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The Effectiveness and Efficiency of Nursing Care Documentation Using the

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The Effectiveness and Efficiency of Nursing

Care Documentation Using the SIMPRO Model
Rr. Tutik Sri Hariyati, Dr SKp, MARS, Achir Yani, Prof.DN.Sc, Tris Eryando, Dr.MA, Zainal Hasibuan, Prof.PhD, and
Ariesta Milanti, MSc.
Rr. Tutik Sri Hariyati, Dr SKp, MARS, is an Associate Professor at the Fundamental of Nursing, Faculty of Nursing,
Universitas Indonesia, Depok, West Java, Achir Yani, Prof.DN.Sc, is a Professor at the Psychiatric Nursing, Faculty of
Nursing, Universitas Indonesia, Depok, West Java, Tris Eryando, Dr.MA, is a Lecturer at the Faculty of Public Health,
Universitas Indonesia, Depok, West Java, Zainal Hasibuan, Prof.PhD, is a Professor at the Faculty of Computer Science,
Universitas Indonesia, Depok, West Java, and Ariesta Milanti, MSc., is a Lecturer at the Faculty of Nursing, Universitas
Indonesia, Depok, West Java, Indonesia.

Search terms: PURPOSE: The study aims to develop and test the effectiveness and efficiency of
Effectiveness and efficiency, the SIMPRO. SIMPRO was developed with NANDA-I, Nursing Intervention Classifi-
nursing care documentation, cation, and Nursing Outcome Classification nursing language.
nursing information system METHOD: The research was divided into two parts, in which we used two different
designs—incremental and quasi-experimental design. Two hundred fifty-five
samples of nursing documentations were randomly assessed with computer-
Author contact:
assisted clustering out of 1,040 nursing records of discharged patients. Data were
tutik@ui.ac.id, rrtutik@yahoo.com, analyzed using Wilcoxon test to compare each elements of evaluation before and
with a copy to the Editor: after the implementation of the system.
journal@nanda.org RESULT: SIMPRO improved the quality of documentation (p = .0001) and time
efficiency (p = .0001).
CONCLUSION: SIMPRO increased the quality and functions of the decision
support system in delivering nursing care as well as in nursing management.
TUJUAN: Penelitian ini bertujuan untuk mengembangkan dan menguji
keefektifan dan efisiensi SIMPRO. SIMPRO adalah sistem informasi manajemen
keperawatan yang dikembangkan dengan menggunakan NANDA-I, Nursing Inter-
vention Classification dan Nursing Outcome Classification.
METODE: Penelitian ini dibagi menjadi dua tahap yang menggunakan desain
incremental dan kuasi-eksperimental. 255 sampel dokumentasi keperawatan
diambil secara acak dengan menggunakan klustering yang dibantu dengan
komputer dari 1040 catatan keperawatan pasien yang sudah pulang. Data
dianalisis dengan Uji Wilcoxon untuk membandingkan masing-masing elemen
sebelum dan sesudah implementasi sistem.
HASIL: SIMPRO memperbaiki kualitas dokumentasi (p = .0001) dan efisiensi
(p = .0001).
KESIMPULAN: SIMPRO meningkatkan kualitas dan fungsi sistem dukungan
dalam memberikan asuhan keperawatan dan manajemen keperawatan.

Nursing documentation is an integral part of the nursing
process. Documentation of the nursing care is important for
continuity of care, communication between nurses and
other professionals, as well as the legal aspect of care
(Ammenwerth, Rauchegger, Ehlers, Hirsch, & Schaubmayr,
2011; Jefferies, Johnson, Nicholls, & Lad, 2012). Documen-
tation is important to provide quality and safe nursing care
to patients (Geurden, Wouters, Franck, Weyler, & Ysebaert,
2014). Furthermore, nursing documentation also serves as
the indicator of the service quality, evidence of responsibil-
ity and accountability of nurses, and database for research
purpose or evidence-based policy making.
Nursing documentation requires completeness, rel-
evance, and accuracy of the data (Blair & Smith, 2012;
Hariyati, 2004). A number of strategies are developed to
assist nurses in documentation. Some of them are narrative
charting, problem-oriented approaches, clinical pathways,
and focus notes. However, many factors still hinder nurses to
maintain complete, accurate, and legally prudent documen-
tation. Some of the issues are lack of time for nursing

© 2015 NANDA International, Inc. 1

International Journal of Nursing Knowledge Volume ••, No. ••, •• 2015
The Effectiveness and Efficiency of SIMPRO
documentation, lack of thorough assessment, and lack of
evaluation throughout the nursing process (Hariyati, 2004).
Poor documentation may negatively impact direct patient
care, professional accountability, as well as the organization.
In recent years, information technology has been devel-
oped to assist nurses in their daily nursing documentation
(Hannah, Ball, & Edwards, 2005). Computer-based nursing
documentation is a part of the nursing management infor-
mation system (NMIS). The NMIS is a combination of com-
puter science, information science, and nursing science to
manage and communicate information as well as knowl-
edge in nursing practice (ANA, 2008; Saba & McCormick,
2001). Nurses must be computer literate and understand
the principles of information science, such as the validity of
the information, as well as the nursing process to be able to
use the NMIS.
The NMIS showed many benefits for nurses, hospital, and
patients as care receivers. It excels in terms of efficiency,
cost-effectiveness, legibility, and completeness of docu-
mentation, compared with paper-based documentation. It
also serves as a communication tool between the health-
care team, as well as a source for education and research
purposes (Fuller, 2009). The organized database on the
NMIS may help hospital management in planning and
decision-making processes. For nurses, the information
system may assist them throughout the nursing process in
conducting assessment, planning the nursing diagnosis and
care plan, and evaluating outcomes. Nurses found the NMIS
helpful in saving time for documenting and reporting, and
patient satisfaction was also found to increase (Moody,
Slocumb, Berg, & Jackson, 2004). Therefore, this system
may increase the quality and the continuity of nursing
service (Abdrbo, 2007; Herdman, 2012).
In Indonesia, nursing documentation is still far from the
ideal. The majority of nursing documentation is paper-
based. Paper-based documentation has many weaknesses
as it can be lost and slipped, which may potentially put a
nurse at legal risk. Moreover, paper-based nursing docu-
mentation may have some issues with its quality and lack of
timeliness, which can diminish its effectiveness (Barker,
Flynn, Pepper, Bates, & Mikeal, 2002).
Most of the nurses in Indonesia still lack awareness
about the professional accountability and legal aspect of
nursing documentation. Many nurses complain about
having plenty of forms to be completed while having insuf-
ficient time to do it on their busy daily works (Hariyati,
2004). Another issue is the lack of standards of nursing
care that nurses often find it difficult to make nursing diag-
nosis and care plan (Hariyati, Delimayanti, & Widiatuti, 2011).
The objective of the research was to develop and test a
prototype of NMIS using the NANDA-I, Nursing Intervention
Classification (NIC), and Nursing Outcome Classification
(NOC). We named and copyrighted this system “SIMPRO,”
which stood for the professional NMIS in Indonesian lan-
guage. Standardized nursing language was used to support
nurses on establishing nursing diagnosis, intervention, and
outcome classification.
2
R. T. S. Hariyati et al.
Methods
The research was divided into two parts, in which we
used two different designs—incremental and quasi-
experimental design. The first part was as an incremental
study with prototyping model. Incremental study is the
development of a system in a series of partial products,
generally with increasing functionality, throughout the
project timescale. After the NMIS was developed, we tested
the effectiveness and efficiency of the system as the
second part of the study. Two hundred fifty-five samples of
nursing documentations were randomly assessed with
computer-assisted clustering out of 1,040 nursing records
of discharged patients. We assessed the completeness of
documentation, continuity of nursing care, and decision
support system function. Moreover, we also compared the
time required for completing the standard paper-based
nursing documentation with the computer-based documen-
tation that we developed.
The instrument that we used to assess the effectiveness
of the system was developed by integrating the standard
instrument of documentation evaluation by the Ministry of
Health Republic of Indonesia (1997) and the concept of data
quality by the American Health Information Management
Association (AHIMA e-HIM Workgroup on EHR Data
Content, 2006). The AHIMA stated that quality data are
accurate, relevant, and comprehensive. Accurate refers to
the valid and correct data, while relevance refers to the
continuity of the nursing documentation components. On
the other hand, comprehensive means the ability of the
data to help nurses on deciding the nursing diagnosis and
intervention. Face validity and content review were carried
out under the review of three nursing experts in Indonesia.
Validity test results were .311–.884, with alpha Cronbach
reliability of .768.
This study took 15 months, which consisted of the devel-
opment phase, user acceptance test, guidance, and evalua-
tion phase of SIMPRO. Prior to SIMPRO implementation,
there was an evaluation of the quality of 255 written
nursing documentations. We used a stopwatch to measure
the charting time.
SIMPRO was developed in the computer laboratory for 6
months before its trial at the hospital. On the first 3 months,
we conducted a user acceptance test, introduction to the
nurses, customization, and system refinement. After the
customization process, we trained and intensively guided
the nurses at the hospital to use NANDA-I, NIC, and NOC on
SIMPRO. Six months after customization and guidance,
nurses got familiar with the system documentation so that
the manual system was no longer used. The evaluation of
the quality of nursing documentation on SIMPRO after its
implementation was conducted through data retrieved
from the SIMPRO database. Time evaluation for data chart-
ing was also collected from the automatic clock of the
SIMPRO system.
Data were then analyzed using the Wilcoxon test to
compare each element of evaluation in the intervention and
R. T. S. Hariyati et al. The Effectiveness and Efficiency of SIMPRO

control group before and after the implementation of
SIMPRO. Ethical approval was obtained from the institu-
tional review board prior to the commencement of the
study.
Results
The systematic steps on the system development of
SIMPRO are described in the following paragraphs.
System Development
The prototype model was developed based on the evalu-
ation of NMIS that we created on the previous study
(Hariyati et al., 2011). The old version of the NMIS database
consisted of the nursing assessment, nursing diagnosis,
intervention, implementation, and evaluation. However, the
limitation of the previous system we made was the lack of
linkage between the elements of nursing process. Thus, in
this research, we emphasized the linkage of NANDA-I, NIC,
and NOC (Hariyati et al., 2011). The use of a standardized
terminology, such as NANDA-I, facilitates the recording of
data, which plays an essential role in patient care and in
communication among nurses and between nurses and
other providers, improves the quality of care, and enhances
patient safety (Albuquerque, Lira, & Lopes, 2010; Ferreira,
Echer, & Lucena, 2014).
Figure 1 shows the SIMPRO model developed in this
research. The SIMPRO model can be described as follows.
We used a head-to-toe approach for documenting a com-
prehensive assessment, which covered bio-psycho-social-
spiritual-cultural aspects. A head-to-toe approach was
selected as it is a systematic and effective way for docu-
mentation. For nursing implementation, NANDA-I was
linked with NIC and was also incorporated with daily nursing
monitoring, such as vital signs, fluid balance, and medica-
tion. Moreover, we added the content of hospital-acquired
infection and patient safety monitoring in the system as it is
a crucial element of hospital management (Montalvo,
2007).
This system also covers management functions and
roles, which is planning, organizing, actuating, staffing, and
controlling (POSAC). The system is integrated with POSAC
because the role and function of management cannot be
separated in the implementation of nursing information
systems. The nursing manager has a major contribution in
the successful implementation of the nursing information
system. Therefore, the system needs to be equipped with a
monitoring and directing system, as well as quality control
related to patient safety and other quality indicators, such
as monitoring of hospital-acquired infection, urinary tract
infections, and bronchopneumonia. The structure of the
nursing information management system, on which nursing
care and nursing management function are embedded, is
depicted in Figure 2.
Figure 2 depicts the decomposition diagram of SIMPRO.
This diagram shows the data file and components of the
system to design the data flow of SIMPRO. Two subdata,
namely the nursing care data and nursing management
data, were two major decomposition contents. The nursing
care database included the assessment, diagnosis,
outcome, and intervention using NANDA-I, NIC, and NOC.
On the other hand, intervention covered up the vital sign
observation, discharge planning, fluid monitoring, and NIC
implementation. Collaborative interventions, such as medi-
cation, were also listed. Subdata service consisted of

Figure 1. The SIMPRO Model

Notes: NIC, Nursing Intervention Classification; NOC, Nursing Outcome Classification; POSAC, planning,
organizing, actuating, staffing, and controlling; SOAP, subjective-objective-analysis-planning form.

• Nursing Intervention (NIC)

Assessment
Nursing
• Bio, Diagnosis
psychosocial, Implementation:
(NANDA-I)
spiritual, Independent:
Evaluation
cultural NIC, vital sign
(NOC)
• Head to toe monitoring ,
• Monitoring vital balance of fluid,
Nursing Patient
Nursing sign prevention of discharge
Nursing record
histories • By system: nosocomial
Outcome (SOAP)
neurology, infection, patient
breathing, (NOC) safety, nursing
cardiology, discharge planning
digestive, Collaboration:
elimination, medication and
reproduction, other
etc.
• Growth and
development
• Daily activity POSAC
• Need of
education

3
The Effectiveness and Efficiency of SIMPRO R. T. S. Hariyati et al.

Figure 2. Decomposition Diagram

Notes: NIC, Nursing Intervention Classification; NOC, Nursing Outcome Classification; SIM, nursing
information management system; SOAP, subjective-objective-analysis-planning form.

planning, organizing, directing, and evaluation functions.
This database may play a role in evidence-based decision
making in nursing management.
The Effectiveness and Efficiency of the NMIS
The effectiveness of the system was measured on the
aspects of quality, completeness, relevance, and decision
support system function of the documentation. The evalu-
ation of the effectiveness of the system is summarized in
Table 1. The table shows that all the evaluation aspects
increased after the implementation of SIMPRO. SIMPRO
could improve quality of documentation, completeness, rel-
evance, and decision support function (p < .05).
Meanwhile, the efficiency of SIMPRO was measured on
its time efficiency. Time efficiency was obtained from the
differences of the time required to do nursing documenta-
tion before and after implementation of SIMPRO. Moreover,
it also measured the efficiency in comparison with the full-
time equivalent (FTE).
Table 2 showed the average time spent in completing the
nursing documentation in the NMIS. The average total time
needed was 117 min before using SIMPRO and was lowered
to 24.62 min after using SIMPRO. The time needed for com-
pleting nursing documentation fell to 92.38 min after using
SIMPRO. It took 27.86% of the total FTE for system docu-
mentation before implementing SIMPRO. However,
it decreased to 3.86% of total FTE after SIMPRO

4
R. T. S. Hariyati et al. The Effectiveness and Efficiency of SIMPRO

Table 1. The Effectiveness of SIMPRO Before and After Implementation (n = 255)

Variable Mean ± SD Neg (−) rank Pos (+) rank Ties MRank p

Quality
Pre 80.33 ± 12.39 69a 154b 2c 109.62 .0001*
Post 94 ± 20.5 117.32
Completeness
Pre 62.99 ± 9.58 75d 143e 7f 102.43 .004*
Post 67.51 ± 14.55 122.98
Relevance
Pre 19.22 ± 3.44 40g 173h 12i 101.20 .0001*
Post 22.85 ± 5.53 132.10
DSS
Pre 12.59 ± 2.39 51j 152k 22l 99.21 .0001*
Post 14,35 ± 3.37 110.30

DSS, decision support system.

*Significant at alpha 0.05.

Table 2. Time Needed for Nursing Documentation Figure 3. Scatter Time Needed Before and After
Before and After SIMPRO Implementation SIMPRO Implementation

Variable Mean Difference p

Time efficiency (min)

Pre 117 −92.38* .0001*
Post 24.62
Time/full-time equivalent (%)
Pre 27.86 −24.00*
Post 3.86

*Significant at alpha 0.05.

implementation. Therefore, the time efficiency of SIMPRO

was 24% of the FTE.
Figure 3 shows that the time needed for documentation
prior to SIMPRO evaluation varied and was not normally
distributed (95% confidence interval, 105–129 min). An
evaluation was carried out 6 months after introduction,
customization, and guidance. Three months after the guid-
ance process, the time recorded by the SIMPRO system
revealed that nursing documentation only needed
25–27 min.

Discussion

This development of NMIS produced a prototype that

consisted of a system model, flowcharts, context diagrams,
and a hierarchy of input, process, and output. The system
had two decompositions—nursing care documentation and
nursing management functions. The system linked
NANDA-I, NIC, and NOC to assist nurses in carrying out the
nursing process. Nurses found this linkage helpful to have
complete, continuous, and quality nursing documentation.
Nurses also took advantage of the decision support system
function embedded in SIMPRO. Standardized nursing termi-
nologies (SNTs) play an important role in describing and
defining nursing care (Rutherford, 2008). They provide the
concepts and clear definitions of the phenomena of nursing,
and enhance nursing care by allowing nurses and other care
providers to use the same terminology to describe patient
problems, nursing interventions, and patient outcomes
in many settings, both nationally and internationally
(Toroddsen & Ehnfors, 2007). SNTs can provide important
information for the development of electronic nursing care
planning within electronic health records as a part of
nursing care (Park, 2014).
A good information system contributes to the continuity
of care (Pereira, 2005). A nursing information system
should be able to describe the patient’s progress, to record

5
The Effectiveness and Efficiency of SIMPRO
implemented nursing care, and to record medical history
for future care (Hariyati, 2004). Moreover, real-time data
management in the nursing information system should
avoid delays in decision making and action to respond to
actual patient conditions (Hariyati et al., 2011). On the other
hand, information technology system also allows nurses to
create an innovative discharge planning as part of nursing
care (Hariyati, Afifah, & Handiyani, 2010).
Prior studies tested the nursing information technology
system using the NANDA-I, NIC, and NOC on its implications
toward nursing practice (Lundberg et al., 2008; Scherb,
2003). Darmer et al. (2006) also concluded that an NMIS
that uses NANDA-I, NIC, and NOC terminology improved the
quality, completeness, and relevance of the documentation,
as well as the accuracy of nursing diagnosis, outcomes, and
interventions. Meanwhile, Bjorvell, Ekstrand, Wredlin, and
Ekstrand (2003) implied that the nursing documentation
system could improve patient safety. A qualitative evalua-
tion of the NMIS by Yu (2006) also indicated that it helped
nurses implement nursing care plans and deliver more
quality nursing interventions. In line with those previous
research results, the present study found that SIMPRO
improved the quality of nursing documentation. SIMPRO
addressed the barriers of nursing documentation, such as
tedious, inefficient forms, as well as the lack of time for
doing nursing documentation.
SIMPRO in this study, on the other hand, was also created
to assist nurse managers in doing their role and functions of
POSAC. A previous study supported the managerial
decision-making support functions of the information
system (Rainio & Ohinmaa, 2005). A computerized informa-
tion system could also be used as a communication tool
between healthcare teams in care delivery, education, and
research (Hellese & Ruland, 2008; Layman, 2009; Pereira,
2005).
The effectiveness, time efficiency, and cost are some of
the performance indicators of an information system. The
effectiveness of an information system is measured on the
system’s usability and performance, while efficiency is
assessed on its economic value and efficiency of time
needed to complete a certain task. In the current study, the
effectiveness was examined from the quality, complete-
ness, relevance, and the decision support system function
of the system, whereas the efficiency was measured on the
elements of time and productivity of the system. The find-
ings of the effectiveness and efficiency of the system in this
study were consistent with the results of the previous study
done by Ruland and Ravn (2003).
The effectiveness of nursing documentation at the hos-
pital used as the study setting improved significantly after
SIMPRO implementation. Some factors might contribute to
this improvement. These factors are nurses’ characteris-
tics, technical support, policy, and leadership support to
create and sustain changes from paper-based to informa-
tion technology-based nursing documentation. Motivational
factors of the nurses, high workload, and low time allocation
for completing nursing documentations were indeed some
6
R. T. S. Hariyati et al.
factors that hindered nurses in doing proper nursing docu-
mentation. Meanwhile, support from the user, information,
technology, and organization might also affect the effec-
tiveness of a system implementation (Alter, 2002). The
current study was found to be consistent with those previ-
ous findings.
SIMPRO was found to be efficient in terms of the time
requirement for completing nursing documentation and the
productivity of the system. The total time spent to fill the
nursing documentation in the system was statistically sig-
nificantly lower after using SIMPRO. Prior study supported
this finding and stated that the NMIS helped nurses save
time for doing paperwork on documentation and instead
have more time with the patients. At the beginning of the
SIMPRO implementation, the nurses took time to adapt to
the computer-based data charting. However, after 6
months, the nurses got accustomed to SIMPRO, thus low-
ering the time required for data charting. According to
Lafond and Field (2003), a new system would need some
process to be well accepted in an organization. Therefore,
the theory of change must be the basis to develop the NMIS.
Eventually, the NMIS may decrease workload and lead to
improved patient care (Moody et al., 2004).
Conclusions
It could be concluded that SIMPRO is an effective and
efficient way to improve nursing documentation in this
study. It increased the quality, completeness, relevance and
sustainability, and functions of the decision support system
in delivering nursing care as well as in nursing management.
SIMPRO showed many benefits on nursing documentation.
It might assist nurses in having thorough, complete, and
better quality nursing documentation. Thus, it might con-
tribute to better and continuous nursing care, as well as
improved patient safety. SIMPRO might also help commu-
nication within nurses and between other healthcare
professionals.
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