Implementation of Case Discussion Reflection to Improve Nurse Professionalism: A Literature Review

: Patient safety is a global issue. Nurses are expected to enhance their abilities and skills in providing quality and safe healthcare to patients. Case-based reflection is one effective method to improve nurses' understanding of complex clinical situations and enhance their performance in addressing challenges in clinical practice. This study aims to explore implementing case discussion reflection to improve nurse professionalism. The method used in this study was a literature review through electronic databases, including ProQuest, Science Direct, PubMed, and Google Scholar. Inclusion criteria for the literature review process were national and international journals discussing the implementation of case-based reflection in hospitals, nursing professionalism, articles published in the last five years (2018-2022), articles written in Indonesian or English, full-text journal articles, and open access. The electronic database search through ProQuest, Science Direct, PubMed, and Google Scholar yielded 85 articles. After abstract screening and exclusion of articles published before 2018, duplicates/same journals, and irrelevant topics, 21 articles remained. Further screening of all articles resulted in 6 articles that will be reviewed for data extraction. The review findings indicate that through case-based reflection, nurses can expand their knowledge and skills in identifying, evaluating, and managing patient care more effectively. This can positively impact healthcare quality, patient safety, and patient satisfaction with the services provided. Therefore, the implementation of case-based reflection is crucial in enhancing nursing professionalism.


INTRODUCTION
Hospitals are complex places, with hundreds of medications, tests, and procedures, as well as various professions and backgrounds of human resources providing continuous 24-hour care to patients (Ministry of Health of Indonesia, 2018).This situation makes hospitals a high-risk place for medical errors.Patient safety is a right, so healthcare professionals have an obligation to provide safe healthcare.Therefore, efforts to improve patient safety must be a top priority for healthcare providers (Marseno, 2013).
Patient safety is the most important global issue at present, with many patient demands being reported for medical errors that occur to them.According to the Institute of Medicine (IOM) report in 2015, at least 100-200 thousand patients die yearly due to medical errors in healthcare facilities worldwide.The latest publication in the United States in 2015 showed that one in three patients hospitalized experienced an Adverse Event (AE) (Institute of Medicine, 2015).Patient safety is a basic principle in the provision of medical services (Adhitama et al., 2023).Collaboration with the patient's family can maximize patient safety mechanisms and improve the quality of hospital services (Wahyono & Ririanti, 2023).The most common types are medication errors, surgical and procedural errors, nosocomial infections, and patient falls (Marseno, 2013).Falls can cause more serious injuries such as joint damage, broken bones, and infections.Complications that patients can suffer are torn blood vessels, broken bones, disability, movement restrictions, and loss of self-confidence (Kurniyawan et al., 2023).
In 2015, the WHO reported that falls occurred in 3.2-16.6%or around 700,000 to 1,000,000 people annually in hospitals in various countries, including the United States, United Kingdom, Denmark, and Australia.Patient falls in Indonesia are recorded at a rate of 2.2-7% or 1,000 beds per day in acute care settings, resulting in 29-48% of patients experiencing injuries, with 7.5% suffering serious wounds (Ministry of Health, 2015).Based on hospital ownership, a report on falls in Indonesia in 2010 found that regional government hospitals had a higher incidence rate of 16% compared to private hospitals at 12%.Falls were most commonly reported in the internal medicine, surgical, and pediatric units, accounting for 56.7% of incidents compared to other units.
The Ministry of Health of Indonesia launched the Patient Safety Movement in Hospitals in 2005.The Indonesian Hospital Association or PERSI became the main initiator by establishing the Hospital Patient Safety Committee.The Patient Safety Movement in Hospitals is also supported by the Ministry of Health Regulation No. 11 of 2017 Article 8, which requires every hospital to improve the quality of services and patient safety.Patient safety in hospitals is a system in which hospitals make patient care safer.Improving patient safety in hospitals is expected to increase public trust in hospital services.
One of the activities to solve problems in healthcare services is through case reflection, which was introduced in Indonesia through Case Reflection Discussion (DRK).If carried out regularly and consistently by the nursing group, this nursing activity will encourage each nurse better to understand the relationship between standards and daily activities.
According to research results, the Case Reflection Discussion (Diskusi Refleksi Kasus/DRK) can improve individuals in making plans and being effective in efforts to develop nursing quality.Other benefits that can be gained from the implementation of DRK are as a means for nurses to introspect themselves on actions or work activities, thus improving the expected quality of work (Ratnasari, 2012).This study aims to explore the implementation of case discussion reflection for improving nurse professionalism.

METHOD
The method used in this literature review employed a search strategy through electronic databases, including ProQuest, Science Direct, PubMed, and Google Scholar.The search terms used were RDK and nursing professionalism.The inclusion criteria for the literature review process were national and international journals discussing the implementation of RDK in hospitals, fall risk, nursing compliance, articles published within the last five years (2018-2022), articles in Indonesian or English language, full-text, journal articles, and open access.Based on these criteria, several articles were selected through the journal screening process, which is presented in the flow chart and table below.

RESULT
Based on the search results, 6 articles met the inclusion criteria.These studies are related to implementing Case Reflection Discussion (DRK) to improve nurses' professionalism.

DISCUSSION
The results of the review of several journals indicate that DRK has a significant relationship with the ability and compliance of nurses in implementing SOPs.Researchers can convey several important points regarding the results of this literature review.Case Reflection Discussion (DRK) is a reflective activity on cases that have occurred or the reflection process of knowledge owned that aims to improve.DRK aims to minimize the gap between nursing science and practice, develop sustainable nursing learning, and improve nurses' competence in providing nursing care to perform their roles and functions based on applicable guidelines, policies, and regulations.The benefits of DRK are improving knowledge, developing professionalism, raising learning motivation, increasing knowledge, skills, and abilities of nurses in implementing SOPs, solving problems, and critical thinking.
DRK activities can increase motivation, metacognition, and autonomy.DRK increases the motivation of nurses to continue learning, activates, and improves metacognitive abilities that allow for deeper learning outcomes that refer to individual awareness and optimal learning process management, as well as the ability to make decisions in acting.
DRK is utilized as an alternative problem-solving technique to create new Standard Operating Procedures (SOPs).For nurses, DRK is essential in improving professionalism, inspiring learning motivation, increasing knowledge, and self-actualization with assertive techniques or without blaming others.Case reflection discussions can also enhance collaboration among nurses and other healthcare team members such as doctors, dietitians, and pharmacists.Directed and structured case discussions can help nurses and other healthcare team members understand and evaluate patient care holistically, resulting in better-coordinated solutions for patients.However, despite recognizing case reflection discussions as an effective method in enhancing nursing professionalism, proper and effective implementation must be considered to achieve optimal results.This may include selecting relevant cases, using effective discussion methods, and providing constructive feedback to nurses.Therefore, further research is needed on implementing case reflection discussions in improving nursing professionalism, including factors that may influence its effectiveness.Thus, developing effective and efficient programs to improve the quality of healthcare services provided by nurses and other healthcare team members will be easier.

CONCLUSION
Case Discussion reflection is an essential component of professional nursing.The benefits of conducting Case discussion reflections can enhance understanding of care standards.Case discussion reflection improves knowledge, confidence, motivation, empathy, and nursing professionalism.Case discussion reflection requires support from all stakeholders, especially those in leadership positions.Case discussion reflection can be supported by providing training, creating spaces for discussion, and, most importantly, following up on the results of discussions.

Figure 1 .
Figure 1.Flowchart of Literature Search Method

Table 1 .
Results of the Selected LiteratureThrough electronic database search with Proquest, Science Direct, PubMed, and Google Scholar, a total of 85 articles were obtained.