Head Nurse Supervision in Nursing Care Documentation: A Literature Review

Tita Rohita, Suci Rahma Oktavia, Dedeng Nurkholik Sidik Permana

Abstract

Nursing care documentation is a key indicator of service quality, patient safety, interprofessional communication, and nurses' legal accountability. However, documentation completeness remains suboptimal in both global and Indonesian health-care settings. Head nurse supervision is a managerial factor that may improve nurses' performance through direction, coaching, monitoring, evaluation, and continuous feedback. This literature review aimed to identify the role of head nurse supervision in nurses' performance in nursing care documentation. The article search was conducted using the PICOS framework in Google Scholar, ScienceDirect, and PubMed for studies published from 2018 to 2026 and selected according to the PRISMA flow. From 2,210 initially identified records, 15 articles met the eligibility criteria and were appraised critically. The review found that 14 articles (93.3%) reported an association or effect of head nurse supervision on nurses' documentation performance, while one article (6.7%) did not show a direct effect. Mixed supervision, combining direct and indirect approaches, was the most frequently used form. Structured, educational, consistent, and sustainable head nurse supervision is recommended to strengthen nurses' documentation performance and nursing service quality.Nursingcaredocumentationisakeyindicatorof servicequality,patient safety,interprofessionalcommunication,and nurses'legalaccountability.However,documentationcompleteness remains suboptimalinbothglobalandIndonesian health-caresettings.Headnursesupervisionis amanagerialfactor thatmayimprovenurses'performancethrough direction, coaching, monitoring, evaluation, andcontinuousfeedback. Thisliteraturereviewaimedtoidentifythe roleof headnursesupervisioninnurses'performanceinnursingcaredocumentation.The articlesearchwasconductedusing thePICOSframeworkinGoogleScholar,ScienceDirect,and PubMedfor studies publishedfrom2018to2026and selectedaccordingtothePRISMAflow.From2,210initiallyidentified records, 15articlesmettheeligibilitycriteriaand wereappraisedcritically.Thereviewfoundthat 14articles(93.3%)reportedanassociationoreffectofheadnurse supervisiononnurses'documentationperformance,whileonearticle(6.7%)didnot showadirecteffect.Mixed supervision,combiningdirectandindirectapproaches,was themostfrequentlyusedform.Structured,educational, consistent,andsustainableheadnursesupervisionis recommendedtostrengthennurses'documentationperformance andnursingservicequality.

Keywords

head nurse supervision; nurse performance; nursing care documentation; nursing management

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References

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DOI: http://dx.doi.org/10.25157/ihc.v1i1.24792

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