelligent,

but the one

most adaptable
to change

Charles Darwin
ELECTRONIC
MEDICAL RECORD?
 EMR stands for Electronic medical records, which are the
digital equivalent of paper records, or charts at a clinician’s
office. EMRs typically contain general information such as
treatment and medical history about a patient as it is
collected by the individual medical practice.
Integration Challenges
By implementing EMR, patient data can be tracked over an extended
period of time by multiple healthcare providers. It can help identify
those who are due for preventive checkups and screenings and monitor how
each patient measures up to certain requirements like vaccinations and blood
pressure readings. EMRs are designed to help organizations provide
efficient and precise care.

Perhaps the most significant difference is that EMR records are universal,
meaning that instead of having different charts at different healthcare facilities,
a patient will have one electronic chart that can be accessed
from any healthcare facility using EMR software.
Flow Chart EMR
RSUD Dr. Soetomo has been implemented EMR

Using standardization of SOAP (Subjective, Objective,

Assessment, Planning)
The Benefits of EMR
 Data become complete and standardizes of (ICD
X, ICD 9 CM)
 Searching process is faster and accurate
 Abstraction, report is easier
and automatically
Storage is more compact, does not require a large
space
 Data can be displayed quickly as needed
Integrated with LIS (Laboratory Information System) 
Integrated with PACS (Picture Archive Communication
System)  for MRI results
 ICU

• Angka kegagalan pengambilan sampling BGA (>3x)

• Angka kejadian phlebitis
• Angka kejadian decubitus
• Angka kejadian pasien jatuh
• Angka kesalahan pemberian obat
• Angka kejadian cedera akibat restrain
• Angka kejadian terekstubasi

NURSALAM-2004
 INTEGRATED NOTES
ONTOH
C
Nursing Care in EMR ?
Clinical documentation supports patient care, improves
clinical outcomes, and enhances interprofessional
communication. When you document your assessments, plans,
and actions, you rely on nursing practice standards, organizational
policies, meaningful use directives, and a variety of quality criteria.

Electronic Medical Records (EMRs) support that documentation with

data that enhance patient safety,
help you
evaluate care quality, maximize efficiency,
and measure staffing needs. And they serve as a
standard form of documentation that can be shared by everyone
on the healthcare team. However, when not used appropriately,
EHRs can reduce nurses’ use of their critical-thinking skills, increase
reliance on workarounds to bypass forms, and lead to errors and
lost documentation.
As with every change project, leadership commitment is key. Nursing
leaders were supportive of the project and the proposed solutions.
However, we encountered some challenges (and developed some
solutions), including:

•Limited resources to spearhead change on a large scale—The

NPC designed a tool to integrate the nursing process in our existing
EHR.
•Inability to reach all users and cover all specialties—The nursing
process tool was disseminated through each NPC representative to
their respective specialties to be used as a guide in EHR
documentation.
•Barriers to measuring the impact of change on patient
outcomes and financial returns—Work has begun to develop a
shorter and better way of auditing real-time documentation and
Ethics for Nurses?
  Empathy and caring
 Communication
 Teaching
The core values of  Critical Thinking
Nursing  Psychomotor Skills
 Applied Therapeutics
 Ethical and Legal Consideration
 Professionalism
 Care

Commit
ment

The 6’Cs of Nursing Compassion Competence

Communica
tion

Courage
 “ …. doing good and avoiding harm
(Bandman & Bandman, 1995:5)

What should humans do

What should be done to someone
An analysis of the process of an action
Based on knowledge, values and norms in society

MORAL (what is considered good / bad by

the community)
ETHICAL PRINCIPLES
J-A-B-V-C-F
JUSTICE (adil)
AUTONOMY (menghargai)
BENEFICIENCY (manfaat) & NON-MALEFICIENCY
VERACITY (kejujuran)
CONFIDENTIALITY (kerahasiaan)
FIDELITY (komitmen)
 Electronic Medical Record (EMR)-based documentation that varied
from established interprofessional practice standards

McBride, S., Tietze, M., Robichaux, C., Stokes, L., Weber, E., (January 31, 2018) "Identifying and Addressing Ethical Issues with Use of Electronic
Health Records" OJIN: The Online Journal of Issues in Nursing Vol. 23, No. 1
Four Component Model (FCM) to identify
and address ethical issues in nursing
practice

Sensitivity

Action Judgement

Motivation
Four Component Model to identify and
address ethical issues in nursing practice

Ethical sensitivity is described as our ability to

Sensitivity recognize an ethical problem, the moral
implications of our decisions, and how our
actions affect other people (Milliken, 2016). Its
development depends on an understanding of
the ethical nature of the role as an obligation
of the nursing profession (
Milliken & Grace, 2017)
Four Component Model to identify and
address ethical issues in nursing practice

Ethical judgment or decision-making, a deliberative

process reflecting knowledge of ethical principles,
theories, and codes. Most have elements that outline an
approach to reaching a decision through identifying facts
and considering specific questions related to ethical
Judgement principles and/or virtue ethics and care ethics. Not all
issues will require an in-depth consideration of all
elements in a specific model, and the goal is to reach a
prudent choice, not certainty (Grace, 2014; 
Milliken & Grace, 2017; Robichaux, 2017)
Four Component Model to identify and
address ethical issues in nursing practice

The third component in the FCM, ethical motivation

is the bridge between decision-making and action (
Robichaux, 2017). Competing personal values... can
impede motivation and action. Competing personal
values such as protecting one’s position or
reputation can impede motivation and action.
“Persevering to do the right thing” (
Motivation Grace, Robinson, Jurchak, Zollfrank, & Lee, 2014)
Four Component Model to identify and
address ethical issues in nursing practice

Individuals with moral courage have developed skills

of effective engagement and “willingness to speak
out and do what is right in the face of forces that
would lead a person to act in some other way” (
Lachman, 2007). Moral courage can also be
Action
“learned, practiced, and mentored” (
Hawkins & Morse, 2014). When moral courage and
ethical action are thwarted by constraints outside
the nurse's control, moral distress can result
Code of Ethics for Nurses?
The ICN Code of Ethics for Nurses
has four principal elements that
outline the standards of ethical Nurses and
conduct People

Nurses Nurses
and Co- and
Workers Practice
Nurses and
the
Profession
  The nurse’s primary professional responsibility is to people
requiring nursing care.
 In providing care, the nurse promotes an environment in which the human
rights, values, customs and spiritual beliefs of the individual, family and
community are respected.
The nurse ensures that the individual receives accurate,
sufficient and timely information in a culturally appropriate
manner on which to base consent for care and related
Nurses and treatment.
 The nurse holds in confidence personal information and uses judgement in
People sharing this information.
 The nurse shares with society the responsibility for initiating
and supporting action to meet the health and social needs of the public, in
particular those of vulnerable populations.
 The nurse advocates for equity and social justice in resource
allocation, access to health care and other social and
economic services.
 The nurse demonstrates professional values such as
respectfulness, responsiveness, compassion, trustworthiness and integrity.
Nurses and
People
  The nurse carries personal responsibility and accountability
for nursing practice, and for maintaining competence by continual
learning.
 The nurse maintains a standard of personal health such that the
ability to provide care is not compromised.
Nurses  The nurse uses judgement regarding individual competence when
and accepting and delegating responsibility.
 The nurse at all times maintains standards of personal conduct
Practice which reflect well on the profession and enhance its image and
public confidence.
 The nurse, in providing care, ensures that use of technology and
scientific advances are compatible with the safety, dignity and
rights of people.
 The nurse strives to foster and maintain a practice culture
promoting ethical behaviour and open dialogue.
Nurses
and
Practice
  The nurse assumes the major role in determining and
implementing acceptable standards of clinical nursing practice,
management, research and education.
 The nurse is active in developing a core of research-based
professional knowledge that supports evidence-based practice.
 The nurse is active in developing and sustaining a core of
Nurses and professional values.
the  The nurse, acting through the professional organisation,
Profession participates in creating a positive practice environment and
maintaining safe, equitable social and economic working
conditions in nursing.
 The nurse practices to sustain and protect the natural
environment and is aware of its consequences on health.
The nurse contributes to an ethical organisational environment and
challenges unethical practices and settings.
Nurses and
the
Profession
  The nurse sustains a collaborative and respectful relationship
with co-workers in nursing and other fields.

 The nurse takes appropriate action to safeguard individuals,

Nurses and families and communities when their health is endangered by a
Co-Workers co-worker or any other person.

 The nurse takes appropriate action to support and guide co-

workers to advance ethical conduct.
Nurses and
Co-Workers
INSTRUMENTS FOR
ETHICAL PERFORMANCE
 Pernyataan yang diukur
Perawat dalam memberikan pelayanan
keperawatan menghargai harkat dan
martabat manusia, keunikan klien, dan
tidak terpengaruh oleh pertimbangan
kebangsaan, kesukuan, warna kulit, umur,
jenis kelamin, aliran politik dan agama
yang dianut serta kedudukan sosial
 
Perawat  
dan Perawat dalam memberikan pelayanan 1.
klien keperawatan senantiasa memelihara
suasana lingkungan yang menghormati 2.
nilai-nilai budaya, adat istiadat dan
kelangsungan hidup beragama
Tindakan/aktivitas yang diukur
1. Perawat wajib memperkenalkan diri kepada klien dan keluarganya pada
setiap awal dan pamit pada akhir shift;
2. Perawat wajib menjelaskan setiap intervensi keperawatan yang dilakukan
pada klien;
3. Perawat dalam memberikan pelayanan keperawatan dilarang mencela adat
kebiasaan dan keadaan khusus klien;
4. Perawat dalam memberikan pelayanan keperawatan dilarang membeda-
bedakan pelayanan atas dasar kebangsaan, kesukuan, warna kulit, umur,
jenis kelamin, aliran politik dan agama yang dianut serta kedudukan sosial
pada klien;
Perawat pada awal bertemu klien, wajib menjelaskan bahwa mereka boleh
menjalankan kegiatan yang terkait dengan budaya, adat dan agama;
Perawat dalam memberikan pelayanan harus memelihara suasana
lingkungan yang menghormati nilai-nilai budaya, adat istiadat dan
kelangsungan hidup beragama dan wajib mencari solusi yang akan berpihak
pada klien bila terjadi konflik terkait nilai-nilai budaya, adat istiadat dan
kelangsungan hidup beragama;
3. Perawat wajib membantu klien memenuhi kebutuhannya pada intervensi
keperawatan sesuai dengan budaya, adat istiadat dan agama;
4. Perawat wajib mengikut sertakan klien secara terus menerus pada saat
memberikan asuhan keperawatan.
 Pernyataan yang diukur Tindakan/aktivitas yang diukur
Tanggung jawab utama perawat 1. Perawat dalam melaksanakan intervensi keperawatan wajib
adalah kepada mereka yang sesuai dengan kompetensi yang dimilikinya;
membutuhkan asuhan 2. Perawat wajib melaksanakan asuhan keperawatan secara
keperawatan tuntas dan tepat waktu;
3. Perawat dilarang melakukan serah terima bila tindakan
keperawatan belum dilaksanakan sesuai dengan rencana yang
Perawat telah dibuat, kecuali bila ada alasan yang dapat diterima;
4. Perawat wajib membuat dokumentasi asuhan keperawatan
dan sesuai dengan kaidah yang berlaku.
Perawat wajib merahasiakan Perawat dilarang membocorkan rahasia tentang segala sesuatu
klien segala sesuatu yang diketahui yang diketahui sehubungan dengan tugas yang dipercayakan
sehubungan dengan tugas yang kepadanya kecuali jika diperlukan oleh yang berwenang sesuai
dipercayakan kepadanya kecuali dengan ketentuan hukum yang berlaku;
jika diperlukan oleh yang  
berwenang sesuai dengan
ketentuan hukum yang berlaku
 Pernyataan yang diukur Tindakan/aktivitas yang diukur
Perawat memelihara dan 1. Perawat harus berusaha untuk meningkatkan ilmu dan keterampilan
meningkatkan kompetensi dibidang sesuai dengan kemampuan;
keperawatan melalui belajar terus 2. Perawat harus mengamalkan ilmu dan keterampilan yang dimiliki;
menerus 3. Perawat harus mempublikasi-kan ilmu dan keterampilan yang dimiliki
baik dalam bentuk hasil penelitian maupun presentasi kasus.
Perawat senantiasa memelihara mutu 1. Perawat wajib memelihara mutu pelayanan keperawatan seoptimal
pelayanan keperawatan yang tinggi mungkin dengan mengikuti seminar/pelatihan/ workshop;
Perawat disertai kejujuran profesional yang 2. Perawat sebelum menerapkan pengetahuan dan keterampilan yang
menerapkan pengetahuan serta baru, wajib dievaluasi oleh perawat yang telah berkompeten;
dan keterampilan keperawatan sesuai 3. Perawat dalam memberikan asuhan keperawatan wajib
praktik dengan kebutuhan klien mengidentifikasi asuhan keperawatan yang tidak sesuai dengan nilai-
nilai profesi keperawatan;
4. Perawat wajib menyampaikan kepada pimpinan, apabila menemukan
pelayanan kesehatan yang tidak sesuai dengan nilai-nilai yang dianut
untuk selanjutnya ditindak-lanjuti;
5. Perawat dalam memberikan intervensi keperawatan wajib merujuk
pada standar yang dikeluarkan institusi pelayanan kesehatan;
6. Setiap teknologi keperawatan yang digunakan wajib diuji validitas
(kehandalan) dan reliabilitas (keabsahan) oleh lembaga yang
berwenang.
 
 Pernyataan yang diukur Tindakan/aktivitas yang diukur
Perawat dalam membuat keputusan 1. Perawat dalam membuat keputusan wajib didasarkan pada
didasarkan pada informasi yang informasi yang akurat;
akurat dan mempertimbangkan 2. Perawat dalam membuat keputusan wajib mempertimbangkan
kemampuan serta kualifikasi kemampuan serta kualifikasi seseorang bila melakukan konsultasi,
seseorang bila melakukan menerima delegasi dan memberikan delegasi kepada orang lain;
konsultasi, menerima delegasi dan
memberikan delegasi kepada orang
Perawat lain
dan Perawat senantiasa menjunjung
tinggi nama baik profesi
1. Perawat dilarang menyampaikan hal-hal yang terkait dengan
kegiatan profesi keperawatan, kecuali ditugaskan oleh pejabat
praktik keperawatan dengan selalu
menunjukkan perilaku profesional 2.
yang berwenang;
Perawat wajib menyelesaikan permasalahan terkait pelaksanaan
tugas profesi keperawatan secara internal terlebih dahulu;
3. Penyelesaian masalah harus dipimpin oleh perawat penanggung
jawab;
4. Perawat harus menjaga kesehatan jasmani dan rohani yang
diperlukan untuk menampilkan sikap profesinya;
5. Perawat yang dalam keadaan tidak sehat dilarang memberikan
asuhan keperawatan.
 Pernyataan yang diukur Tindakan/aktivitas yang diukur
Perawat mengemban tanggung 1. Perawat dibawah institusi tempat bekerja wajib melakukan
jawab bersama masyarakat untuk kegiatan pengabdian masyarakat satu kali dalam setahun;
memprakarsai dan mendukung 2. Perawat wajib memberikan informasi pada masyarakat
berbagai kegiatan dalam tentang area cakupan pelayanan keperawatan yang diberikan
Perawat dan memenuhi kebutuhan dan dengan menggunakan media yang disepakati secara berkala;
masyarakat kesehatan masyarakat 3. Perawat dapat ikut serta menyelesaikan masalah kesehatan
masyarakat sesuai dengan kompetensinya;
4. Perawat wajib ikut berperan serta dalam mengembangkan
teknologi keperawatan.
 Pernyataan yang diukur Tindakan/aktivitas yang diukur
Perawat senantiasa memelihara 1. Perawat harus berdiskusi dengan sesama perawat membahas
hubungan baik dengan sesama hal terkait dengan profesi secara berkala;
perawat maupun dengan tenaga 2. Dalam menyampaikan pendapat, Perawat harus
kesehatan lainnya dan dalam menggunakan rujukan yang diakui kebenarannya;
memelihara keserasian suasana 3. Perawat wajib menghargai pendapat kolega;
Perawat lingkungan kerja maupun dalam 4. Perawat harus menyimpulkan hasil pertemuan dengan saling
mencapai tujuan pelayanan menghargai.
dan kesehatan secara menyeluruh
teman
Perawat bertindak melindungi 1. Perawat wajib memberikan perlindungan pada klien;
sejawat klien dari tenaga kesehatan yang 2. Perawat harus memahami alur untuk menyampaikan masalah
memberikan pelayanan bila terjadi pelayanan kesehatan yang tidak mengikuti kaidah
kesehatan secara tidak kompeten, etik;
tidak etis dan ilegal 3. Pimpinan Perawat wajib melindungi anggotanya dalam
membahas dan mengemuka-kan pendapat;
 Pernyataan yang diukur Tindakan/aktivitas yang diukur
Perawat mempunyai peran utama 1. Perawat wajib memberikan masukan kepada institusi
dalam menentukan standar pendidikan tentang kemajuan ilmu pengetahuan dan
pendidikan dan pelayanan teknologi keperawatan;
keperawatan serta 2. Perawat wajib mengadakan pertemuan dengan institusi
menerapkannya dalam kegiatan pendidikan secara efektif;
pelayanan dan pendidikan 3. Pimpinan Keperawatan pada institusi pelayanan kesehatan
keperawatan harus memantau penerapan kode etik keperawatan;
Perawat 4. Pimpinan keperawatan wajib mengadakan pertemuan dengan
dan Komite Etik Profesi secara berkala;
profesi 5. Komite Etik Profesi pada institusi pelayanan kesehatan harus
melaporkan dan membahas kegiatannya dengan PPNI secara
berkala.

Perawat berperan aktif dalam 1. Perawat wajib melakukan kajian asuhan keperawatan yang
berbagai kegiatan pengembangan diberikan secara terus menerus dibawah bimbingan perawat
profesi keperawatan yang ditunjuk;
2. Perawat wajib membahas hasil kajian asuhan keperawatan
dalam forum temu ilmiah perawat pada institusi terkait
sekurang-kurangnya satu kali dalam satu tahun.
 Pernyataan yang diukur Tindakan/aktivitas yang diukur
Perawat berpartisipasi aktif dalam 1. Perawat wajib menjalankan tugas profesinya dengan penuh
upaya profesi untuk membangun tanggung jawab;
dan memelihara kondisi kerja 2. Perawat wajib menyampaikan asuhan keperawatan yang telah
Perawat yang kondusif demi terwujudnya dilakukannya pada setiap serah terima;
dan asuhan keperawatan
bermutu tinggi
yang 3. Perawat penanggung jawab wajib memastikan terlaksananya
asuhan keperawatan yang diberikan oleh perawat pelaksana
profesi yang ada dibawah tanggung jawabnya;
4. Perawat penanggung jawab wajib menyampaikan
perkembangan asuhan keperawatan kepada penanggung
jawab perawatan yang lebih tinggi secara berkala.
Why ethics & legal became a greater
dimension in management decision making?

 Increasing technology, and regulatory pressures.

 Competitiveness among health care providers.
 Nursing shortages, and reduced fiscal resources
& spiraling costs of supplies and salaries.
 The public’s increasing distrust of the health care
delivery system and its institution.
THANK YOU