executive summary dissertation lenny van ameijde empowerment indonesian nurses

Empowerment of Indonesian nurses and quality of care: A Patient perspective _________________________________________________________________________

Executive summary

Empowerment of Indonesian nurses and quality of care: A Patient perspective

Healthcare in Indonesia is lacking behind, not only compared with western healthcare but also with other Asian countries like Singapore and Malaysia. Indonesian cultural aspects such as power distance and lack of support are some of the reasons that nurses are still not empowered but merely seen as the doctor’s helper.Nevertheless the time has come that nurse educators started to take the initiative to develop professionalism by introducing high nursing education. Because they started without the support of doctors, in hospital practice nurses still do the same work regardless of their level of education.

A previous study about empowerment of Indonesian nurses was conducted by the author in 2006, following a study about empowerment of nurses in Iran (Hagbahery et al, 2005). The findings of the Indonesian study confirmed most of the findings of the Iranian study. However, the opinion of the Patient was not included in both studies. Therefore the previous study was extended with this case-study to look at the relationship of empowerment of Indonesian nurses and quality of care from a Patient perspective.

This study seeks to answer the problem statement: from the Patient’s point of view, does empowerment of nurses influence the quality of care?The research objectives are 1) to analyze Patient requirements or expectations of the quality of healthcare and setting and 2) to identify elements of Patient care that can be improved by empowerment of Indonesian nurses.Based upon the problem statement and research objectives the following research questions are formulated:1. How do Patients perceive the quality of care in their relation to nurses and doctors2. What elements are essential in trusting nurses and doctors?3. What are the differences in the servicescape and in quality of care provided by nurses to

1st, 2nd and 3rd class patients?4. What is the role of the family in Patient’s wellbeing 5. How could empowerment of nurses improve patient care?

This single-case study explores and compares the perception of different classes of Indonesian Patients about the quality of care. Crucial are the main characteristics of Patient-centred care: access to information, compassionate interaction, involvement of social support systems, and healing environment (Frampton et al 2003). The findings of the literature review lead to a holistic conceptual model that links nursing education, empowerment, and the quality of care.In the study also the cooperation between doctors and nurses was integrated, because of the interconnectedness of their functions.

To investigate Patient’s perspective within the real-life context of a hospital, for this research a single-case study was designed. An interpretative/ constructivist/phenomenological research philosophy was applied to get insight in the perception, feelings and views of Indonesian Patients. A qualitative approach was followed to gain a deep understanding of the perception of Patients in 1st, 2nd and 3rd class about the quality of care, provided by nurses. Triangulation of data was used by scrutinizing documents, conducting semi-structured depth interviews and direct observation. The data were analyzed using thematic analysis (Benner, 1994). Categorization was based on the literature review and classified according to the four main characteristics of Patient-centred care (Frampton et al, 2003).

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Dissertation Master of Arts in International Service Management

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Main findings were that access to information was limited for 2nd and 3rd class patients. Barriers to lack of information were power distance, lack of time and lack of empathy leading to a negative impact on trust-based relationship between doctors, nurses and Patients. Moreover the lack of initiative by nurses was seen as a barrier to get quick access to information. If patients did not ask, no information was given about their treatment, medication, side effects and after care. Nurses were merely seen as the doctors’ helpers. To the opinion of the Patients a good education of the nurse would improve nurses’ ability to discuss the Patients’ situation with the doctor before the doctor visits the Patient, which would reduce the waiting time. The low education level of 3rd class Patients was a reason for doctors to give a very brief explanation about the disease and treatment. The incapability of the doctors to communicate at the level of the Patient was a barrier for Patients to get the necessary information.

It can be concluded that nurses can only play a role in enhancing Patient’s access to information if nurses themselves know their boundaries and have the professional knowledge, skills and attitude that create trust between nurses and Patients as well as effective communication and trust between doctors and nurses. Only if nurses are empowered themselves, they can optimize access to information to Patients and act as advocates of Patients, providing the necessary information to doctors.

With regard to compassionate human interaction Patients experience that in general nurses are more task–centred than human-centred. This is partly due to their heavy workload and many non-nursing duties. Except lack of time also an impolite attitude and not showing real interest is hindering Patients and nurses to get a trust-based relationship, that would enable nurses to comfort, reassure and encourage patients when they are worried. Patients don’t consider standard, superficial friendliness as compassionate.A big difference exists in skills and attitude between student-nurses and diploma nurses. The few bachelor nurses were valued most, because they were more self-confident, paid more attention and could provide Patients with the necessary information about their treatment.

When looking at involvement of social support systems it can be concluded that family is invaluable in meeting Patient’s needs. This applies to their physical and their emotional needs, as well as advocacy and safety. The lack of appropriate facilities and the imbalanced nurse-to-patient ratio, especially in lower classes, is replaced by family in their role of voluntary care-takers.

Regarding the Healing environment it can be concluded from both interviews and observations that there is not so much difference between 2nd and 3rd class, while the difference between 2nd and 1st class is remarkable.In 3rd and 2nd class lack of most basic equipment (such as a bell) has a negative impact on Patient’s comfort and safety, while imbalanced doctor/nurse-to-patient ratios and non-nursing duties have a negative impact on personal attention and empathic care. Family fills these gaps as much as possible. In 1st class the facilities are good and the family can trust the care is more professional, so their presence is not needed all the time.

Overall it can be concluded that empowerment of nurses does have an impact on the quality of care. The findings of the literature review link up perfectly with the findings of this study, on the understanding that 2 aspects, namely trust and family, stand out. Trust and family are dominant cultural variables in the Indonesian situation. Therefore these elements are integrated in the new model of empowerment of Indonesian nurses. Because the findings in this study are strongly supported by the literature review and because of the

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adaptation of the model with trust and family, it is plausible that this model can be applied in Indonesia, both in education and research.

The results of this study can contribute to the development of empowerment of Indonesian nurses, leading to increased quality of Patient-centred care. In this respect three recommendations are given:1. The integration of the new model of empowerment of Indonesian nurses *1) in the

education of nurses on all levels. 2. Strategic cooperation with The Netherlands for curriculum and competencies

development based on international standards.3. Further research in two phases, namely a qualitative multiple-case study, replicating the

present study in comparable hospitals in different provinces in Indonesia, and a quantitative study testing the outcome of the qualitative cross-case study.

Lenny van Ameijde, MAInternational Service Managementemail: [email protected]

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trust

trust trust

Reforming nursing

education

Reforming nursing services

Patients’Perception

Family

Empowerment Indonesian

nurses

Personal empowerment

Professional empowerment

Knowledge & SkillsAuthority

Confidence

unity nursessupport/

doctors

Patient-centered careAccess to informationCompassionate human interaction Social support systemsHealing environment

*1) Figure: Model empowerment of Indonesian nurses and quality of care

executive summary dissertation lenny van ameijde empowerment indonesian nurses

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