The Assessment of Nurse’s Performance by Using a Logbook in Hospital

Background : Nurses are the majority of human resources in the hospitals whose role determines the quality of health care and they are most closely associated with patients. They are the most dominating human resources in hospital who have the most frequent interaction with the patients. Therefore, the primary indicator of the hospitals' quality service is in its nursing services. The capabilities and competencies of the nurses can be assessed through a nursing logbook strategy. Objective : This research aimed to explore the implementation of performance assessments using the nursing logbook. Method : This research was conducted using a qualitative method with a phenomenological approach. Data collection was conducted from November to December 2017 by using in-depth interviews with six participants who were selected by using purposive sampling techniques. The participants were nurses in Dr. H. Moch. Ansari Hospital. Results : The research results covered six themes, namely the existence of a nursing logbook for nurses, the purpose and the benefit of logging book in nursing, the relationship between a nursing logbook and credentials, the implementation of nursing logbook, the constraints or the barriers in the implementation of the nursing logbook, and the expectations of nurses towards the nursing logbook. Conclusion: The system of implementing the logbook as a tool for the nurses' performance assessment is not optimal due to the limited socialization to the nurses in the hospital.


INTRODUCTION
Nurses are the majority of human resources in hospitals whose role determines the quality of health care as they are responsible for patient safety. They are also the most frequently interacting hospital personnel with the patients. Nursing services are part of the health service in the hospital that the quality of which is influenced by the quality of nursing services. It, moreover, becomes one of the indications of the community's valuation towards the Health Services Agency (hospital) as nurses are the largest working group in the hospital's service system and also the highest number of professions most closely associated with the patient. Therefore, one of the indicators of the hospital service quality is the quality of the nursing service itself. One strategy to improve the quality of the nurse is through an effective nurse performance assessment mechanism as the goal of the assessment is to motivate and improve the performance. When the motivation of work is unwell, the performance of nurses is also low, and vice versa (Witjaksono, Hartiningsih, & Indriana, 2017).
The performance assessment of nurses is a process by which the achievement of individual or group performance is measured, evaluated, and compared to the predefined standards (Ellis, & Hartley, 2012). Besides referring to five nursing care standards, the nurse's performance assessment aspect also includes nursing practice quality, nurse education, nurse professional practice, collegiality, collaboration, ethical action, resource utilization, and research (ANA, 2010).
The results of the observation and the interview with several nurses in Dr. H. Moch. Ansari Saleh Hospital regarding the implementation of performance assessments using the logbook in the get data is still empty based on their competence, their work, their nursing actions towards the patients as they have not implemented the logbook optimally. Based on the assessment conducted, it showed that the supervisor (head of the room/team leader/charge shift) and the peer/co-worker did not observe the subordinates and their peers. The nurse stated that they hardly understood how to fill the logbook, and it was difficult to fill after performing such competency actions.
The implementation of a performance assessment using the logbook in Indonesia is still not yet widely used. However, this form of assessment is suggested by the Committee of Hospital Accreditation (KARS) because the logbook can ease the nursing committees to do the tasks, particularly the credentials section. Logbook can be used as a proof of credentials and can also be a determinant of Continuing Professional Development (CPD) or continuing education, setting a career-level in nursing or career-level development, as well as providing clinical authority and competence in the work unit. The development of education and training for nurses is highly crucial as it can affect the performance of nurses. (KARS, 2011;Ayed, 2015).

METHOD
This research used a qualitative method with a phenomenological approach. This study explored the implementation of nurse performance assessments using a logbook. Data collection was conducted by undertaking in-depth interviews or structured interviews, field records, and recording aids. The subject of the research was nurses at Dr. H. Moch. Ansari Saleh Hospital Banjarmasin, taken with the purposive sampling technique. There were six participants in this study selected based on their level of obedience. Criteria of the selection were, such as the nurses had to have a logbook, understood about the logbook, would be willing to become a proven participant by signing a statement of research approval, and was able to disclose their experience well. The data collection was conducted for a month from November 2017 to December 2017 in emergency areas, pediatric areas, and medical areas at Dr. H. Moch. Ansari Saleh Hospital. Data analysis was done through data reduction, data presentation, and withdrawal of conclusions or verification (Miles andHuberman 1984 in Sugiyono 2014).

RESULTS
The results of qualitative data analysis collected through an in-depth interview with six participants were 6 (six) themes and 23 (twenty-three) categories identified. The explanation of each theme based on the responses of participants is as follows:

The existence of a nursing logbook
This nursing logbook is very good but raises several different perceptions among nurses, such as the definition of the logbook itself, the timing of the implementation of the logbook, and the procedure of how to fill a logbook. The following responses are: "This logbook for nurses hmm.. it is quite good because we can finally know the competencies that we have to master." (Participant 5). So it is like we are full of assumptions. Nevertheless, the implementation of the logbook will ease us, and we will understand where we are heading on." (Participant 6).
Regarding the time of the implementation of the nursing logbook, it can be concluded from the research result that there is a difference in the starting time of the implementation of the nursing logbook in each treatment area, as responded by the following participants: "This is already the beginning of the year and the logbook is still not collected yet.. hmm.. still in the process. I think it will have been collected by the end of this year." (participants 1) "The nursing logbook actually started to be applied by the beginning of 2017. Nevertheless, not all of us here could have carried out optimally, including in the ICU area." (participant 2) "The mapping here started in 2015. It means the determination of the first career-levels development... and then the logbook was implemented in 2016." (Participant 4) The Logbook owned by all nurses has a format of 9 (nine) columns divided into 3 (three). The first three columns named "supervision" indicate the actions of the nurse that correspond to the content of the logbook, and it should be viewed by the supervisor as much as three times. Meanwhile, the next three columns named "peer group" indicates that the nurse does the action along with other nurses three times, and the last three columns are self-reliant, which indicates that the nurse can take action independently. Furthermore, if the nurse wants to fill the logbook, they first have to complete the first three columns, and then it is followed by filling the next columns. However, by the time researchers sought the information in the field, it was found that many nurses still did not understand how to fill it, as expressed by the following participants: "I filled the logbook only based on what I understand so far as sometimes, others understand it differently." (participant 1) "... what firstly is in the book is supervision, isn't it? It means the person who supervises the nurses when they are doing the action… for example, the supervision is done today and who is supervising the nurse when they do the action. That is the person who has to sign" (Participant 4) "There are three types of columns in the logbook, such as supervision, peer, and self-reliance that have to be filled. Moreover, the supervision type here has levels." (participant 5) "To fill the logbook… there is a clue on how to fill it in the first page. Like what I told... the action is done at least three times.... "(participant 6)

The purpose and the benefit of the nursing logbook
The nursing logbook can be prerequisites for career development and a credit score for the promotion of nurses. As the following participants respond: "One of the purposes is for the promotion to raise the credit score… it is one of the requirements " (participant 2) "Yeah, the benefit of the logbook is that the workload of the nurse can fit each of their career levels." (Participant 6) By using the logbook, we will be able to know what competencies have been mastered by the nurse. Furthermore, we also can assess whether the workload is following the competencies of the nurse.
"So, the benefit is to know the competencies." (participant 1) "Our work will be more directed and specific. Thus, we will have our valuation on whether or not our work complies with the competence "(participant 3) "It is good to assess if the competence of clinical nurse has been achieved. For instance, some competencies have to be mastered by clinical nurse level 1, so we can measure whether a nurse has been able to achieve the competence of clinical nurse level 1 level." (participant 4) The nursing logbook is very useful for nurses because it can improve their individual skills by referring to a list of competencies in the logbook.
"The goal is actually to improve the individual ability, for example, to achieve competencies… Like us, we are here in this room as an individual judgment." (Participant 4) Participants revealed that the purpose and the benefit of the logbook are for the safety of patients, after all.
"The benefit is, after all, for the safety of patients. If we work based on the Standard Operational Procedure (SOP), the patient will obtain a safe and good service.. as it is already based on the right procedure." (participant 5)

The connection between the nursing logbook and the credentials
Participants reveal that there are nurses who take nursing actions based on their right career level, and there are some who do not. for instance, the nurse who is supposed to be still in clinical nurse level I already has authority in clinical nurse level II or III.
"As there are many workloads they have to bear, they still carry the duty both in clinical nurse level 2 and clinical nurse level III. In terms of the duty in clinical nurse level I, it is because the selection on both clinical nurse level I and clinical nurse level II is still inappropriate." (Participant 2) "Maybe, the morning shift is already appropriate because there are much personnel. However, the evening shift lacks personnel so that the duty that is supposed to be carried out by clinical nurse level III is handled by clinical nurse level II. Thus the duty has not been carried out optimally." (Participant 4) The logbook is based on the White Book of its clinical authority that it is also based on its career path and its departments, such as critical departments, surgery, children, psyche, and maternity. Each department has a different logbook and career path. For example, the surgical department has various types of the logbook, such as clinical nurse level I, clinical nurse level II, clinical nurse level III, and clinical nurse level IV, as well as other departments. However, in fact, many nurses have not yet adjusted the action with the logbook and the career path. As the following participants responded: "Hmm.. the fulfillment still depends on the level." (Participants 2) "Yea... It has been divided into clinical nurse level I, clinical nurse level II, and clinical nurse level III." (Participant 5) "Yea... It has been divided accordingly. Each of the levels has a working period." (Participant 6) Participants revealed that the nursing logbook is an essential element to credential proposal in the Nursing committee. It is because when the nurse proposes a re-credential, they must submit a logbook that has already been filled as a portfolio that will later be verified by the nursing committee.
"I do not know about it. It maybe has affected the valuation process because here they can know our real competencies and abilities." (Participant 1) "One of the purposes is to propose promotion and to apply credit scores." (Participant 2) "Yes. It is useful for measuring instruments. For example, we will be able to know whether a nurse deserves to level up into the next clinical nurse level." (Participant 4) Five participants revealed that there are still many nurses' duties that have not yet corresponded well with the levels; for instance, the logbook for the children room is mixed with the one for the maternity room.
"There are some nurses who do not perform 100% optimally because of an inadequate room… and competence is not optimal yet." (Participant 1) "There are some inappropriate divisions." (Participant 2) "Sometimes, there are some duties which do not correspond with the patients. Theoretically, this may already be in line with the clinical nurse level III.

NURSING PRACTICES
However, we sometimes get the duties which are not based on our level of competence." (Participant 5)

The implementation of the nursing logbook
Based on the results of the interview on the readiness of the nurse in the implementation of using the nursing logbook, it was revealed that some nurses are still confused and half-ready to implement the logbook, as responded by the following participants: "I am still half-ready because I need training." (Participant 1) "The nurses are ready to implement the logbook. However, it remains a plan. They have not mastered the SOP." (participant 2) "As far as I know, the division of the duty is still confusing." (Participant 3) In this category, participants revealed that Human Resources and Hospital Nursing committee had done socialization but it is still not yet in detail. As responded by the following participants: "The hospital committee may not have socialized it in a more detail" (participant 1) "The hospital committee only distributes the logbook. They said they would socialize it later." (participant 3) "It has been socialized by the HR and quality department.. and then the socialization has been further carried out by ward leader, and then by the team leader." (Participant 4) The monitoring of the nursing logbook fulfillment was only carried out by the head of the division and the nursing committees, and not by the management of the nursing hospital. As stated by the following participants: "It is ward leader who handles it by far... and division of discipline explains how to fill the logbook. " (Participant 1) "There is no direct supervision from the management of nursing hospital.. only from the committee." (Participant 4) The evaluation of the implementation of the nursing logbook is still carried out differently from one division to another. It is drawn from the expression of the participants taken by the researchers in three treatment areas, such as: "There may be an evaluation of the logbook from the hospital upon the submission at the end of this year." (participant 1) "The duration of the logbook is four semesters per year. If I am not mistaken, it is four semesters per year... yea.. not quarterly." (participant 2) "It is also once per three months." (Participant 3) "When we did accreditation, we had not filled the logbook that much. The purpose is to check how much we have filled it, isn't it?. But when we did the accreditation, they instead asked us just to copy it." (Participant 5)

The constraints in implementing the nursing logbook
The constraints in the implementation of the nursing logbook is most likely in the limited time to fill the logbook because of the heavy workload, as revealed by the following participants: "We are sometimes swamped and that we have no time to fill the logbook." (Participant 2) "It may be because of the limited time, or maybe we are too busy." (Participant 4) Participants reveal that there are still many nurses who do not understand how to fill the logbook correctly, even though there is a guideline.
"Sometimes, I understand all.. hehe (giggling while smiling). However, there is a time when I do not understand some parts." (Participant 1) "There are some parts I do not understand." (participants 4) Participants reveal that they already know and understand. Yet, they have not remembered the steps and the procedure.
"They have already done the duty.. the important points in the clinical nurse level based on their level of competencies. However, the problem is that they are hard to remember the procedure in the SOP." (Participant 2) Two participants revealed that they do not understand how to fill the nursing logbook because there is no detail explanation. Thus, the nurse does not know the detail of how to fill it correctly.
"I do not understand. If they explain it further, I will probably understand. Nevertheless, it has not been explained in detail, so I hardly understand." (Participant 3) "There are some who have not yet understood." (Participant 5) The constraint in the implementation of the logbook is also influenced by the willingness of the nurse to fill it. As revealed by the following participants: "Hmm.. what is it? I think it is a matter of willingness. I mean the willingness to make time to fill the logbook." (Participant 5) Furthermore, there is no appreciation received by the nurses when they perform correctly. As revealed by the following participants: "One more constraint is that there is no additional incentive to implement it." (Participant 2)

The nurse's expectation towards the implementation of the logbook
A participant reveals that the duty of each nurse is expected to be in line with each of their career levels.
"I hope that the logbook is in line with each of the nurse's career level and each clinical nurse level." (Participant 2) "Hopefully, the nurse can master all the competencies based on their career level to achieve promotion." (Participant 5) Participants revealed that in addition to the career level, they hope that the logbook implementation can be understood by at least 99% of the nurses.
"Hopefully, at least 99% of the nurses understand the implementation of the logbook." (Participant 6) Participants revealed that the nurse could take action based on the standard in the SOP.
"The competence of the nurse is already based on the standard. For example, one division can be occupied with professional actions based on the SOP." (Participant 4) "I hope at least they are responsible for their own duty, which is in line with the SOP." (Participant 5) In terms of the nursing logbook update, participants expressed confusion towards the current logbook format. As revealed by the following participants: "To avoid confusion, the format of the logbook can be renewed. Although there is a guideline already in the logbook, it needs to be explained further." (Participant 1)

DISCUSSIONS 1. The existence of the nursing logbook
The existence of a nursing logbook is implemented at Dr. H. Moch. Ansari Saleh hospital, the function of which is as one of the tools to raise the nurse's competence. Therefore, it is imperative to be understood by all nurses. The logbook encompasses how the nurse assesses and understands their performance and professionalism both as individuals and groups. The indicator of nurse performance is a variable in measuring the nurse's activity within a certain period of time. The indicator focuses on the results of nursing care to the patient and the process of managing the department (Rivai, 2008).
The result of this study reveals that the perception of nurses towards a nursing logbook is that they perceive the logbook as a performance assessment, both individual assessment and clinical nurse assessment, and good competency development for them. However, in terms of the implementation, the nurse can hardly understand the procedure based NURSING PRACTICES 88 on the existing rules. Human resource competence requires knowledge and skills to be able to help create a strategy of the company or organization (Dessler, 2015). The implementation of the nurse's performance assessment by using the logbook should conform to the standard of nursing actions. Due to the fluctuating complex health system, it is a reference to growing and increasing the level of nurse competence at step by step, which requires a lifelong learning process (Liou & Ching-yu, 2014).

The performance of individual nurses in Dr. H. Moch
Ansari Saleh Hospital is recorded in the nursing logbook which is evaluated quarterly (three months). The fulfillment of the logbook to meet the targets of the nurse's competence is carried out based on each level such as the assessment from the supervisor (head of the room/team), peer/coworker, and self-assessment.

It is described in American Nurses Association
Leadership Institute TM (2013) that "competence in nursing practice must be evaluated by the individual nurse (self-assessment), nurse's peers, nurse's supervisor, coach, mentor, or preceptor. Additionally, other aspects of nursing performance may be evaluated by professional colleagues and patients." In this case, Dr. Haryati (KARS surveyor) creates a model and a format of a logbook by dividing into 3 (three) types such as supervision, peers, and autonomy. The health department, known as Declinical nurse leveles (2003) mentions that the nurse is expected to be proficient and able to do independent action and should be monitored by the supervisor as much as five times. As for this logbook, it requires nurses to be supervised three times, monitored by a peer three times, as well as carrying out a self-reliant action.

The purpose and the benefit of the nursing logbook
The purpose of performance assessment is to improve performance and communication, strengthen positive behavior, communicate problems related to task termination (ultimately), provide the basis of reward to strengthen motivation, provide the basis for termination employment (if necessary), and identify the individual learning and development needs (Huber, 2013;Robbins & Judge, 2008;Tomey, 2009).
Career development of nurses is a career plan that can be used for the placement of nurses at a level that suits their expertise and provides better opportunities in accordance with the ability of potential nurses (Marquis & Huston, 2010). The benefits of the development of a nurse's career can determine their competence and their clear career path so that the nurse can provide quality service. Benner (2001), from a novice to an expert theory of this concept, explains that nurses develop skills and understanding of patient care over time that comes from a combination of education and experience. By the presence of a logbook, nurses will implement and can provide quality services in accordance with the competence-based on the standard operational procedure (SOP).
In addition to career development, the purpose and the benefit of logbooks are to know the competence, assess the competence, and improve ability. It is also in line with the opinion of Vandenhouten et al. (2015), stating that to improve the competence of a nurse, it requires an accountable and sustainable system for assessment as competence can only be achieved through ongoing development and credentials. Furthermore, it is in line with the research conducted by Harlie (2010), revealing that there is a connection between career development and the performance of employees in Tabalong Tanjung South Kalimantan. Nurses who work based on their competence and area of authority, and are given the award based on their achievement will raise their motivation, and that their performance will increase, and surely they will give quality services.

The connection between the nursing logbook and the credentials
Nurses, as one of the hospital's healthcare professionals, play an important role in achieving health development goals, such as providing quality services for patients. The nurse's career path starts from the time of recruitment to the process of the development of human nursing resources in the hospital. In terms of nurses who have worked in the hospital with the education level of Nursing Vocational High School, they will level up to maximum until clinical nurse level II. Meanwhile, nurses with a vocational degree can be assigned to clinical nurse level i upon undergoing a 2-year orientation period. They will level up to clinical nurse level ii if they meet other requirements set up. According to the Directorate General of Health and Development (2013), upon undergoing a 4-year experience in the level of clinical nurse level ii, the nurses will be able to level up to clinical nurse level iii if they meet other requirements that have already been set up. Furthermore, in terms of leveling up into clinical nurse level iv, meeting the requirement of the minimum working period is not enough. They have to meet the minimum standard of formal educational degrees, namely Bachelor of Nursing as well as a professional nurse degree.
The system of a professional career-level contains three interconnected aspects, such as performance, professional orientation and nurse personality and competencies that influence professional performance. According to Werther & Davis, (1996), a career is interpreted as a person's lifetime working journey.
Credentials are the process of an evaluation conducted to determine the clinical authority. It is in line with the regulation of health ministry, known as PERMENKES, about the nursing committee in 2013 that the credential is the process of evaluation of nurses to determine the clinical authority. In other words, it is the understanding of assigning the scope of tasks and authority. At the same line of thought, Kleinpell, Hravnak, and Hinch (2008) stated that the credential process is there to obtain the clinical authority of nurses to provide clinical services to the patients. Cusveller & Akkerman (2016) suggest that a nurse's competence, as well as the assessment tool, are ethical. The results of nursing research in Taiwan, according to Lin et al. (2016), showed that the competence of clinical nurses can be measured through the scale. Ellis & Hartley (2012), in his book entitled Nursing in Today's World: Challenges, Issues, and Trends, state that credentials is a measuring instrument to assess the ability of a person. In this context, credentials are considered as a standard and a tool to assess a nurse's competence.
An important aspect of professional development for nurses is maintaining competence (Patricia, B & Strasser, 2012). Human resource competence requires knowledge, skills, and competence to be able to help create a strategy of the company or organization (Dessler, 2015). Hospitals, for example, need to ensure the competent nursing staff, resources, and patients' needs. Nurses who have not been competent have to join the training as a form of committee responsibility in maintaining the competence of the nurses. In other words, the nurse needs to be highly competent in the provision of nursing care. However, there is a challenge for the nursing committee to encourage their members in maintaining the competence, and to obtain remuneration.

The implementation of the nursing logbook
Assessing the individual nurses' performance by using the nursing logbook is also influenced by the nurse's readiness to accept the new system. Monitoring the performance assessment using the logbook has not been optimal because the head of the division only does it. The evaluation of the use of the logbook also does not work optimally. Hence it can be said that the implementation of the logbook is hardly optimal.
Evaluating and monitoring the use of logbook are the most important part as they are the benchmark of the logbook implementation. Thus, apart from readiness, supervision, and evaluation in the implementation of a logbook must be supported by proper management, which is the center of the hospital service system. It is in line with the theory presented by Holt et. al. (2010), stating that readiness is one of the main factors that affect the performance and subsequent outcomes.

The constraints in implementing the nursing logbook
The function of nursing management in the implementation of standard operational procedures (SOP) is important to improve the quality of nursing services. It is in line with the Indonesian Health Department (2003) explaining that hospitals should make efforts to improve the quality of public services and medical services, either through accreditation, certification or other quality improvements.
In addition to the heavy workloads that make nurses have no time to fill the logbook, some of them still do not understand how to fill the logbook and cannot comply with the SOP-based actions. As a result, they do not perform the duty based on their SOP. In this case, the nurses should be willing to provide time to fill the logbook. As stated by Huber (2013), the work of the employee is measured based on the standard to provide an overview of the quality of job performance. However, the incentive is one of the constraints in the implementation of the nursing logbook which is later such a contrary to the importance of the award program for an organization.
Furthermore, it is said that Hasibuan (2007) award is an action where the organization assesses the contributions of employees to distribute the monetary or non-monetary award either directly or indirectly as a form of the ability to organize based on the legal regulations. In relation to this, the guideline of the remuneration system drafted by health minister (2010), states that there is a component of the remuneration system for the hospital personnel's performance.

The expectation of the nurse towards the implementation of logbook
A professional career path can lead nurses to pursue the field of expertise and improve their professionalism. Therefore, the greater the conformity between the expectations of nurses and the reality found in the workplace is, the higher the satisfaction will be. The opinion is in line with the research result conducted by Suroso (2011), stating that the professional career path can improve nursing work satisfaction.
The Logbook is expected to be the basic standard of nurse competence that can determine the competence level of the nurses. It is in line with the opinion of Vandenhouten et al. (2015), stating that creating a competent nurse requires an accountable system and competency assessment can only be achieved through credentials.
Furthermore, in terms of nurses' expectations, they want the logbook format to be updated to get them to understand easily. Lewin's theory expresses that the process of the update encompasses three stages, namely unfreezing, moving, and refreezing. The Lewin theory also states that the update process can be carried out when the driving factor has arisen more than the inhibitory factor (Marquis & Huston, 2010). In addition, nurses also want the implementation of the logbook to be socialized.
In the end, this research cannot avoid limitations, such as researchers do not conduct the interview optimally. They conducted interviews only in meeting rooms and the headroom of each serving participant and did not consider to conduct interviews outside the hospital to avoid interruption. The second limitation is that the interview with one of the participants did not go optimally as the participant had to accompany the doctor in the middle of the interview process. However, it continued after a three-hour break.

CONCLUSIONS
The system of implementing the logbook as a tool for the nurses' performance assessment is not optimal due to the limited socialization to the nurses in the hospital. Besides, the result of the research showed that there are several constraints in the implementation of the logbook such as limited time in filling the logbook, the inadequate understanding of the nurses about the procedure of filling the logbook, and a lack of appreciation towards the nurse when they fill the logbook.