empowerment of indonesian nurses and quality of care: a patient perspective

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The influence of empowerment

of Indonesian nurses on

the quality of care:

A Patient perspective

(2007)By Lenny van Ameijde, MA

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Empowerment Indonesian nurses

Patient centred care and empowerment of nurses

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• Dissertation MA Dissertation MA International Service ManagementInternational Service Management• London Metropolitan University/London Metropolitan University/ Stenden University The NetherlandsStenden University The Netherlands• Single case study Single case study • Dr. Kariadi HospitalDr. Kariadi Hospital Semarang, Central Java Semarang, Central Java • Qualitative studyQualitative study• 2006/20072006/2007

Patient centred care Indonesia

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• Rationale

• Definition empowerment

• Four dimensions Patient centred care

• Problem statement and objectives

• Methodology

• Main Findings

• Conceptual model

• Conclusions

• Recommendations

Steps of research


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• Healthcare Indonesia is lagging behind in comparison with the international standard

•No recognition of own identity nursing profession

• RTC 2004 Bali about professionalism and specialization of Indonesian nurses One of recommendations RTC: research

• Research in 2 phases: previous research 2006 integrated in the dissertation 2007

Rationale

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“The ability to mobilize resources to get things done”

Social structures within the work environment that provide employees with access to information, support, resources, strong interpersonal relationships and opportunities to learn and grow, are empowering and allow employees to accomplish their work in meaningful ways. (Kanter,1993)

Definition empowerment

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Literature review: 4 dimensions patient-centred care

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Access to informationAccess to information

Compassionate human interactionCompassionate human interaction

Social support systemsSocial support systems

Healing environmentHealing environment

Source: Frampton (2003)Source: Frampton (2003)

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Problem statement

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From the Patient’s point of view, From the Patient’s point of view, does empowerment of nurses does empowerment of nurses influence the quality of care?influence the quality of care?

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Objectives

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To analyze Patient requirements or To analyze Patient requirements or expectations of the quality of expectations of the quality of healthcare and settinghealthcare and setting

To identify elements of Patient care To identify elements of Patient care that can be improved by that can be improved by empowering Indonesian nursesempowering Indonesian nurses

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MethodologyP

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Qualitative research:Qualitative research:

Subjective, understanding the Subjective, understanding the perception, feelings and views of perception, feelings and views of Indonesian PatientsIndonesian Patients

Knowledge and insight based Knowledge and insight based upon the subjective viewpoints of upon the subjective viewpoints of PatientsPatients

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Methodology: MethodsP

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Triangulation of data:Triangulation of data:

• Documents (literature review)Documents (literature review)• Semi structured depth interviewsSemi structured depth interviews with 8 Patients from 1with 8 Patients from 1stst, 2, 2ndnd, 3, 3rdrd class, class, selected by hospital, based uponselected by hospital, based upon criteria, assisted by Indonesiancriteria, assisted by Indonesian professional, familiar with healthcareprofessional, familiar with healthcare who speaks fluently Englishwho speaks fluently English• Direct observationsDirect observations

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Main findings: 1st class PatientsP

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Quality of care: get the best care provided by specialist doctors and D3 and S1 nurses

• Have good access to information because they are more educated and able to communicate with doctors on an equal level: less power distance.• Prefer S1 nurses who give better information, have a better attitude and skills

• Get compassionate care: personal attention, creating a trust-based relationship with doctors and nurses. Still they would like to get more time to communicate their feelings to doctor/nurse.

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Main findings: 1st class Patients

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• Have less need of the presence of their family to monitor and take care of them because they get the best care

• Their environment is healing because of more privacy, good accommodation and equipment, supporting their needs (ac, tv, bell, own bathroom), the staff needs (supplies, patient/nurse ratio, space, mushola) and family needs (own bed)

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Access to information 1st class P

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Discussion healthcare team and patient

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Healing environment 1st class P

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Nursing post 1st class P

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Patients’ view 1st class P

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“I hope there will be specialization in the nursing

department, may be the heart patient will be

taken care of by a heart disease nurse”

“Nurses and doctors must do a

lot of meetings together so that

they can share the problems”

“Usually they visit us a few minutes only. I hope nurses and doctors spend more time during the visits so that we are able to communicate what we feel”.

“My family just does the laundry and brings food. My family completely trusts the hospital”


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Patients’ view 1st class P

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“When the nurse serves us with a warm friendliness and smile, I think it is healing for the patient”.

“Most of all I trust the doctor because all

the information is from the doctor”

“ Sometimes they respond by making a

joke. It makes me feel relaxed”

“My servant accompanies me”

“Some have better knowledge, like one nurse who studied abroad. She pays more attention to me, explaining the disease in detail”


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Main findings: 2nd class PatientsP

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Better communication between doctors and nurses regarding exchange of information would make Patients feel more confident about the treatment.

Lack of time doctors and nurses, lack of cooperation between doctors and nurses and lack of empathy have a negative impact on trust-based relationship between doctor, nurse and patients.

Lack of initiative nurses is barrier to get quick assess to information. Nurses are reactive instead of pro-active because they are not empowered, patients/family are only informed if they ask.


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Main findings: 2nd class PatientsP

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Nurses are task centred instead of patient centred

The power distance is high, Patients often are afraid to ask the doctor or nurse, especially after experiencing impoliteness.

For their wellbeing Patients are to a great extend dependent on the care provided by family, who fills the gaps caused by imbalanced nurse-to-patient ratio.

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2nd class wardP

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2nd class Healing environmentP

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Patients’ view 2nd classP

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“How can Patients heal fast if they keep Patients waiting and asking about the treatment without giving a fast response? The nurse must give fast & up to date information to the doctor about the Patients. No more delaying.”

“The nurse and the doctor work separately, there is no cooperation. It is an indirect communication because they communicate through memo”.

“For the doctor, I hope they talk more to the Patient

and not just examine us and say nothing. Please talk to

us, it makes us feel relieved. But if they are just silent,

we will be worried. There’s a big question mark in our

head”


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Patients’ view 2nd class

“No the nurse never informs me about

the side-effect of the treatment,

because I never ask. I sometimes ask

the Patient next to me”.

“Some nurses pay attention but

some pay less attention. Even

sometimes Patients (not

accompanied by family) don’t eat

all day because nurses don’t

help to feed them”.

“Even if the nurse answers my question, still it doesn’t satisfy me. I think the doctor and the nurse don’t communicate well”.

“I hope in future nurses visit us more and are not just sitting in the office after visiting us”. So they are ready if there’s a sudden accident. Hopefully they are more close to Patients.

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Main findings: 3rd class Patients

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• Grateful for access to hospital

• Often already in a critical phase of disease

• Treated by student nurses: painful interventions

• Limited time spent by doctors and nurses is a barrier to get a trust-based relationship. They do not listen to Patients.


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Main findings: 3rd class Patients

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• Long waiting time before action is taken

• High power distance, afraid to ask, therefore low or no access to information

• Family needed to provide the most basic care and monitor to prevent accidents


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Access to information 3rd classP

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Doctor, please talk to me

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Family 3rd class P

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Compassionate human interaction 3rd class

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“Diploma nurses are most of the time in nursing post instead of the ward” for administrative duties

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3rd class Patients’ viewP

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“I never know any issue. I only know

the information from the Patients next

to me. They always tell me what to do

during the treatment”. “Nurses should be more active and pay more attention to us. Doctor and nurse must cooperate well. The nurse must give the doctor a report of the patients condition as soon as possible”

“The doctor is better, because the nurses just do what the doctor tells them”.

“When I got less information I felt worried about it. I always try to find some information from the nurse. But important is the doctor’s answer”.


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3rd class Patients’ view

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“Well, you know how it feels being loved by your family.

Its good, because they provide all my needs”.

“The most important is communication between patients to nurse and doctor or any other people involved”

“For certain things, nurses are

always waiting for the doctor

instructions”

“we don’t interact for a long time, for example when they do the infusion. They just help me with that and then they go. We don’t have a long conversation”


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Model empowerment of Indonesian nurses and quality of care

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trust trust

Reforming nursing

education

Reforming nursing services

Patients’Perception

family

Empowerment Indonesian

nurses

Personal empowerment

Professional empowerment

Knowledge & Skills

AuthorityConfidence

unity nursessupport doctors

Patient-centered careAccess to informationSocial support systemsCompassionate human interactionHealing environment

trust

Adapted from Haghbaghery et al (2005)

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General Conclusions (1)

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• 1st class patients are satisfied and able to judge the care

• 3rd class patients are grateful and have no option but to trust

• 2nd class patients are most critical about the care• Patients with a higher level of education seem be able

to build a trust-based relationship, leading to better access to information and compassionate human interaction.

• Small difference in service between 2nd and 3rd class• Big difference in service between 2nd and 1st class


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General Conclusions (2)

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• Most important: trust and family• Patients observe lack of trust between doctors and

nurses, resulting in lack of trust by patients towards nurses.

• They see that nurses are still in many cases treated as the doctor’s helper, with little or no authority of their own. So how can they trust the nurse, if the doctor does not?

• A good communication and cooperation between nurses and doctors would lead to nurses who are empowered to handle situations more effective and inform doctors about Patients’ questions, doubts, anxieties and complaints, leading to reduced waiting time.


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General Conclusions (3)P

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Opinion of nurses in previous study “ Empowerment of nurses in Indonesia” (206) is in line with the perception of patients’.

An exception is that nurses perceive they are valued more than the doctor, because they provide more personal attention and compassionate care.In contrast, the Patients in 2nd and 3rd class complain that nurses spend more time in their nursing post than in taking care of Patients.

Last but not least it is likely that empowerment of nurses influences the quality of care.


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Conclusions four dimensions Patient centred care (4)

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Access to information should be given about disease:treatment, side-effects, alternatives and aftercare in a proactive, empathic but honest way, sometimes with a sense of humour, taking into account the level of communication of the patient. They feel receiving information is healing.


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Conclusions four dimensions Patient centred care (5)

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Compassionate human interaction means nurses being reassuring; personal attention, showing real interest and find time to listen; professional with the appropriate knowledge, skills and attitude (polite); not task centred but human centred.

Patients want doctors and nurses to treat them like family….


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Conclusions 4 dimensions Patient centred care(6)

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Social support systems: family in 3rd and 2nd class is present 24 hours a day, which makes patients feel more safe. Also patients among themselves take care of each other when necessary

Healing environment: a bell in case something is wrong for 2nd and 3rd class, clean bathroom nearby.


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Strategic Recommendations (1)P

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Education

• Integrate the model of empowerment of Indonesian nurses and quality of care in the nursing education in Indonesia

• Implement the 4 dimensions of Patient-centred care, placed in the heart of the model, to raise education to international standards.

• Upgrade Diploma 3 to S1 (bachelors)• Continue with specializations

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Strategic recommendations (2)

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International cooperation

• Curriculum development

• Competency development

• Education and clinical training

• Master programs and specializations

National cooperation

• Necessity to cooperate with doctors on equal terms, find modern thinking doctors who are supporting empowerment of nurses. This will be helpful creating a trust-based relationship with the patieny

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Scientific recommendationsP

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Increase validity and reliability of this single-case study by:

Extending the present study to a multiple-case study in two phases:

1. Replication of study in some other provinces in comparable hospitals, using the same qualitative approach and methods.

2. Test and generalize the results of this cross- case study statistically using a quantitative approach.

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Implementation

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Hopefully this research will be helpful to lift the

quality of healthcare to international standards,

meeting the needs of patients in Indonesia

Thank you for your attention

empowerment of indonesian nurses and quality of care: a patient perspective

Documents

stclass patients patients

empowering indonesian

s1 nurses

methodology patients

elements of patient

objectives patients

quality of healthcare

methods patients