Nursing assignment
Development of Holistic Nursing Care Model for Mental Disorder Patients Care in Indonesia
Ah. Yusuf1, Rizki Fitryasari1, RR Dian Tristiana1, Hanik Endang Nihayati1, Ahsan2, Suprajitno3
1Nursing Faculty of Universitas Airlangga, Surabaya, 2Nursing Program of Universitas Brawijaya, Malang, 3Poltekes Kemenkes Malang
Abstract
Background: Holistic care is a comprehensive model of caring. It has been known as bio-psycho-socio- cultural approach.
Objective: This study aims to develop a holistic nursing care model for mental disorder patients in Indonesia.
Method: This study using explanative design with cross sectional approach. The participants are nurse in mental health hospital in one province in Indonesia. The sampe size is 120 nurses. Data were collected using questionnaire then analyzed using Partial Least Square.
Results: Comprehensive modality therapy (path coefficient=0.621;t=11.75), written standard operational procedures for modality therapy (path coefficient=0.749;t=4.107), nurse competency (path coefficient=0.838;t=30.341), hospital policy (path coefficient=0.567;t=10.736), hospital facilities (path coefficient=0.861;t=23.028), community and family engangement (path coefficient=0.797;t=14.252), and cross-sector collaboration (path coefficient=0.756;t=11.326), influenced the implementation of holistic nursing care in treating mental disorder patients.
Discussion: The holistic nursing care model in treating mental disorder patientst not only bio-psycho-socio- spiritual approach but also depend on supportive healthcare facility, policy and community.
Keyword: holistic, nursing care, mental disorder
Introduction
Mental disorder is a behavioral syndrome associated with symptoms of suffering, limitations, and inability to perform essential human functions (1,2). Indonesian basic health research which conducted in 2013 shows that 1.7/1000 of Indonesia’s population has severe mental disorder, with 14.3% experienced restrained in home (3). Six out of 100 Indonesians suffer from emotional mental disorders, resulting in poor productivity and quality of life. Mental health nursing goals is to improve and maintain the patient’s adaptive behavior to contribute to their integration function.
Various therapeutic alternatives intervention in treating mental disorder patients has been developed: psychopharmacology drug, electroconvulsive therapy, cognitive and behavioral therapy, group activity therapy,
family therapy and psychiatric rehabilitation. Indonesian government roadmap about “Indonesia free restrain” by 2014 has been socialized since 2010. In fact, the case finding of mental disorder patients who are being restrained in home continues to increase. The Indonesian Ministry of Health data showed the case finding of mental disorder patients who are being restrained in 2010 was 383, in 2011 was 1139, and data from January to August 2012 was 803.
Holistic care is a comprehensive care that aim to meet the patient’s physical, mental, social and emotional needs(4,5).
Caring for mental disorder person will cause productivity loss of family member who become their caregiver. That condition will lead to economic potential lost due to mental disorder. The potential economic lost
DOI Number: 10.5958/0976-5506.2019.02084.9
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due to severe mental disorder is equivalent to the number of patients times by regional minimum wage (58,520 people x 2,2 million) around idr 128,744,000,000 cost.
Preliminary study shows that mental disorders not only a patient problem, but also family, community, health care, including nurses. Nurses should have the competence such as delivering nursing care, implementing standard operational procedures, and conducting modality therapy in caring for mental disorders patients. A number of barriers in giving care for mental disorder patients in hospital include: incompleteness of nursing care documentation, limited service facilities, ineffective of management implementation in the ward, lack of human resources in nurses (quantity and competence), workload (5) and the condition of patients treated (6). Problems concerned to family and community include: family perception that one family member had mental disorder, caring for family member mental disorder, family feeling, stigma from family and community, perceived impact, and family expectation. It is necessary to formulate a holistic model of mental health nursing. Holistic service is a design of a comprehensive model of health care in view of the various healthy responses of illness by taking into account all components such as biological, psychological, social, cultural and even spiritual (7). The holistic model will involve the contribution of all elements include patient, family, community and health care providers especially nurses. So this study aims to develop a holistic model in giving care of mental disorders patients.
Materials and Method
Study Design
This study uses explanative method. The population of the study was nurses at mental hospital Menur Surabaya and mental hospital Lawang Malang. The sample was 120 respondents obtained through simple random sampling technique.
Measures
The data quantified using questionnaires that developed based on previous result of our study. The questionnaire is consist of 55 questions dividing in 8 categories that reflect the study variables: the implementation of holistic nursing care, the implementation of modality therapy), standard
operational procedures, human resources nursing, hospital policy, hospital facilities, community condition, and cross-sector role. Each questions is rated on four- point of likert scale (always, sometimes, rarely and never).
Data collection
Respondents were completed the study questionnaire individually after obtaining an explanation of the purpose, benefits, rights and responsibilities of the respondent, and provided the inform consent to follow the study. The respondents fill out questionnaires data characteristics of respondents include gender, age, employment, place (unit) work, and level of education and questionnaire research variables. The collected data is then tabulated for analysis.
Data Analysis
The data were analyzed using partial least square variance-based structural equation modeling (PLS- SEM) in order to model for simultaneous relationships among multiple constructs.
Findings
Characteristics of Respondents
Characteristics of respondents based on the results of the description presented in table 1 in the form of frequency and percentage values. The data show that the majority of respondents are at productive age (36- 40 years old) with year of services in 11-15 years. Respondents mostly work in in-patient ward and some have educational backgrounds as Nursing and Nursing Diploma 3.
Model test results Analysis of research variables
The holistic nursing care model test in caring for mental disorders patients begins by evaluating the relationship of latent variables with the study variables through validity and reliability tests. Table 3 describes valid latent variables in forming research variables. Reliability of latent variable is shown with composite value of reliability >0.7. While variable validity is indicated by measuring convergent validity and discriminant validity. Convergent validity was achieved after the research variables obtained the average value of extracted (AVE) >0.5.
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Structural model analysis
Structural test of holistic model is used to test the research hypothesis. The results of the holistic model structuring test in treating psychiatric patients were performed on valid and reliable research variables. Based on the results of the structural model test as can be seen in table 5 that the modality therapy is built significantly by 3 research variables, namely modal
therapy, hospital policy and community situation. The three variables each have a positive relationship, in the sense that the better the nurse modality therapy, the more supportive of hospital policies and the more supportive of the community situation then the application of holistic models in mental patients will be better. These three variables together determine the implementation of the holistic model in treating psychiatric patients by 40.5%, and the rest is influenced by other variables that are not examined.
Table 1 Respondent Characteristic (n=100)
Characteristics Category N (%)
Gender Female 58 (48,3)
Male 62 (51,7)
Age (year)
21 – 25 5 (4,1)
26 – 30 19 (15,8)
31 – 35 18 (15,0)
36 – 40 24 (20,0)
41 – 45 16 (13,3)
46 – 50 23 (19,1)
51 – 55 14 (11,6)
56 – 60 1 (0,8)
Work Tenure (years)
1 – 5 14 (11,7)
6 – 10 22 (18,3)
11 – 15 25 (20,8)
16 – 20 15 (12,5)
21 – 25 13 (10,8)
26 – 30 19 (15,9)
31 – 35 8 (6,7)
36 – 40 1 (0,8)
Missing 3 (2,5)
Workplace Inpatients room 89 (74,2)
Outpatients 31 (25,8)
Latest Education
D3 (3-year diploma) 55 (45,8)
D4 (4-year diploma) 15 (12,5)
S1 (Undergraduate) 49 (40,9)
Magister of health 1 (0,8)
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Table 2 rho_A test
Original Sample (O)
Sample Mean (M)
Standard Deviation (STDEV)
T Statistics (|O/ STDEV|)
P Values
Nursing intervention 0.621 0.629 0.053 11.754 0.000
Hospital policy 0.567 0.574 0.053 10.736 0.000
Community 0.797 0.799 0.056 14.252 0.000
Modality therapy 0.824 0.818 0.074 11.169 0.000
Hospital facility 0.861 0.874 0.037 23.028 0.000
Human resource for nursing 0.838 0.843 0.028 30.341 0.000
Standard operational procedure for modality therapy
0.749 0.792 0.182 4.107 0.000
Cross-sector collaboration 0.756 0.781 0.067 11.326 0.000
Table 3 Composite Reliability Test
Original Sample (O)
Sample Mean (M)
Standard Deviation (STDEV)
T Statistics (|O/ STDEV|)
P Values
Nursing intervention 0.749 0.742 0.031 24.087 0.000
Hospital policy 0.730 0.727 0.022 32.485 0.000
Community 0.841 0.838 0.022 37.569 0.000
Modality therapy 0.849 0.841 0.018 48.066 0.000
Hospital facility 0.869 0.866 0.018 48.694 0.000
Human resource for nursing 0.853 0.852 0.015 56.701 0.000
Standard operational procedure for modality therapy
0.829 0.825 0.023 36.759 0.000
Cross-sector collaboration 0.886 0.884 0.018 48.153 0.000
Discussion
This study shows that holistic model in treating psychiatric patients was shaped significantly by the implementation of nursing modality therapy, hospital policy and the situation in the community which in line with previous study (8–11) that the holistic approach consists of two aspects: the patient and the multidimensional which becomes complicated by the
patient’s pain situation. The holistic model focuses on the health conditions of psychiatric patients and attempts to the outside aspects of the patient’s system, the hospitals and the community.
Mental health hospital should have supportive policy towards modality therapy implementatin for mental disorder patients. The holistic model pays attention to the community’s response and community engagement
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to mental disorder patients when back to their home. Mental hospital should develop community-based interventions, family-based interventions, preparing the community readiness to caring for mental illness patients to warrant the continuity of modality therapy implementation.
The results of the study show that the mental health nursing holistic model is applied by performing integrated nursing care starting from the assessment especially in the spiritual aspect, making the diagnosis based on 10 major nursing problems, bio-psycho- spiritual-social problem and individual-based intervention, and implementing intervention based on Standard operational procedure. This model is in line with previous study (12) that stating that holistic nurses will provide care to a patient thoroughly covering the process of assessment, determination of diagnosis, formulating goals and treatment plans, intervening and evaluating. Previous study shows that a holistic nursing approach raises demands for nurses to interact with patients well so as to determine the health status of patients and determine appropriate actions to improve health (11). So the approach of nursing care is an appropriate method in compiling a holistic nursing care model development in caring for mental disorders patients.
Spiritual aspect need to be assess by nurses during hospitalization. Hospital should facilitate the patients spiritual fullfillness, spiritual consultants and the patient’s expectation of his illness (13). Currently the nursing care given to the patient still focuses on the biological, psychological and social aspects, so that the addition to the spiritual aspect will complement the nursing approach in the holistic model of nursing.
Modality therapy is one component of the application of holistic models in treating psychiatric patients. Modality therapy has a varied approach to mental disorder including somatic therapy, psychological therapy, environmental therapy, community therapy and activity therapy (14) and aims to change maladaptive behavior to be more adaptive. Nurses should pay attention to patient characteristics and disease conditions in providing modality therapy, so that the patient is willing and able to follow the therapeutic process.
The holistic model integrates the biological, psychological, social and spiritual aspects in caring for mental illness patients. The biological aspect is
manifested in the medication which will help mental patients achieve improved mental functioning(14). Medication intervention should be accompanied by psychological intervention. Psychological therapy focuses on the use of both verbal and non-verbal communication, improving the thought process and helping the patient understand all about mental disorder (15,16). Psychological therapy is delivered simultaneously with social therapy (World Health Organization, 2005).
The holistic model use individual therapy, cognitive therapy, behavioral therapy, psychosocial therapy and group activity therapy to train patients independently. During the treatment process the nurse pays attention to the patient’s verbal and non-verbal responses, with clear outcome. The holistic model adds spiritual therapy as an important part in the application of modality therapy by helping patients to recognize their ability to deal with illness, especially with regard to motivation, positive attitude and optimism (13).
The key of modality therapy is a good therapeutic patient-nurse relationship(17). The relationship should be established so nurses can select the right modality therapy which can help the patient to achieve better outcome.
Hospital policy is the second component that needed to apply holistic model to ensure patients receive holistic services. The results showed that hospital policy related to job description, authority, remuneration, and reward is needed to implement mental health holistic model. Job descriptions are information that describes job standards and task lists to be done in relation to a person’s position in a particular job (18) which relate to the authority in perform an action. Nurses working in health institutions according to Indonesian Law No. 23 of 1992 on health that state that the ability and authority to perform nursing care is based on their education level. The authority of the nurse is the right and autonomy to perform nursing care based on the ability, level of education, and the position held.
Mental health nurses in Indonesia have multiple job including structural position that obstruct to fully carry out the main task of carrying out treatment to the patient. The findings of this study are consistent with Fisher’s (2011) opinion that patient-nurse rasio is high which cause incomplete documentation and could not carry out intensive psychological intervention. The results show
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that remuneration and reward systems are an important aspect of hospital policy when implementing holistic model. Inappropriate reward that nurses get will affect the intervention implementation. The holistic model in this study requires a clear policy about job descriptions and authorities and appropriate remuneration and reward systems.
Community is important aspect in applying holistic model in caring for mental illness patients. The results of this study indicate the existence of elements of community empowerment in the mental health nursing holistic model. Patients with mental illness after hospitalization will return to their families and communities, thus requiring favorable circumstances to avoid recurrence. Nevertheless it is well known that the stigma of society is still high on the existence of patients Schizophrenia, so it takes an intensive approach so that people begin to receive and support the patient’s existence in family and society. The stigma that developed in the community is caused by the lack of understanding related to mental disorders, the impact and the way of treatment (19). The application of holistic models requires a special strategy to manage the stigma in the community. So that the nursing holistic model that has been applied since the patient is hospitalized can be continued with good community acceptance, even the community to support the use of health service facility, will be able to decrease the recurrence rate.
Conclusion
The holistic model in caring for mental disorders patients using nursing care approach of the soul which in its implementation pay attention to the patient from biological, psychological, social and spiritual aspects. The holistic model is carried out by applying the treatment of soul-nursing modalities supported by the hospital policy and the existence of a conducive community situation.
Onflict of Interest: There is no actual or perceived conlfict interest during this study conduct.
Source of Funding: This study is supported by a grant from Ministry of Research, Technology & Higher Education Indonesia.
Ethical Clearance: This study has been approved for ethical clearance from lawang mental Health Hospital and Menur Mental Health Hospital.
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