Illuminating professionalism among nurses in their documentation within the Malaysia context - A qualitative study

Nursing documentation is the key to nursing care in hospitals. Pertinent literature suggest nursing documentation that contains evidence regarding the comprehensive level of nursing care has a strong correlation with nurses’ professional practice. 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, this study utilised a qualitative design to explore the evidence of professionalism in nursing in Malaysia, specifically in the context of their nursing documentation. A total of 40 semi-structured interviews were conducted with nurses involved in completing the nursing documentation. Thematic analysis was used to identify categories and themes in nurses’ accounts of their documentation, in relation to professionalism in nursing. Findings reveal that the nurses could not demonstrate their comprehension of the existence of professionalism within their documentation. These findings are likely to suggest the need to emphasise the quality of nursing documentation in nursing practice, besides the significance of education to improve professionalism among nurses in Malaysia.