BASIC CONCEPTS OF NURSING

1.1 Introduction

Nurses as one of the health workers play an important role in efforts to achieve

health development goals. The success of health services depends on the

participation of nurses in providing quality care for patients. Patient services in

nursing require comprehensive, careful services to prevent death and disability

by paying attention to biopsychosocial and cultural aspects. Of course, to

support this, the basic concept of nursing is needed which is expected to

achieve professional nursing as the object of nursing care provided. Referring

to the condition of services in Nursing, nurses must have minimum abilities

which are then outlined and developed in the nursing education curriculum in

the Professional Nursing course (Tussaleha, 2014).

Nursing is a form of professional service that is an integral part of health

services, based on nursing science and tips, in the form of comprehensive bio-

psycho-social-spiritual services, aimed at individuals, families and

communities both sick and healthy which covers the entire process of human

life (Kusnanto,

2003). Nurse comes from the Latin word nutrix which means to care or

maintain. According to Kusnanto (2003), a nurse is a person (a professional)

who has the ability, responsibility and authority to carry out nursing

services/care at various levels of nursing services. Meanwhile, nurses,

according to Wardhono (1998), are people who have completed professional

nursing education, and are given the authority to carry out their roles and

functions.

1.2 Definition of Nursing

In 1999 the UKCC stated that "the definition of nursing will be too restrictive

for the profession", however, in practice the definition of nursing includes

policy formulation, service specifications, and educational curriculum

development (Mcgee, 2017; Nursing, 2003). Nursing can control the services

that are budgeted, financed, research activities and policy determination.

Different types of nursing definitions are needed for a variety of different

purposes. The definition of nursing can be interpreted implicitly and explicitly,

the code of ethics, the specification of the scope of nursing practice, and the

educational curriculum.

Nursing care has been defined by the Health and Social Care Law since 2001

which distinguishes 'social care' or 'personal care' from 'professional care'

which aims to define the responsibility for the provision of services and the

feasibility of using the budget (President of the Republic of Indonesia, 2014).

This definition of legislation affects the definition of professional nursing

service delivery which places basic concepts to overcome all client problems

from the nursing side.

The definition of nursing presented in this paper is expressed in the form of

concepts supported by six characteristics. The provision of nursing care is

holistic and includes the provision of services for healthy and sick clients in

groups and individuals, so it must involve other professions in the form of

collaboration. The difference between professional nursing and other nursing

lies in the type of task performed, or in the level of skill required to perform a

particular task.

Berikut ciri-ciri praktik professional (Koning et al., 2021; Maglione & Neville,

2021):

1. Clinical assessment inherent in the process of assessment, diagnosis,

prescription and evaluation

2. Knowledge that is the basis of needs assessment and determination of

actions to meet needs

3. Personal accountability for all decisions and actions, including the decision

to delegate to others

4. A structured relationship between nurses and patients that combines

professional regulations and codes of ethics within a legal framework.

The complexity of public health care needs requires collective knowledge,

skills and actions from many disciplines and professions. Each discipline

collaborates in the form of knowledge and skills, but still contributes in

accordance with the expertise and domain of their respective assignments

agreed upon by the profession (Nursing, 2003). The unique contribution of

each discipline lies in the special and unique combination of elements and

perspectives and orientations of each.

The main concept in nursing is also found in the definition of nursing

developed by the World Health Organization: "The mission of nursing in

society is to help individuals, families and groups achieve

optimal physical, mental and social health (Darling et al., 2021; Nursing,

2003). This requires nurses to develop and perform the functions of health

promotion and maintenance as well as the prevention of poor health conditions.

Nursing also includes the planning and execution of care during illness and

rehabilitation which includes hissic, mental and social aspects of life as they

affect health, illness, disability and death.

The focus of nursing care is individuals, families, and groups across the entire

life span from conception to death. Nursing is an art and science that requires

the understanding and application of knowledge and skills in the discipline. It

also refers to knowledge and techniques derived from the humanities and

physical, social, medical and biological sciences."

1.3 Basic Concepts of Nursing

Health is considered a fundamental concept in nursing practice. Nurses must

understand and learn concepts and clarifications to be able to improve nursing

practice. According to the dictionary, a concept is defined as "something

contained in an abstract or generic mind or idea that is generalized from certain

events". A concept is an abstract used to describe several phenomena that occur

naturally (Kynoch et al., 2021).

Theories in various disciplines related to nursing are psychological and

biological disciplines (Patel, 2019). The Psychological discipline talks about

personality, intelligence, and cognition while the biological discipline involves

protoplasmic cell species. There are four concepts in nursing theory that affect

nursing practice, including the goals, roles, and functions of patients, the

environment, health and nursing (Patel, 2019). Practice in nursing needs to be

improved, one of which is by clarifying the concepts that build it. This clarity

refers to a process called concept development (Fhirawati; Sihombing Marlyn,

2020). As a healthcare professional, it is important to develop scientific

research from basic concepts related to the field of interest. Concept analysis is

about learning the meaning of concepts aimed at resolving gaps and providing

a better understanding. Concepts range from reality to abstract and are

influenced by certain factors.

1.4 Critical Thinking and Critical Reasoning

Nurses in providing care to patients, must make decisions using critical

thinking and clinical reasoning. Critical thinking is a term often used in nursing

that includes "reasoning about clinical issues such as teamwork, collaboration,

and streamlining the flow of work (Process & Nurhaliza, 2013; Puji, n.d.).

Using critical thinking means that nurses are able to independently take extra

steps to keep patients safe and means also independently doing their duties,

rather than just following orders. The accuracy of patient information is

validated and the plan to treat patients is based on their needs, current clinical

practice, and research.

Critical thinking makes nurses choose certain attitudes, eventually cultivating

the habit of doing things based on rational thinking. These attitudes are as

follows:

1. Independent thinking: thinking for yourself

2. Fair mind: treat every point of view in an impartial and unpredictable way

3. Thinking about the greater good and not just thinking about oneself,

knowing when to think of oneself (egocentrism) and when to think or act

for the greater good (sociocentricity)

4. Intellectual humility: recognizing intellectual limitations and abilities

5. Non-judgmental: using professional ethical standards and not basing

judgments on personal or moral standards

6. Integrity: Be honest and demonstrate strong moral principles

7. Perseverance: Persist in doing things even if it is difficult

8. Belief: Believe in yourself to complete a task or activity

9. Interest in exploring thoughts and feelings: Want to explore different ways

of knowing

10. Curiosity: Asking "why" and wanting to know more

Clinical reasoning is defined as, "A complex cognitive process that uses formal

and informal thinking strategies to collect and analyze patient information,

evaluate the importance of this information, and weigh alternative course of

action. The purpose of critical thinking is to make a good judgment about the

care provided to the patient. Nurses must have alternatives in action, weigh

each action based on evidence, and be able to choose the best course of action

that benefits the patient and family. The ability to reason clinically develops

over time and is based on a person's knowledge and experience (Aung et al.,

2016).

Inductive and deductive reasoning are critical thinking skills that help nurses

make clinical judgments in the nursing process (Sitanggang, 2019). The

reasoning process involves cues, making generalizations, and making

hypotheses, making it possible to also make data that is beyond the expected

findings, this is what gives the nurse clues or indications of potential problems

or conditions of the patient (Puji, n.d.; Sitanggang, 2019). The nurse organizes

these cues into patterns and creates generalizations. A judgment is formed from

a series of facts, cues, and observations and is similar to putting together pieces

of a puzzle of an image into a pattern until the whole picture becomes clearer.

Based on generalizations made from data patterns, nurses make hypotheses

about patient problems. This tries to explain the "why" behind the problem that

occurs. If the "why" is identified, then solutions can begin to be explored.

No one can draw conclusions without first paying attention to the cues. Paying

attention to the patient, the environment, and interactions with family members

is essential for inductive reasoning When nurses work to improve inductive

reasoning begins by first paying attention to details about things around the

nurse. A nurse is similar to a detective looking for cues in a picture. Nurses

need strong inductive reasoning patterns and can take action quickly, especially

in emergency situations. They can see how certain objects or events form

generalized patterns that indicate a common problem, i.e., hypotheses.

1.5 Nursing Process

The nursing process is a model of critical thinking based on a systematic

approach to patient-centered care (Nursing, 2003). Nurses use the nursing

process to perform clinical reasoning and make clinical judgments when

providing patient care. The nursing process is based on the Professional

Nursing Practice Standards set by the American Nurses Association (ANA)

internationally. These standards are authoritative statements of the actions and

behaviors expected to be performed by all registered nurses, regardless of role,

population, specialty, and setting, which are expected to perform competently

(Aung et al., 2016; Nursing, 2003). The nursing process is an ongoing process,

adapting to the patient's current health status.

1.6 Rating

The Standard Practice "Assessment" is defined as, "Registered nurses collect

data and information related to the health of healthcare consumers or their

situation (Ahtisham & Jacoline, 2015). A registered nurse uses a systematic

method to collect and analyze patient data. The assessment includes

physiological data, as well as psychological, socio-cultural, spiritual,

economic, and lifestyle data. For example, nurses' assessment of hospitalized

patients in pain includes patient responses to pain, such as inability to get out

of bed, refusal to eat, withdrawal from family members, or anger directed at

hospital staff (Nursing, 2003).

When conducting a general survey assessment, nurses use all of their senses to

observe the patient closely. They look at a patient and ask themselves, what are

they seeing? They listen to a patient and ask themselves, what do they hear,

both verbally and nonverbally? They smell the patient and ask themselves, is

there anything unusual that we need to judge further? They observe the

patient's behavior and make notes about their functions and ability to complete

daily activities according to their level of development.

Before conducting a general survey assessment, it is important to first ensure

the patient is medically stable by completing a short primary survey. After

confirming the patient's medical stability, the general survey assessment is an

overall observation of the patient's general appearance, behavior, mobility,

communication, nutrition, and fluid status in general.

The assessment of a general survey also includes an analysis of height, weight,

and vital signs for values that are out of reach and require additional follow-up.

1. Survei Primer

2. Mental Status

3. Airway and Breathing

4. Sirkulasi

5. General Appearances include:

a. Signs of pain or distress: the patient may show signs of pain or distress

that should be reported to the provider such as: grimacing, moaning, or

increased anxiety. Set priorities for your focused assessment based on

the signs of distress shown by the patient

b. Age: observe if the patient appears to be of the declared age. Chronic

diseases can cause patients to appear older than their age. Factors can

occur in older adults that can affect how well the patient can participate

in the assessment.

c. Body type can reflect nutritional status and lifestyle choices.

d. Hygiene, care, and clothing: Observe the overall cleanliness of the

patient's hair, face, and nails and watch for any odors. Odors can

indicate poor hygiene or various disease states. Validate odors by

conducting additional focused assessments as needed. Pay attention to

the appearance of the patient's clothing; Is it clean and suitable for the

season? Otherwise, the findings may reflect the patient's cognitive

abilities, emotional state, and ability to complete daily activities.

6. Behaviour

7. Mobility

8. Communication

9. Nutritional Status

10. Liquid Status

11. Height, Weight and BMI.

1.7 Diagnosis

Standard Practice "Diagnosis" is defined as registered nurses analyzing

assessment data to determine actual or potential diagnoses, problems, and

problems (Kaveevivitchai et al., 2009; Taylor et al., 2020). A nursing diagnosis

is a clinical assessment of a nurse's response to an actual or potential health

condition or need. Nursing diagnosis is the basis for a nurse's care plan and is

different from a medical diagnosis (Bradford et al., 2021).

1.8 Result Identification

The Standard Practice "Identification of Outcomes" is defined as, "Registered

nurses identify the expected outcomes for an individualized plan with the

health care consumer or the situation (Setyaningsih et al., 2020; Wahidah,

2018). Nurses set measurable and achievable short-term and long-term goals

and specific outcomes in collaboration with patients based on their nursing

assessment and diagnosis data.

1.9 Planning

The Standard Practice "Planning" is defined as, "Registered nurses develop a

collaborative plan that includes strategies to achieve the expected outcomes.

Assessment, diagnosis, and goal data are used to select evidence-based nursing

interventions tailored to each patient's needs and concerns. Objectives,

expected outcomes, and nursing interventions are documented in the patient's

nursing care plan so that nurses, as well as other health professionals, have

access to them for continuity of care (Aung et al., 2016; Department of Health,

2014).

1.10 Nursing Care Plan

Creating a nursing care plan is part of the "Planning" step of the nursing

process, is a type of documentation that shows the individual planning and

delivery of nursing care for each particular patient using the nursing process.

Nurses create nursing care plans so that the care provided to patients across

shifts is consistent among healthcare workers. Nursing care plans are

developed by nurses and in their implementation can be delegated

appropriately.

1.11 Implementation

The Standard Practice of "Implementation" is defined as, "Nurses implement

the identified plan (Ackley et al., 2017). Nursing interventions are

implemented or delegated with supervision in accordance with the care plan to

ensure continuity of care in some nurses and health professionals caring for

patients. The intervention is also documented in the patient's electronic medical

record as they are completed. The "Implementation" Professional Practice

Standards also include the subcategories "Care Coordination" and "Health

Teaching and Health Promotion" to promote health and a safe environment.

1.12 Evaluation

The Standard Practice of "Evaluation" is defined as, "Registered nurses

evaluate progress toward achieving goals and outcomes (Mobley et al., 1978).

During the evaluation, nurses assess patients and compare findings with initial

assessments to determine the effectiveness of the intervention and overall

nursing care plan. Both patient status and the effectiveness of nursing care

must be continuously evaluated and modified as needed (Kurniasari & Astuti,

2015; Nurcahyati et al., 2021).

1.13 Benefits of Using the Nursing Process

Using the nursing process has many benefits for nurses, patients, and other

healthcare team members. The benefits of using the nursing process include:

1. Promotes quality patient care

2. Reduce omissions and duplication

3. Provide guidance for all staff involved to provide consistent and responsive

care

4. Encourage collaborative management of patient healthcare issues

5. Improving patient safety

6. Improves patient satisfaction

7. Identify the patient's goals and strategies to achieve them

8. Increase the likelihood of achieving a positive patient outcome

9. Save time, energy, and frustration by creating a maintenance plan or path to

Using these components of the nursing process as a critical thinking model,

nurses plan interventions tailored to the patient's needs, plan outcomes and

interventions, and determine whether the measures are effective in meeting the

patient's needs. Any component of this nursing process that implements

evidence-based practices is referred to as "the science of nursing.

ROLES, FUNCTIONS AND COMPETENCIES OF

NURSES

2.1 Introduction

Currently, the world of nursing is growing. Nurses are considered as one of the

health professions that must be involved in achieving health development goals

both in the world and in Indonesia.Along with the passage of time and the

increasing need for health services, nurses today demand that nurses have

knowledge and skills in various fields. Nowadays nurses have a wider role

with an emphasis on health improvement and disease prevention, also looking

at clients comprehensively. Nurses perform functions in relation to the various

roles of caregivers, clinical and ethical decision-makers, protectors and

advocates for clients, case managers, rehabilitators, communicators and

educators.

As a nursing care provider, nurses help clients regain their health through the

healing process. Nurses focus care on the client's health needs holistically,

including efforts to restore emotional, spiritual and social health. Caregivers

provide assistance to clients and clients' families using minimal energy and

time. In addition, in their role as a nursing care provider, nurses provide care

by paying attention to the state of basic human needs needed through the

provision of nursing services using the nursing process so that nursing

diagnoses can be determined so that appropriate actions can be planned and

implemented in accordance with the level of basic human needs, then the level

of development can be evaluated. The provision of nursing care is carried out

from simple to complex.

Regulation of the Minister of Health of the Republic of Indonesia No. 004 of

2014 states that the health education strategy must be strengthened with the

right methods and media (Ministry of Health of the Republic of Indonesia,

2014). The role of a nursing care provider is the most important role for a

nurse. Professional nurses who can provide nursing care well and skillfully will

build a better image of nursing in the eyes of the public. Currently, vocational

nurses still dominate nursing practice in hospitals and other health care

settings. It is undeniable that vocational nurses have good application skills in

practicing nursing. However, vocational nurses have more limited theoretical

knowledge when compared to professional nurses. With the increasing number

of professional nurses today, it is hoped that it can complement the

competencies possessed by vocational nurses (Sunaryo, 2016). A professional

nurse must understand the theoretical basis in practicing nursing. This

theoretical foundation will be very useful for professional nurses when

explaining the purpose and purpose of the nursing care provided rationally to

the client.

2.2 Role of Nurses

Nurses are those who have the ability and authority to carry out nursing actions

based on the knowledge they have obtained through nursing education. A

person is said to be a professional nurse if he has knowledge, professional

nursing skills and has a professional attitude according to the professional code

of ethics.

A role is a set of behaviors that others expect of a person according to their

position in a system. The role is influenced by social conditions both from

within and from outside and is stable (Kusnanto, 2014). So the role of nurses is

a way to declare the activities of nurses in practice, who have completed their

formal education, are recognized and given the authority by the government to

carry out nursing duties and responsibilities professionally in accordance with

their professional code of ethics. The roles possessed by a nurse include the

role of an implementer, the role of an educator, the role of a manager, and the

role of a researcher (Asmadi, 2017). In carrying out nursing care, nurses have

roles and functions as nurses, including care providers, as family advocates,

disease prevention, education, counseling, collaboration, ethical decision-

makers and researchers (Hidayat, 2012)

2.2.1 Types of Nurse Roles

In carrying out nursing, according to Hidayat (2012), nurses have the following

roles and functions as nurses:

1. Care Giver

The main role of nurses is to provide nursing services, as nurses, the

provision of nursing services can be done by meeting the needs of

sharpening, loving and nurturing. Examples of nursing care include actions

that help the client physically and psychologically while maintaining the

dignity of the client. The nursing measures needed can be total care, partial

care for patients with partial dependency and supportive-educative care to

help the client achieve the highest possible level of health and well-being

(Berman, 2010). Effective nursing planning for patients treated should be

based on the identification of the needs of the patient and family.

2. As a family advocate

In addition to performing the main duties in caregiving, nurses are also

able to act as family advocates as family defenders in several ways, such as

in determining their rights as clients. In this role, nurses can represent the

needs and expectations of clients to other health professionals, such as

conveying the client's wishes regarding information about his or her illness

that the doctor is aware of. Nurses also help clients get their rights and help

patients express their wishes (Berman, 2010).

3. Disease prevention

Prevention efforts are part of the form of nursing services so that every

nursing care must always prioritize preventive measures against the

emergence of new problems as a result of the disease or problems suffered.

One of the most significant examples is safety, because each age group is

at risk of certain types of injuries, preventive counseling can help prevent

many injuries, thereby significantly reducing the rate of permanent

disability and mortality due to injury in patients (Wong, 2009).

4. Educators

In providing nursing care to patients, nurses must be able to play the role of

educators, because some messages and ways to change behavior in patients

or families must always be carried out with health education, especially in

nursing. Through this education, it is sought that patients no longer

experience the same disorders and can change unhealthy behavior. An

example of the role of nurses as educators is that the overall goal of patient

and outpatient counseling is to minimize patient and family stress, teach

them about therapy and nursing care in hospitals, and ensure families can

provide appropriate care at home when they return home (Kyle & Carman,

2015).

5. Counseling

Counseling is an effort by nurses in carrying out their roles by providing

time to consult on problems experienced by patients and families, these

various problems are expected to be overcome quickly and it is also hoped

that there will be no gap between nurses, families and patients themselves.

Counseling involves providing emotional, intellectual and psychological

support. In this case, nurses provide counseling, especially to healthy

individuals with normal self-adjustment difficulties and focus on making

the individual to develop new attitudes, feelings and behaviors by

encouraging clients to seek alternative behaviors, regarding available

options and develop a sense of self-control (Berman, 2010).

6. Collaboration

Collaboration is an act of cooperation in determining the actions that will

be carried out by nurses with other health teams. Patient nursing services

are not carried out independently by the nursing team but must involve

other health teams such as doctors, nutritionists, psychologists and others,

considering that patients are complex individuals or who need attention in

development (Hidayat, 2012).

7. Ethical decision-making

In making decisions, nurses have a very important role because nurses are

always in contact with patients approximately 24 hours a day, always next

to patients, so the role of care as ethical decision-makers can be carried out

by nurses, such as carrying out nursing service actions (Wong, 2009).

8. Researchers

This nurse role is very important that all patient nurses must have. As a

nurse researcher, she must conduct a study of patient nursing, which can be

developed for the development of nursing technology. The role of nurses as

researchers can be carried out in improving the quality of patient nursing

services (Hidayat, 2012).

The role of nurses in providing comprehensive nursing care as an effort to

provide comfort and satisfaction to patients, includes:

1. Caring, is an attitude of caring, respecting, respecting others, meaning

paying attention and learning about someone's likes and how people think

and act.

2. Sharing means that nurses always share experiences and knowledge or

discuss with their patients.

3. Laughing, meaning that a smile is the main capital for a nurse to increase

the patient's sense of comfort.

4. Crying means that nurses can receive emotional responses from both

patients and other nurses as a normal thing in times of joy or sorrow.

5. Touching means that physical and psychological touch is a sympathetic

communication that has meaning.

6. Helping Means nurse ready help with nursing care.

7. Believing in others means that nurses believe that others have the desire

and ability to always improve their health.

8. Learning means that nurses are always learning and developing themselves

and their skills.

9. Respecting means showing respect and appreciation for others by

maintaining the patient's confidentiality to those who do not have the right

to know.

10. Listening means wanting to hear the complaints of their patients.

11. Feeling means that the nurse can receive, feel, and understand the patient's

feelings of grief, joy, frustration, and satisfaction.

2.3 Nurse Functions

The function of nurses in conducting assessments on healthy and sick

individuals where all activities carried out are useful for health recovery based

on the knowledge they have, these activities are carried out in various ways to

restore patient independence as quickly as possible in the form of a nursing

process consisting of the assessment stage, problem identification (nursing

diagnosis), planning, implementation and evaluation.

Gartinah, et al. stated that in nursing practice, nurses perform the following

functions:

1. As a perpetrator or provider of nursing care directly to patients using the

nursing process.

2. As patient advocates, nurses function as a liaison between patients and the

rest of the health team, advocating for the interests of patients and assisting

clients in understanding all the information and health efforts provided.

The role of advocacy also requires nurses to act as resource persons and

facilitators in decision-making on health efforts that must be undertaken by

patients or their families.

3. As patient educators, nurses help patients improve their health through the

imparting of knowledge related to nursing and medical procedures so that

patients and their families can receive it.

4. As coordinators, nurses utilize all available resources and potentials in a

coordinated manner.

5. As collaborators, nurses work closely with other health teams and families

in determining plans and implementation of nursing care to meet the health

of patients.

6. As a reformer, nurses innovate in the way they think, behave, behave and

improve the skills of patients or families to be healthy.

7. As a manager, nurses organize activities in an effort to achieve the

expected goals, namely the fulfillment of basic satisfaction and satisfaction

of nurses doing their duties.

In nursing practice, the functions of nurses consist of three as follows:

1. Independent Function

It is an independent function and does not depend on others, namely nurses

in carrying out their duties are carried out by themselves with their own

decisions in carrying out actions in order to meet basic human needs such

as the fulfillment of physiological needs (fulfillment of oxygenation needs,

fulfillment of fluid and electrolyte needs, fulfillment of nutritional needs,

fulfillment of activity needs and others), fulfillment of needs and comfort,

fulfillment of love needs, fulfillment of self-esteem and self-actualization

needs.

2. Dependent Function

It is the function of nurses in carrying out their activities on messages or

instructions from other nurses. So that as an act of delegation of tasks

given. This is usually done by specialist nurses to general nurses, or from

primary nurses to managing nurses.

3. Interdependent Function

This function is carried out in a group of teams that are interdependent with

each other. This function can occur if the form of service requires

teamwork in providing services such as in providing nursing care to

patients with complex diseases. This situation cannot be overcome by the

nurse team alone but also by doctors or others, such as doctors in providing

treatment actions in collaboration with nurses in monitoring the reaction of

the drugs that have been given.

2.4 Nurse Competencies

2.4.1 Nurse Competency Standards

Standards are defined as agreed measures or benchmarks, while competence

can be interpreted as a person's ability to be observed covering knowledge,

skills and attitudes in completing a job or task with set performance standards.

Nurse competency standards reflect the competencies expected to be possessed

by individuals who will work in the field of nursing services. Facing the era of

globalization, these standards must be equivalent to standards that apply to the

health industry sector in other countries and can be applied internationally.

Competency standards are prepared with the following objectives:

1. For nursing education and training institutions;

a. Providing information and references for the development of nursing

education programs and curriculums

b. Providing information and references for the development of nursing

training programs and curriculums

2. For the business world/health industry and users, as a reference in:

a. Determination of job descriptions for nursing staff.

b. Recruitment of nurses.

c. Performance evaluation

d. Development of specific training programs

3. For institutions that provide testing and certification of nurses, as a

reference in formulating certification program packages according to

qualifications and types.

2.4.2 Systematics of Nurse Competency Standards

The Nurse Competency Standard consists of 5 (five) competency areas derived

from the description of the duties, roles, and functions of nurses. The

competency area is also an adaptation of the 5 (five) domains of the ASEAN

Nursing Common Core Competencies which are agreed upon by all ASEAN

member countries. Each area of competence is defined by its definition, which

is then elaborated into several competency components.

Schematically, the systematics of the Nurse Competency Standards is described

as follows:

Figure 2.1: Systematics of Nurse Competency Standards

The Nurse Competency Standards are equipped with subject matter, a list of

problems, a list of diagnoses, and a list of nursing skills, with the following

description:

The List of Subject Matter contains the types of knowledge according to the

branches of knowledge needed to fulfill the competencies of vocational nurses

and nurse professions.

The Problem List contains problems that are often found in Nursing Practice

that underlie the need for Nursing Services. This list is necessary to train and

familiarize students.

Nursing recognizes the problems that will be faced in Nursing Practice by

making the list a trigger for discussion in the Nursing education process.

The Diagnosis List contains Nursing Diagnoses that refer to the Indonesian

Nursing Diagnosis Standards (SDKI). This list is needed to assist nursing

educational institutions in the preparation of teaching materials and skills

training to achieve the competency standards of nurses.

The Skills List contains nursing interventions that refer to the Indonesian

Nursing Intervention Standards (SIKI). This list is necessary for the

formulation of forms, mechanisms, health facilities, and means of supporting

skills needed to meet the competency standards of Nurses.

2.4.3 Nurse Competency Standards

1. Areas of Competence

Nursing is a synthesis of biomedical, psychological, social, behavioral,

anthropology, and cultural sciences. Quality nursing services/care for the

community need to be guaranteed competency standards. Nurse

Competencies include knowledge, attitudes and skills (soft and hard skills).

The Nurse competency framework is grouped into 5 (five) competency

areas. This area corresponds to the 5 (five) domains of the ASEAN Nursing

Common Core Competencies as follows:

a. Ethical, Legal, and Culturally Sensitive Practices

b. Professional Nursing Practice

c. Leadership and Management

d. Education and Research

e. Personal and Professional Quality Development

Figure 2.2: Nurse Competency Area

2. Competency Components

a. Areas of Nursing Practice based on Ethics, Legal, and Sensitivity

Culture

1) Ethics

2) Legal

3) Cultural Sensitivity

b. Areas of Professional Nursing Practice

1) Nursing Care Management

2) Quality of Nursing Practice

c. Leadership and Management Area

1) Leadership

2) Nursing Service Management

d. Education and Research Area

1) Education

2) Research

e. Personal and Professional Quality Development Area

1) Professional development and continuing education

2) Science and Technology Development

3. Competency Description

a. Areas of Nursing Practice based on Ethics, Legal and Sensitivity

Culture

1) Core competencies:

Able to practice Nursing based on ethical, legal, and culturally

sensitive practices.

2) Nursing graduates are able to:

a) Ethical Nursing Practice

[1]. Understand the concepts of ethics, norms, religion, culture,

and human rights in Nursing Services.

[2]. Respecting the differences in religious, cultural, and social

backgrounds between Clients and Nurses.

[3]. Prioritizing the interests of the Client in the provision of

Nursing Services.

[4]. Maintaining the Client's right to privacy.

[5]. Keeping the Client's confidentiality obtained due to the

therapeutic relationship.

[6]. Maintain the health of the nurse so that it does not have an

impact on the Client.

[7]. Avoiding conflicts of interest with Clients in providing

health services.

[8]. Showing empathy and caring attitude (caring) in the

provision of Nursing Services.

[9]. Maintain and build professional relationships with fellow

Nurses and with other professions for quality Nursing

Services.

[10]. Protecting Clients from substandard health services.

[11]. Actively participate in professional development to

maintain the quality of Nursing Services.

b) Legal Nursing Practice

[1]. Understand the provisions of laws and regulations related

to health and nursing services.

[2]. Conducting professional nursing practice in accordance

with laws and regulations related to health services and

nursing.

[3]. Showing a legal awareness attitude in health and nursing

services.

c) Nursing Practice Based on Cultural Sensitivity

[1]. Using a cultural approach to improve the quality of service

delivery

Nursing.

[2]. Encouraging community independence based on local

culture to improve public health status.

b. Professional Nursing Practice Areas 1) Core

competencies:

Able to practice Nursing professionally based on Nursing science.

2) Nurse graduates are able:

a) Apply the latest biomedical sciences, humanities, nursing

sciences, and public health sciences to manage nursing

problems in a holistic, integrated, and continuous manner

including:

[1]. Service promotion health to individuals, families,

groups, communities, and societies.

[2]. Prevention of general and specific health problems for

individuals, families, groups, communities, and society.

[3]. Formulation of Nursing Diagnosis and analysis of Nursing

problems in accordance with the standards of Nursing

Practice

[4]. As Foundation to Preparation intervention

plan and evaluation of Nursing Care outcomes.

[5]. Nursing Intervention according to Problems and Nursing

Diagnosis in all service orders in primary, secondary,

tertiary, and special Health Service Facilities.

[6]. Health recovery services for individuals, families, groups,

communities, and communities to achieve a better degree

of health.

b) Understand the quality standards used in Nursing Services to

protect Clients in fulfilling their needs for health services,

including:

[1]. Formulation of inputs, processes, and outputs in the

provision of Nursing Services for individuals, families,

groups, communities, and communities.

[2]. Able to adapt to the availability of resources without

sacrificing the quality of Nursing Services for individuals,

families, groups, communities, and society.

c. Leadership and Management Areas 1) Core

competencies:

Able to practice leadership, nursing care management and service

management

Nursing.

2) Nursing graduates are able to:

Applying leadership and management concepts in management:

a) Nursing Care for individuals, families, groups, communities,

and societies.

b) Community health programs for the purpose of promoting and

preventing health problems.

c) Facilities health to Support Nursing

Services.

d) Human resources, facilities and infrastructure, and finance for

quality Nursing Services.

e) Implementation of personalized, collaborative, institutional

nursing services that are effective, efficient, accountable and

affordable.

f) Health issues and Government policies in the field of health

and nursing with the formulation of problems and the selection

of effective and efficient intervention priorities.

d. Education and Research Areas 1) Core

competencies:

Able to carry out educational practices in Nursing and research in

the field of Nursing.

2) Nursing graduates are able to:

a) Understand the role and function of clinical educators

(Preceptors) in Nursing education.

b) Understand the educational needs and clinical skills in Nursing

education.

c) Designing and implementing simple research in the field of

Nursing.

d) Applying the results of research to improve the quality of

Nursing Care.

e. Areas of Personal and Professional Quality

Development 1) Core competencies:

Able to develop the quality of personal and professional practice in

the field of Nursing.

2) Nurse graduates are able:

a) Recognize the need to maintain and improve nursing

competencies through continuing professional development

programs.

b) Follow the development of science and technology in the field

of Nursing to support the quality of Nursing Services.

CONCEPT OF HEALTHY SICK

3.1 Introduction

Individuals have different reactions to the symptoms of the disease/health

problems experienced. The reaction is greatly influenced by the understanding

and belief in his health problems. This behavioral reaction is a manifestation of

different concepts regarding health and illness. Because each individual must

have a different concept. This will be proven by how the individual's behavior

takes action in solving the health problems he is experiencing.

3.2 Public Health Concepts

Public health is a series of efforts aimed at nourishing a group/the entire

population with a prevention and/or improvement orientation, carried out

cross-sectorally or cross-program, also involving the community and well

organized (Achmadi, 2014).

A group of individuals in society or the community itself needs to be equipped

with an understanding of the concept of healthy illness because understanding

this is the basis for the formation of community behavior to make efforts to

prevent and control infectious or non-communicable diseases.

3.3 Behavioral Concepts

Health behavior is an action taken by a person to maintain or achieve health or

prevent disease.

According to Notoatmodjo (2012), health behavior is a person's effort to

maintain health so that illness does not occur and an effort to heal.

3.3.1 Behavioral Domain

Behavior is divided into three domains, namely cognitive, affective and

psychomotor. Cognitive is measured from a person's knowledge of something

that is being studied or will be learned.

Knowledge or often said cognitive is the most important thing in the formation

of a person's behavior. This is a psychological encouragement in fostering

attitudes and behaviors every day, and can be said to be a stimulation of one's

actions/behaviors.

Attitudes are different from behavior, and behavior does not necessarily reflect

a person's attitude. Attitudes can change as information about what is learned

increases, through persuasion and encouragement from their social group.

Health behavior is a person's response to stimuli related to illness and disease,

the health service system, food and beverages, and the environment.

Nutritional behavior is one of the tangible forms of health maintenance.

Because food and drink are things that can maintain and improve a person's

health, but it can be the opposite, namely a decrease in a person's health. And it

is very closely related to behavior.

So behavior change is said to be successful if a person carries out the process

of change cognitively, there will also be a change in attitude and behavior. This

is in accordance with the research of Tria, Fauza, Inne and Zahrofa (2021),

there has been an increase in knowledge, attitudes and practices regarding

nutrition of pregnant women after health education.

3.3.2 Factors of Behavior Formation Factors

1. Predisposing factors are manifested in knowledge, attitudes, beliefs,

traditions, beliefs, values and so on. Those related to health, the value

system adhered to, the level of education, socio-economics and so on.

2. Enabling factors, which manifest in the physical environment, the

availability or unavailability of health facilities or facilities: Health centers,

medicines, contraceptives, latrines; human resources.

3. Reinforcing factors, which are manifested in the attitudes and behaviors of

health workers or other officers, which are the supporting groups of

community behavior. Such as community leaders, religious leaders,

regulations and laws.

3.4 Concept of healthy sick

3.4.1 Definition of Healthy and Sick

WHO provides healthy limits, which is a state of well-being both physically,

mentally and socially as a whole and that is not only free from diseases and

disabilities. Healthy is meant here to be physical, emotional, and social health.

3.4.2 Public Health Degree Factor

Four factors affect the health status of the community:

1. Milieu

a. Physical environment: garbage, water, housing and others

b. Social environment: education, economy, culture

c. Biological environment: animals, plants, crushed bodies

2. Behaviour

A habit of the community. The health of the environment and family

depends on behavior.

3. Service

This can be decisive in health recovery, disease prevention, and health care

services. And it is also influenced by the location or distance to the health

service place, human resources, information on the suitability between

health service programs and community needs.

4. Descendents.

Factors that have existed and are carried from birth. If there is a family that

has the disease, it is likely to be passed on genetically to the family.

Figure 3.1: Factors affecting public health status

(Achamdi, 2017)

3.4.3 Concept of illness based on Trias Epidemiology

The image above explains how the relationship between the three

interconnected elements is concerned. What is meant by Host is a

person/individual in a family, community. The agent is the seed of disease,

while the environment is the environment. The three elements must be in

balance. If there is an imbalance, health problems will arise.

The first element here is the Host. The specifics of the host here are the

family's understanding of the importance of prevention that must be carried out

regularly, the ability of the family to carry out early detection of the problems

experienced, and the preparedness of the community in recognizing the level of

risk of health problems and the efforts made. The host here is the first element

that is easily influenced by agents through an unhealthy environment.

Figure 3.2: Triassic Epidemiological Model (Ewen, 2015)

The second element is the agent. This includes germs, viruses, or other

chemicals through vectors or intermediates that depend on the characteristics

of the agent, the nature and cycle of the agent. The absence of agents or the

absence of agents will determine the status of public health.

The third element is the environment inside the house or outside the house,

including buildings or public places. A bad or less good environment will be a

breeding ground for agents in causing diseases. Such as standing water inside

the house or outside the house that is at risk of mosquito development.

Interactions in conditions of imbalance such as; The increase in the ability of

agents due to unclean and unhealthy environmental conditions results in a

decrease in the endurance of the Host so that health problems arise. Hosts as

humans have an important role in modifying causative agents and the

environment through a variety of specific preventions.

3.4.4 Interaction of Healthy Ranges of Pain

1. Family efforts in health promotion

According to Campbell, (2000); Doherty, (1992) in Friedman (2010), said

that the family plays an important role in all forms of health promotion and

risk reduction to the cause of problems in the family. This statement is

supported in Kaakinen (2010), one of the causes of obesity and overweight

is nutrition fulfillment behavior and family activities.

Health improvement and disease prevention activities start from choosing a

family lifestyle. For example: father's habit of eating carelessly without

paying attention to excess weight and having hereditary factors of DM

disease.

The family is a source of health problems for their family members.

Therefore, health promotion starts from the family. The purpose of the

health promotion is to improve the lifestyle of all family members.

Health promotion includes consuming a balanced diet, immunizations,

activities and exercises (exercise), pregnancy check-ups, etc.

2. Family assessment of symptoms of illness.

This second stage, starting from the symptoms of the disease in family

members is known, then the severity is estimated, then looking for the

cause and how the disease affects oneself and family.

Figure 3.3: Stages of assessment of pain symptoms (Friedman, 2010)

This assessment stage is also influenced by socio-economic factors. Families

that have less economic factors will usually respond less to the symptoms

experienced by family members. It will be different from families who have

economic factors above average, who often do medical check-ups before the

onset of disease symptoms.

3. Treatment search

This third stage begins when the family is really sick and needs help or

help.

The sick family begins to seek information, advice from other family

members or friends related to the problem experienced. As a result of the

search for information, the advice was discussed with all family members

to find alternative actions to be taken. Whether it is necessary to carry out

treatment at home or need health services.

Families in Indonesia, often when they experience ordinary illnesses such

as coughing and cold, their fever is not brought to health services. Families

usually provide stall medicine or traditional medicine, but if the disease is

severe or does not heal within 3 days, they are immediately taken to health

services. Sometimes, families also look for alternative services such as

cupping,

GURAH.

4. Get treatment and get referrals.

This fourth stage begins when the family has interacted with health

services or traditional medicine practices.

Usually, the determination of the choice of the place where the treatment is

carried out is determined by a mother. Mothers who often get information

from their colleagues or through the mass media.

The determination of treatment is influenced by 4 factors, namely funding,

ease of access to health services, acceptance and adequacy (quality) of

services.

5. Acute response of families and clients to illness.

The acute response here is how the family treats the sick. The treatment of

sick people depends on the type of disease, the severity.

The role of sick family members becomes the role of the sick person (the

role of the sick). When being a sick person, having a full dependence on

the person who provides the service.

Some families usually release sick family members, and their roles are

replaced by others.

For example: A mother is sick, who does housework every day. The role

can be temporarily replaced by a father or grandmother who lives with the

family.

6. Adaptation to healing and the disease experienced. The adaptation referred

to here is when the family comes to health services or nurses in dealing

with health problems.

Each health problem has a different impact, depending on whether the

disease is serious or not. Usually nurses are asked for advice at this stage,

if the impact of the problem experienced is severe or the problem becomes

widespread.

In this stage, it is necessary to consider whether the sick family can still

carry out their activities as before the illness or maximize their existing

abilities. It is also influenced by who and the role borne by the sick. The

family has a very important role in the recovery and rehabilitation of the

family.

3.5 Health prevention approach

3.5.1 Primary Prevention

It is an activity that aims to prevent the occurrence of illness, by reducing

exposure to vulnerable individuals. This prevention has 2 elements, namely:

health promotion and specific protection.

The health promotion in question is an effort to increase resilience factors,

protection and have a healthy population target.

For example: the promotion of good nutrition, the provision of adequate

housing and regular exercise.

Special protection efforts by reducing or eliminating risk factors from the

target. For example: immunization, water purification.

3.5.2 Secondary Prevention

Focuses on early detection and immediate intervention during the pathogenesis

period of the disease. It is done after the problem has occurred but no signs of

symptoms have appeared, and populations that have risk factors are targeted in

this area. For example: blood pressure checks, blood sugar tests, pap smears.

3.5.3 Tertiary Prevention

Populations that already experience health problems, and focus on disability

restrictions and rehabilitation. The goal is to prevent health problems from

getting worse, as well as reduce the effects of the disease; injury and restore to

optimal function.

Examples: teaching individuals or families who have diabetes to take injections

(insulin), educating families and sick people to manage diabetes, referring to

physiotherapists/doctors who have bone injuries.

NURSING SERVICES

4.1 Introduction

The concept of service is a product produced by an organization, either in the

form of goods or services. Services can be offered and can produce something

that is not promising but can be enjoyed or felt (Triwibowo, 2013). The

characteristics of the service are as follows: a. Intangibility (Intangible)

Services have an intangible, intangible, invisible, inaudible, smelled before

being purchased by the consumer. Inseparibility (inseparable) Service can be

produced and felt at the same time. Services can be produced and consumed at

the same time. c. Variability Services are on-standardized and always undergo

changes d. Parishability (not durable) Services do not last long and cannot be

stored (Triwibowo 2013).

According to Law Number 38 of 2014, the definition of nursing is the activity

of providing care to individuals, families, groups, or communities, whether in a

sick or healthy state. Nurses develop nursing care plans, working closely with

doctors, therapists, patients, patients' families and other teams to focus on

disease care and improving quality of life.

Nurses work in most specialties where they work independently or as part of a

team to assess, plan, implement and evaluate care.

Nursing services are efforts to help individuals, both sick and healthy, from

birth to death in the form of knowledge, willingness, and abilities. So that the

individual can carry out daily activities independently and optimally

(Yulihastin, 2009). Meanwhile, professional nursing services are carried out in

various health service settings, reaching all groups and levels of society in

need, both in the health service order in the community, and in the hospital

service order (Kusnanto, 2009).

Nursing services are developed in stages ranging from basic nursing to nursing

that is complicated or specialized or even subspecialized, accompanied by a

nursing referral system as part of an effective and efficient health referral.

Specialized nursing services/care, both clinical and community nursing,

include pediatric nursing, maternity nursing, medical surgical nursing,

psychiatric nursing, emergency nursing, family nursing, gerontic nursing, and

community nursing. Simultaneously develop professional nursing management

skills with professional nursing leadership, so that nursing can develop in

accordance with the rules of nursing as a profession (Kusnanto, 2009).

4.2 Theory of Nursing Services

The quality of nursing services is a statement that has been commonly used,

both by the academic life environment and in daily life. Although its meaning

can generally be felt and understood by anyone, quality as a concept or

understanding, has not been widely understood by people and in fact the

meaning of quality itself is not the same for people. Each person or society will

define that quality according to opinions and needs that may differ from others

(Imbalo, 2007). A thorough description and characteristics of the goods or

services, demonstrating their ability to satisfy specified or implied needs. The

product or service in question is: comfortable to use, satisfying the patient,

according to the patient's expectations, available and on time, and cheap.

4.2.1 Nursing Service Perspective

Perspective of Nursing Services According to (Karunia, 2011) various

viewpoints regarding the definition of nursing services include: Patient's

Perspective (individual, family and community) according to Meishenheimer

(2001) in Karunia (2011), explains that patients or patients' families define

quality as the presence of nurses or health workers who provide skilled care

and the ability of nurses to provide care. Meanwhile, Wijoyo (2000) in Karunia

(2011), explained that service quality means empathy, respect and

responsiveness to their needs, service must be in accordance with their needs,

provided in a friendly way when they visit.

In general, they want services that effectively reduce symptoms and prevent

disease, so that patients and their families are healthy and able to carry out

their daily tasks without physical disturbances. Based on the definitions above,

it can be said that the quality of nursing services is defined by patients

(individuals, families, communities) as the implementation of nursing services

that are in accordance with their needs based on the empathy, appreciation,

responsiveness, and friendliness of nurses as well as the ability of nurses to

provide services. In addition, through these nursing services, it can also result

in an improvement in the patient's health degree. Nurse's Perspective where

quality is based on the nurse's point of view is often interpreted by providing

nursing services according to the patient's needs in order to become

independent or free from their illness ((Meishenheimer, 2001) in (Karunia,

2011)). Another opinion was put forward by Wijoyo (2000) in Karunia (2011),

that service quality means the freedom to do everything professionally to

improve the health status of patients and society in accordance with advanced

science and skills, good service quality and meeting good standards. Thus, it

can be said that nurses as professionals who provide nursing services to

patients define the quality of nursing services as the ability to provide

professional nursing care to patients (individuals, families, communities) and

in accordance with nursing standards, the development of science and

technology. Nursing Manager's Viewpoint where the quality of service is

focused on good staff, patient and community management by carrying out

supervision, financial and logistics management properly and appropriate

allocation of resources.

Nursing services require good management so that nursing managers have an

important role in improving the quality of nursing services by carrying out

management functions well that focus on managing nursing staff and patients

as individuals, families and communities. In addition, management also

includes financial management and logistics. According to Meishenheimer

(2001) in Karunia (2011), the quality of service is assumed to be the ability to

survive, important considerations include the type and quality of staff to

provide services, the institution's accountability for inappropriate patient care,

and analyzing the financial impact on the institution's operations.

Based on the description above, the definition of nursing service quality from

the perspective of the service institution is the implementation of the

effectiveness and efficiency of services including in terms of manpower,

equipment, operational costs, and service time. The effectiveness and

efficiency of the service is supported by improving the quality of its staff,

besides that hospitals are also required to have responsibility for nursing

services that have a negative impact on patients.

Factors that affect nursing services According to Supranto (2006), the factors

that affect the quality of services are:

1. Reliability The ability to provide services accurately as promised.

2. Responsiveness The ability to help consumers provide services quickly as

desired.

3. Assurance The knowledge and courtesy of employees and their ability to

generate trust and confidence or assurance.

4. Emphaty (empathy) Employees must pay attention individually to

consumers and understand consumer needs.

5. Tangibles (reality/tangible) The appearance of physical facilities, personal

equipment and communication media.

6. The cost of expensive treatment and the limited information that patients

and families have about the treatment they receive can be their complaints.

7. High Personal Contact (communication Understanding the use of services

about the services that he will receive, in this case the communication

aspect plays an important role.

In addition, according to Nursalam (2002), the success of service activities to

ensure the quality of nursing services is influenced by various factors, namely:

1. Knowledge factor Knowledge is the result of knowing and this occurs after

people sense humans generally obtained through the eyes and ears

(Notoatmodjo, 2003) Knowledge can be measured by interviews or

questionnaires to respondents about the content of the material being

measured. In the knowledge that is to be measured, it is adjusted to the

level of kignitive knowledge (Notoatmodjo, 2003). The knowledge of

nurses to nursing service quality assurance activities is an activity of

assessing, monitoring or regulating patient-oriented services (Nurachmah,

2001).

2. Workload factor Work is a form of activity that aims to get satisfaction and

this activity involves both physical and mental activity. Workload is a

condition or circumstance that is burdensome on the achievement of

activities to carry out activities. The workload of nurses is high and diverse

with the demands of work institutions in achieving the expected quality of

service.

3. Communication factor Communication is something to be able to compose

and deliver a message in an easy way so that others can understand and

receive it (Nursalam, 2002). Communication in professional nursing

practice is the main element for nurses in carrying out nursing services to

achieve optimal results. The factors that affect the implementation of

therapeutic communication include: Education, length of work, knowledge,

attitudes, psychological conditions.

4.2.2 Quality of Nursing Services

The quality of nursing services is a quality related to the provision of nursing,

which must be available, acceptable, comprehensive, sustainable and

documentable. Quality is related to the dimension of officers' responsiveness to

patients, concerns, and hospitality of officers in serving patients who are in the

healing period (Triwibowo, 2013).

Dimension of nursing service quality Five main dimensions in the quality of

nursing services:

1. Reliability (Reability) Reliability is the ability to provide appropriate and

reliable service. Trusted service is competent and consistent service.

Service has two aspects, namely appropriate and accurate service (Asmuji,

2016). Providing accurate services, not making mistakes and delivering

services according to the agreed time. This dimension can be seen from the

ability of the therapist to provide services and be friendly and ready to help

patients.

2. Responsiveness is the willingness of nurses to serve consumers quickly,

namely the service must be responsive to consumers. Communication and

the surrounding physical situation are things that must be considered

(Asmuji, 2016). The willingness of nurses and the ability of nurses to help

and respond to patient requests, as well as providing information about

when services are carried out and providing services quickly (Triwibowo,

2013). Nurses are expected to provide health services in a timely manner

according to the set time (Muninjaya, 2015)

3. Assurance Guarantee is an activity to ensure certainty of the services

provided to consumers. To guarantee. Certainty of nurses must be armed

with knowledge, attitudes, and abilities to provide a sense of trust and

confidence in the services provided (Asmuji, 2016). Nurses are able to

foster patient trust in nurses, as well as create a sense of security and

comfort for patients (Triwibowo, 2013). This criterion is related to

knowledge, politeness and the nature of officers who can be trusted by

users, this is related to the factors of friendliness, competence, credibility

and security applied (Muninjaya, 2015)

4. Empathy Empathy is the provision of full service and individual attention

to consumers, listening to consumer complaints, fostering relationships of

mutual trust are examples of empathy. Nurses can understand patient

problems and take actions according to the patient's interests, provide

personal attention and have comfortable operating hours. This is related to

the factor of special concern and attention of staff to each service user,

understanding their needs and providing ease of communication

5. Physical Evidence (Tangibles) Physical evidence is any type of service that

can be directly felt by consumers, and enjoyed through the sense of sight,

the tangible form can be in the form of hygiene facilities, availability,

equipment, appearance, and communication that are directly obtained by

consumers Related to the physical appearance, completeness and neatness

of nurses in providing services. The quality of service can be felt directly

by its users by providing adequate physical facilities and equipment

(Muninjaya, 2015)

4.2.3 Nursing Services/Care

Specialized nursing services, both clinical nursing and community nursing,

include:

1. Pediatric Nursing

In providing nursing care to children, it is certainly different compared to

adults. There are many differences that must be considered and adjusted to

the age and growth and development of the child because non-optimal

treatment will have a negative impact both physiologically and

psychologically on the child himself. Nurses should pay attention to some

principles, let's study those principles. Nurses must understand and

remember some different principles in the application of pediatric nursing

care as follows:

a. Children are not miniature adults but as unique individuals, meaning

that children should not be viewed only in terms of their physical

nature but as unique individuals who have a pattern of growth and

development towards the process of maturity.

b. Children are unique individuals and have needs according to their

developmental stages. As a unique individual, children have various

needs that are different from each other according to their growth and

development. Physiological needs such as nutrients and fluids, activity,

elimination, sleep and others, while psychological, social and spiritual

needs that will be seen according to their growth and development.

c. Children's nursing services are oriented towards disease prevention

efforts and improving health degrees which aim to reduce the rate of

illness and death in children considering that children are the

successors of the nation's generation.

d. Pediatric nursing is a health discipline that focuses on children's

welfare so that nurses are comprehensively responsible for providing

child nursing care. In the welfare of children, nursing always

prioritizes the interests of children and efforts are inseparable from the

role of the family so that it always involves the family.

e. The practice of pediatric nursing includes contracts with children and

families to prevent, review, intervene and improve the welfare of life,

by using nursing processes that are in accordance with moral (ethical)

and legal aspects.

f. The goal of child and family nursing is to promote healthy maturation

or maturity for children and adolescents as biopsychosocial and

spiritual beings in the context of family and society. Children's

maturity efforts are to always pay attention to a good environment

internally and externally where a child's maturity is determined by a

good environment.

g. In the future, the tendency of pediatric nursing to focus on the science

of growth and development, because this will study aspects of

children's lives.

2. Maternity Nursing

Maternity nursing is a form of nursing professional service aimed at

women of childbearing age (WUS) related to the reproductive system,

pregnancy, childbirth, postpartum, between two pregnancies and newborns

up to 40 days of age, along with their families, focusing on meeting basic

needs in adapting physically and psychosocially to achieve family welfare

by using a nursing process approach. Every individual has the right to be

born healthy, so every individual has the right to get quality health

services. Maternal nursing believes that birth events are normal physical

and psychological processes and require physical and psychosocial

adaptation from individuals and families, so that normal childbirth care is

needed (Bobak, 2004)

3. Medical Surgical Nursing

In its concept, Medical Surgical Nursing is a professional service based on

the science and techniques of Medical Surgical Nursing in the form of bio-

psycho-socio-spiritual services for adult clients to meet basic human needs

in the form of improving the abilities that exist in individuals, preventing,

repairing, and rehabilitating from a sick state by individuals. The scope of

practice of Medical Surgical Nursing is the provision of nursing care to

adult clients who experience physiological disorders due to illness, trauma

or disability. Nursing care includes treating individuals to obtain comfort,

assisting individuals in improving and maintaining their health conditions,

preventing, detecting and overcoming disease-related conditions, seeking

recovery until the client can reach his or her highest productive capacity,

and helping clients face death with dignity.

4. Psychiatric Nursing

Mental health nursing is a form of professional service that is an integral

part of health services, applying human behavior theory as a science and

therapeutic self-use as a tip.

Mental health for humans means the realization of harmony in the

functioning of the soul and being able to face problems, feel happy and be

able to be self-sufficient. A mentally healthy person means having the

ability to adjust to oneself, others, society, and the environment. Human

beings consist of bio, psycho, social, and spiritual that interact with each

other and influence each other.

5. Emergency Nursing

Emergency nursing is nursing care provided to individuals and families

who experience life-threatening conditions or tend to threaten life that

occurs suddenly (Luckman & Sorensen, 1993) The application of the

nursing process to emergency conditions as a scientific approach, in

principle is the same as in other practice fields, although there are specific

factors that affect the assessment or implementation of interventions.

Some of the influencing factors are a) time limitations; b) critical condition

of the patient; c) the possibility of the need for immediate action in another

room; d) limitations of existing data. Usually action is taken before the

assessment of Iengkap is carried out. Nursing actions are carried out based

on the main assessment. Therefore, in general, in emergency patients, a

standard nursing care plan is used which consists of two main nursing

problems.

6. Gerontic Nursing

Gerontic nursing is the practice of care related to diseases in the aging

process (Kozier, 1987) According to (Lueckenotte, 2000) gerontic nursing

is a science that studies the care of the elderly which focuses on the

assessment of health and functional status, planning, implementation and

evaluation. The scope of Gerontic Nursing Gerontic nursing care is the

prevention of disability as a result of the aging process, treatment to meet

the needs of the elderly and recovery to overcome the limitations of the

elderly. Its nature is independent (independent), interdependent

(collaboration), humanistic and holistic. Nursing specializing in caring for

the elderly was named for the first time as geriatric nursing. The name was

replaced with Gerontological. Gerontology comes from the word geros

which means elderly and logos means science. Gerontology is a science

that studies the elderly with problems that occur in the elderly which

include biological, sociological, psychological, and economic aspects.

Gerontology is a scientific approach to various aspects of the aging

process. The role of gerontic nurses can be broadly classified into two

types, namely the role in general and the role of the specialist. The role in

general is in various settings, such as hospitals, homes, nursing homes,

communities, by providing care to individuals and their families (Touhy,

2005). Nurses work in a variety of forms of service and work closely with

experts in client care from planning to evaluation. The role of specialists is

divided into two types, namely gerontological clinical nurse specialist

(CNS) and geriatric nurse practitioner (GNP). The role of CNS is direct

clinical nurses, educators, nurse managers, advocates, case management,

and researchers in planning care or improving the quality of care for

elderly clients and their families in hospital settings, long-term care

facilities, outreach programs, and independent consultants. Meanwhile, the

role of GNP is to meet the needs of clients in remote areas; intervene for

health promotion, maintain and restore the client's health status; case

management, and advocates in ambulatory clinic settings, long-term

facilities, and independent practice.

7. Community Nursing

Definition of Community Nursing Community means a group of

individuals who live in a certain area, have relatively similar values, beliefs

and interests, and interact with each other to achieve goals (Mubarak,

2005). Community nursing is a synthesis of nursing practices and public

health practices that are applied to improve and maintain the health of the

population. The target of community health nursing is individuals, namely

malnourished toddlers, high-risk pregnant women, the elderly, and people

with infectious diseases. The target family is families who are vulnerable to

health problems and priorities. The target group is a special group, a

community both healthy and sick who have health problems or treatment

(Ariani, 2018).

4.2.4 Nursing Service System

The health service system is one of the multidisciplinary structures that aims to

achieve optimal health degrees. Nursing is an integral part of the health service

system that aims to improve human welfare. Nursing services are an effort to

help individuals, both sick and healthy, from birth to death in the form of

knowledge, willingness and abilities possessed. Nursing services are needed to

assist humans in meeting their needs. The nursing services provided to

individuals are in the form of nursing care (Yulihastin, 2009). Quality health

services can be seen from the behavior and skills shown by health service

providers from the knowledge they have. Nurse behavior is the most important

thing in determining the quality of health services. Because the relationship

between health care providers is a factor that affects the healing process of

patients. The nursing profession is the spearhead of the health service itself.

Nursing staff are the most dominant human resources in hospitals. The number

of nurses ranges from 55-56% of the total human resources in the hospital.

Nurses have an important role in achieving service quality because nurses are

in charge of providing health services continuously every day for 24 hours. In

providing nursing services, it is inseparable from the arrangement of delivery

of nursing care hours, which is better known as work shifts.

Engineering Systems in the provision of nursing care The terminology about

the technical system of services has always been a debate among health

practitioners in the USA. The reason is that the engineers are not sure that it

will not be able to improve quality and productivity. A technical system is

defined as a comprehensive effort to utilize and integrate resources,

regulations, and technology of medical equipment by partnering with engineers

in evaluating service results across disciplines. Technical systems can be used

in a variety of service practices to achieve quality, efficiency, safety, and/or

patient needs-oriented processes, products and services. The health service

sector as the largest service in Indonesia is apparently too slow to implement

the technical system. Initially, in the USA the technical system did not show

optimal outcome acceptance values but almost most hospitals have utilized the

system (Fone, 2003). The health care system in Indonesia is not fully willing to

take advantage of the system for various reasons. Health services in Indonesia

are divided into various levels of service, ranging from level C to A. The

resources owned by hospitals at level C are certainly not as complete and

sophisticated as those owned by level A hospitals. The need for service quality

is not felt to be at a high level. The ability of the source of funds is also

certainly different at these various levels. Component Of Delivery System

Referring to research on several things in the provision of nursing care, he

determined five components in the provision of nursing care. These

components are position descriptions, patient escort services, evaluation

process, chart audit, communication system. Job description of nurses Each

nurse needs special instructions or information in carrying out orders in

providing care where this can be obtained through continuous skills training. In

some developed countries, team leaders are given to nurses who have

graduated from bachelor's degrees (BSN, while in Indonesia Nurses) while

team members are those who have graduated from diplomas or equivalent

(LPNs). The job description of a nurse generally consists of: (1) job description

in general, (2) job title, (3) job conditions, (4) methods and methods of salary

payment, (5) opportunities for advancement, (6) qualifications, educational

requirements, professional experience, abilities, and personal characteristics,

(7) job functions: work frequency, work period. Patient assistance services The

task of this service is to help the needs of patients so that all the programs set

can be accepted by patients. Abroad this task is done by LPNs nurses, but in

Indonesia it seems unclear. In the future, it is necessary to establish the type of

qualification for this job. The evaluation process referred to is a thorough

evaluation of the performance of nurses and an evaluation of the care process

itself. Sometimes this process is considered unimportant because nurses

(prefer) routine activities. So that the parameters of service success are not

measurable.

4.2.5 Quality of Nursing Services

Nursing Service Quality is a process of activities carried out by the nursing

profession in fulfilling the needs of patients in maintaining the patient's

biological, psychological, social, and spiritual conditions (Suarli, 2012). The

quality of nursing services is professional nursing care which refers to 5

dimensions of service quality, namely, (reability, tangibles, assurance,

responsiveness, and empathy) (Bauk, 2013). The quality of nursing services is

a service that describes the products of the nursing service itself which includes

biologically, psychologically, socially, and spiritually in sick and healthy

individuals and is carried out according to nursing standards (Asmuji, Nursing

Management: Concepts and Applications, 2012). Based on the statement of the

three theories above, it can be concluded that nursing services are service

activities or efforts that can be carried out independently or together with the

aim of meeting the needs of patients holistically.

Nursing Service Quality Objectives According to Nursamalam cit, the quality

objectives of nursing services have 5 stages, namely: a. The first stage is the

preparation of standards or criteria. It is intended that nursing care is more

structured and planned based on the standard criteria of each nurse.

b. The second stage is to identify information that meets the criteria. The

information here is expected to be more supportive in the nursing care process

and as a measure of the quality of nursing services. c. The third stage is the

identification of the source of information. In selecting accurate information,

strict and continuous selection is required. Some information is also obtained

from the patient himself. d. The fourth stage is collecting and analyzing data.

Nurses can select data from patients and then analyze them one by one. e. The

fifth stage is re-evaluation. At this stage, it serves to minimize mistakes in

decision-making in nursing care and actions.

A nursing service can be said to be good if it runs appropriately in meeting the

needs of patients. From this good service, it will create a culture of good

handling to all patients. And the highest standard of patient satisfaction will be

achieved. The quality of nursing services is a measure of the quality of health

services and is one of the determining factors for the image of health service

agencies in the community. Because nursing is one of the professions with the

highest number and the closest to patients. The quality of nursing services

itself is seen from patient satisfaction with the services provided satisfied or

dissatisfied.

4.2.6 Types of Nursing Care Methods

Professional Nursing Practice Model (MPKP) assignment method in nursing:

1. Case method

The case method is the first method of providing care used. Until World

War II, this method was the most widely used method of providing nursing

care. In this method, one nurse will provide nursing care to a client in total

in one service period. The number of clients cared for by a single nurse

depends on the nurse's abilities and the complexity of the client's needs.

(Sitorus Ratna, 2006).

2. Functional Methods

In the functional method, the provision of nursing care is emphasized on

the completion of tasks or procedures. Each nurse is given one or several

tasks to be carried out to all clients in one room (Sitorus Ratna, 2006).

In this method, the head of the room determines the duties of each nurse in

a room. The nurse will report the tasks she is doing to the head of the room

and the head of the room is responsible for making the client's report.

Functional methods may be efficient in completing tasks when the number

of nurses is small, but the client does not get the satisfaction of the care he

receives (Sitorus Ratna, 2006).

3. Team Method

The team method is a method of providing nursing care, where a

professional nurse leads a group of nursing staff in providing nursing care

to a group of clients through cooperative and collaborative efforts. The

team method is based on the belief that each group member has a

contribution in planning and providing nursing care so that it creates a high

sense of responsibility (Sitorus Ratna, 2006).

4. Primary Nurse Method

According to (Gillies, 1989) "primary nursing is a method of providing

nursing care, where there is a close and continuous relationship between

the client and a certain nurse who is responsible for planning, providing

and coordinating the client's nursing care, as long as the client is cared for."

(Sitorus Ratna, 2006). In the primary nursing method, nurses who are

responsible for providing nursing care are called primery nurses,

abbreviated as PP (Sitorus Ratna, 2006).

PATIENT SAFETY IN HOSPITALS

5.1 Introduction

Patient safety is one of the global issues in health services, including in

hospitals. Hospitals as health service agencies should ensure patient

safety while receiving/undergoing treatment in the hospital, one way to

realize patient safety guarantees in hospitals is by implementing patient

safety management correctly. Safety issues consist of five issues, namely

patient safety, health care provider safety, building and equipment that

support hospitals (building and equiptment safety), environmental safety

(green productivity), hospital business safety (business safety) The five

safety issues must be carried out in unison in a hospital, and carried out

consistently and comprehensively (Ministry of Health, 2015).

The history of patient safety dates back 2400 years, where Hippocrates

said prium non nocere (first, do no harm), which is the main principle in

health services to this day

(NHS, 2015 in Simbolon et al., 2022). Then in 1999 the issue of patient

safety reached a critical point, where IOM (Institute of Medicine), said

that at least 44,000-98,000 patients die every year due to medical errors

in America (Emsli et al, 2015 in Simbolon et al, 2022).

The incidence of patient safety accidents is like an iceberg, where the

visible numbers are only a small part of the actual incident. Based on a

report from WHO, in several countries the rate of Unexpected Events or

KTD in hospitalized patients of 3% to 16% occurs in New Zealand,

12.9% occurs in the United Kingdom, 10.8% in Canada (Basri, 2021 in

Huriati et al., 2022). Meanwhile, in Indonesia itself, the KKPRS in 2010

reported at least 145 KTD incidents occurred in the Sabang region of

Indonesia or the Aceh region by 0.68%, South Sulawesi 0.69%, Bali

1.4%, West Java 2.8%, South Sumatra 6.9%, East Java 11.7%,

Yogyakarta Special Region 13.8%, Central Java 15.9%, Jakarta 37.9%.

The results of the report are known that based on the status of hospital

ownership in 2010 in the third quarter, data was obtained that local

government hospitals had a higher percentage of 16% while private

hospital data was 12% (Basri, 2021 in Huriati et al., 2022).

The results of another study stated that Stella Maris Makassar Hospital

recorded a patient safety report in 2013 there were 13 types of patient

safety incidents that occurred in the hospital, namely wrong

administration of drugs in the pharmacy department by 16%, wrong

administration of drugs in the inpatient room by 6%, after diagnosis by

6%, misdistribution of drugs from pharmacies by 13%, Almost incorrect

drug aploss by 3%, misinterpretation by 3%, mistyping laboratory results

by 6%, patients falling by 9%, potential injury incidence by 9%, sentinel

incidence by 3%, mistaking of medication by 3% and Unwanted Events

(KTD) by 14%. In the 1st quarter of January to April 2011, KKP-RS

reported patient safety incidents with 34 incident reports, nurses spent a

lot of time caring for patients, so that the nursing team made a significant

contribution to patient safety (Haritsal, 2021 in Huriati, 2022).

To overcome this problem, the Indonesian Ministry of Health has issued

Regulation of the Minister of Health No. 11 of 2017 concerning patient

safety in hospitals. Patient safety is the right that patients have to feel

safe and comfortable while being treated in the hospital. Government

department

esehatan (2009) states that in accordance with Article 53 (3) of the

Health Law Law 36/2009, the patient's life must be the top priority in the

implementation of health services. Furthermore, the regulation of the

Minister of Health of the Republic of Indonesia No. 1691 of 2011

concerning hospital patient safety, states that every hospital must

implement patient safety standards, and some of these patient safety

standards consist of seven standards, namely: 1). Patient rights, 2).

Educating patients and families, 3). Patient safety and continuity of

service, 4). The use of performance improvement methods to conduct

evaluations and safety improvement programs patients, 5). Leadership

role in improving patient safety, 6). Educating staff on patient safety, 7).

Communication is the key for staff to achieve patient safety (UU Kes RI,

2011).

5.2 Definition of Patient Safety

Hospital patient safety is a system in which hospitals make patient care

safer which includes risk assessment, identification and management of

matters related to patient risks, incident reporting and analysis, the ability

to learn from incidents and their follow-up as well as the implementation

of solutions to minimize risks and prevent injuries caused by mistakes

due to carrying out an action or not taking appropriate actions (Ministry

of Health, 2011).

Another definition states that patient safety is an action to reduce the risk

of unwanted damage related to health care (Duarte et al in Buhari et al.,

2022). Some experts define patient safety as a state of being free from

physical and psychological injury that ensures patient safety, through

operational determination and minimizing errors, reducing insecurity in

the health care system and improving services optimally (Canadian

Nursing Association, 2009; KKPRS, 2015; WHO, 2017 in Buhari et al.,

2022).

A patient safety incident hereinafter referred to as an incident is any

accidental event and condition that results in or has the potential to result

in a preventable injury to a patient, consisting of an Unexpected Event, a

Near Injury Event, a Non-Injury Event and a Potential Injury Event. An

Unexpected Event, hereinafter abbreviated as KTD, is an incident that

results in injury to a patient. The Incident of Almost Injury, hereinafter

abbreviated as KNC, is the occurrence of an incident that has not been

exposed to the patient. Non-Injury Incident, hereinafter abbreviated as

KTC is an incident that has been exposed to a patient, but no injury has

occurred. Potential Injury Condition, hereinafter abbreviated as KPC, is a

condition that has the potential to cause injury, but there has not been an

incident. A sentinel event is a KTD that results in death or serious injury.

Patient safety incident reporting, hereinafter referred to as incident

reporting, is a system for documenting patient safety incident reports,

analysis and solutions for learning.

5.3 Patient Safety Objectives

The purpose of patient safety is the creation of a culture or habit of

prioritizing hospital safety, increasing hospital accountability to patients

and the community, decreasing KTD in hospitals and implementing

prevention programs so that there is no repetition of KTD (KKPRS, 2015

in Buhari et al., 2022).

According to the Joint Commission (2015), several objectives of patient

safety are:

1. Improve the accuracy of patient identification by using two patient

identities to prevent errors in patient identification

2. Improve communication between health care providers by using

regular communication procedures and reporting critical information

and improving patient handover patterns.

3. Improve the safety of drug use by labeling drugs, and reduce the use

of anticoagulants.

4. Reduce the risk associated with infection by washing hands properly,

preventing resistance to the use of antibiotics, keeping the central

line from the process of spreading infection through the blood.

5. Using medication during treatment accurately and completely,

communicating treatment to the next officer, making a list of patient

treatments, trying to get the patient treatment as little as possible.

6. Reduces the risk of fall hazards

7. Prevents pressure sores from occurring

8. Organizations identify safety risks in all patients in hospitals

9. General protocols to prevent misplace, wrong procedures and people

at the time of surgery

5.4 Patient Safety Standards

The Ministry of Health has regulated and established diving safety

standards for undergoing treatment in hospitals, and this explanation has

been enshrined or written in the health law of the Republic of Indonesia

(2011), as for the description of patient safety standards as follows:

1. The right to leave is that patients and their families have the right to

obtain information about service plans and outcomes, including the

possibility of incidents. In this standard, the hospital must have a

doctor in charge of the service and then make a service plan and the

doctor in charge of the service is obliged to give a clear and correct

explanation to the patient and his family about the plan and results of

the service, treatment or procedure for the patient, including the

possibility of an incident or the impact of providing health measures

while in the hospital.

2. Educating patients and families, namely hospitals must educate

patients and their families about the patient's obligations and

responsibilities in patient care. Safety in service delivery can be

improved by the involvement of patients who are partners in the

service process. Therefore, in hospitals, there must be a system and

mechanism to educate patients and their families about the patient's

obligations and responsibilities in patient care. With this education, it

is hoped that patients and families can: provide true, clear, complete

and honest information, know the obligations and responsibilities of

patients and families, ask questions for things they do not

understand, understand and accept the consequences of service,

comply with instructions and respect hospital regulations, show

respect and tolerance, fulfill agreed financial obligations.

3. Patient safety in continuity of service: The hospital guarantees

patient safety in continuity of service and ensures coordination

between personnel and between service units. There are several

criteria to realize this standard, namely: There is overall service

coordination starting from the moment the patient enters,

examination, diagnosis, service planning, treatment actions, referrals

and when the patient is discharged from the hospital, there is service

coordination that is adjusted to the patient's needs and the feasibility

of resources on an ongoing basis so that at all stages of transitional

services between service units can run well and smoothly, There is

service coordination which includes improved communication to

facilitate family support, nursing services, social services,

consultation and referrals, primary health services and other follow-

up, there is communication and information transfer between health

professions so that a coordination process can be achieved without

obstacles, safely and effectively.

4. The use of performance improvement methods to conduct

evaluations and programs to improve patient safety. Hospitals must

design new processes or improve existing processes, monitor and

evaluate performance through data collection, intensive analysis of

incidents, and make changes to improve patient performance and

safety. The criteria to achieve this standard are that each hospital

must carry out a good design process, referring to the vision,

mission, and goals of the hospital, the needs of patients, health care

workers, the latest clinical principles, healthy business practices, and

other factors that have the potential to be risky for patients in

accordance with the "Seven Steps Towards Hospital Patient Safety",

each hospital must collect performance data which among other

things is related to reporting incidents, accreditation, risk

management, utilization, service quality, finance, each hospital must

conduct an intensive evaluation related to all incidents, and

proactively evaluate a single high-risk case process, each hospital

must use all data and information from the analysis to determine the

necessary system changes, so that patient performance and safety are

guaranteed.

5. Leadership role in improving patient safety: Leadership encourages

and ensures the implementation of patient safety programs in an

integrated manner within the organization through the

implementation of the "Seven Steps Towards Hospital Patient

Safety", Leadership ensures the continuation of proactive programs

for the identification of patient safety risks and programs to suppress

or reduce incidents, Leadership encourages and fosters

communication and coordination between units and individuals

regarding recruitment decisions on patient safety, the leadership

allocates adequate resources to measure, review, and improve

hospital performance and improve patient safety, the leadership

measures and reviews the effectiveness of its contribution in

improving hospital performance and patient safety.

6. Educating staff on patient safety: the hospital has an education,

training and orientation process for each position covering the

relationship between the position and patient safety clearly, the

hospital organizes continuous education and training to improve and

maintain staff competencies and supports an interdisciplinary

approach in patient care. Some of the criteria to achieve this standard

are: Each hospital must have an education, training and orientation

program for new staff that contains patient safety topics according to

their respective duties, each hospital must integrate patient safety

topics in every in-service training activity and provide clear

guidelines on incident reporting, each hospital must organize training

on teamwork to support interdisciplinary and collaborative approach

in order to serve patients.

7. Communication is key for staff to achieve patient safety: Hospitals

plan and design patient safety information management processes to

meet internal and external information needs, and data and

information transmission must be timely and accurate. Some of the

criteria in achieving this standard include: It is necessary to provide a

budget to plan and design the management process to obtain data and

information on matters related to patient safety, there is a mechanism

for identifying problems and communication obstacles to revise the

existing information management.

To achieve patient safety standards in hospitals, each hospital is required

to strive to meet patient safety goals, including: Accuracy of patient

identification, improvement of effective communication, improvement of

drug safety that needs to be watched out, certainty of right-location,

right-procedure, right-patient surgery, reduction of the risk of infection

related to health services, and reduction of the risk of patient falls.

Patient safety goals are a requirement to be implemented in all hospitals

accredited by the Hospital Accreditation Commission. The preparation of

this target refers to the Nine Life-Saving Patient Safety Solutions from

WHO Patient Safety (2007) which is also used by the PERSI Hospital

Patient Safety Committee (KKPRS PERSI), and from the Joint

Commission International (JCI).

Patient safety is driving specific improvements in patient safety. The

objective highlights problematic areas of health care and explains the

evidence and solutions of the evidence-based consensus and expertise on

these issues. It is recognized that intrinsically good system design is to

provide safe and high-quality health services, as far as possible the

general goal is focused on comprehensive solutions.

The six patient safety goals are the achievement of the following:

1. Accuracy of patient identification

Errors in identifying patients can occur in almost all aspects/stages of

diagnosis and treatment. Misidentification of patients can occur in

patients who are in a state of anesthesia/intoxication, experiencing

disorientation, unconscious, exchanging beds/rooms/locations in the

hospital, the presence of sensory abnormalities, or due to other

situations. The purpose of this goal is to carry out two checks,

namely: first, to identify the patient as an individual who will receive

services or treatment; and second, for the suitability of services or

treatment for the individual.

Policies and/or procedures that are collaboratively developed to

improve the identification process, in particular in the process of

identifying patients when administering medicines, blood or blood

products; collection of blood and other specimens for clinical

examination; or the administration of medication or other measures.

Policies and/or procedures require at least two ways to identify a

patient, such as the patient's name, medical record number, date of

birth, patient identification bracelet with bar-code, etc. The patient's

room number or location cannot be used for identification. Policies

and/or procedures also describe the use of two different identities in

different locations in hospitals, such as in outpatient services,

emergency departments, or operating rooms including identification

in comatose patients without identity. A collaborative process is used

to develop policies and/or procedures to ensure all possible situations

can be identified.

2. Improved effective communication

Effective communication, which is timely, accurate, complete, clear,

and understood by patients, will reduce errors, and result in

improved patient safety. Communication can be electronic, oral, or

written. Communication that is prone to errors mostly occurs when

commands are given verbally or over the phone. Another

communication that is prone to errors is the re-reporting of critical

examination results, such as reporting the results of the CITO Clinic

laboratory by phone to the service unit.

The hospital collaboratively develops a policy and/or procedure for

oral and telephone commands including: recording (or entering into a

computer) complete commands or the results of examination by the

recipient of the order; then the recipient of the order reads back the order

or the results of the examination; and confirm that what has been written

and reread is accurate. The identification policy and/or procedure also

explains that it is permissible not to do a read back when it is not

possible, such as in the operating room and emergency situations in the

emergency room or ICU. 3. Increasing Drug Safety that Needs to Be

Aware (High-Alert) When drugs are part of a patient's treatment plan,

management must play a critical role to ensure patient safety. High-alert

medications are drugs that often cause serious errors (sentinel events),

drugs that have a high risk of causing adverse outcomes such as drugs

that look similar and sound similar (Look Alike Soun Alike/LASA).

Medicines that are often mentioned in patient safety issues are accidental

administration of concentrated electrolytes (e.g., potassium chloride of

2meq/ml or more concentrated, potassium phosphate, sodium chloride

more concentrated than 0.9%, and magnesium sulfate-50% or more

concentrated). This error can occur if the nurse is not properly oriented in

the patient care unit, or if the contract nurse is not oriented first before

being assigned, or in an emergency. The most effective way to reduce or

eliminate these events is to improve the process of managing

medications that need to be watched out for, including moving

concentrated electrolytes from patient service units to pharmacies.

Hospitals collaboratively develop a policy and/or procedure to make

a list of drugs that need to be watched out for based on the data

available in the hospital. Policies and/or procedures also identify

which areas require concentrated electrolytes, such as in the

emergency room or operating room, as well as properly labeling

electrolytes and how they are stored in those areas, thereby

restricting access, to prevent unintentional/careless administration.

4. Exact Location, Procedure, and Patient Accuracy Surgery

Mislocation, mis-procedure, patient-error on surgery, is something to

worry about and is not uncommon in hospitals. These errors are the

result of ineffective or inadequate communication between surgical

team members, lacking/not involving patients in site marking, and no

procedures for surgical site verification. In addition, inadequate

patient examinations, inadequate review of medical records, a culture

that does not support open communication between surgical team

members, problems related to illegible handwriting and the use of

abbreviations are common contributing factors. Hospitals need to

collaboratively develop effective policies and/or procedures to

eliminate this worrying problem. Evidence-based practices are also

used, as described in the Surgical Safety Checklist from WHO

Patient Safety (2009).

Marking the surgical site needs to involve the patient and be done on

one of the recognizable signs. The mark should be used consistently

in the hospital and should be made by the operator/person who will

perform the action, be carried out while the patient is awake and

conscious if possible, and must be visible until the time of incision.

Surgical site marking is performed in all cases including lateral

(laterality), multiple structures (fingers, toes, lesions) or multiple

levels (spine).

The purpose of the pre-cooperative verification process is to:

a. Verifying the correct location, procedures, and patients;

b. Ensure that all relevant documents, photographs (imaging),

inspection results are available, properly labeled, and displayed;

and

c. Verify the availability of special equipment.

The "Before the incision" stage (Time out) allows all questions or

mistakes to be resolved. The time-out is done on-site, where the

action will be taken, just before the action starts, and involves the

entire operations team. Hospitals establish how the process is

documented succinctly, for example using a checklist.

5. Risk Reduction of Service-Related Infections

Infection prevention and control is the biggest challenge in the

healthcare order, and the increasing cost of addressing healthcare-

related infections is a major concern for patients and healthcare

professionals alike. Infections are commonly found in all forms of

health care including urinary tract infections, blood stream infections

and pneumonia (often associated with mechanical ventilation).

The center of the elimination of this infection and other infections is

proper hand hygiene. Hand hygiene guidelines can be read in the

WHO literature, and various national and international organizations.

Hospitals have a collaborative process to develop policies and/or

procedures that adapt or adopt generally accepted hand hygiene

guidelines and for the implementation of those guidelines in

hospitals.

6. Reducing the Risk of Falling Patients

The number of fall cases is quite significant as a cause of injury for

inpatients. In the context of the population/community served, the

services provided, and the facilities, hospitals need to evaluate the

risk of patients falling and take measures to reduce the risk of injury

if they fall. Evaluations can include a history of falls, medication and

alcohol consumption, gait and balance, and walking aids used by the

patient. The program must be implemented by hospitals.

5.5 Seven Steps Towards Hospital Patient

Safety

Referring to patient safety standards, hospitals must design new

processes or improve existing processes, monitor and evaluate

performance through data collection, intensive analysis of incidents, and

make changes to improve patient performance and safety. The design

process should refer to the vision, mission, and goals of the hospital, the

needs of patients, health care workers, the latest clinical practices,

healthy business practices, and other factors that have the potential to be

risky for patients in accordance with the "Seven Steps to Hospital Patient

Safety". The description of the Seven Steps Towards Hospital Patient

Safety is as follows:

5.5.1 Building Awareness of Patient Safety Value

Creating an open and equitable leadership and culture. The steps to

implement anny are as follows:

1. For Hospitals:

a. Make sure the hospital has a policy that describes individual

roles and accountability in the event of an incident.

b. Cultivate a culture of reporting and learning from incidents that

occur in hospitals.

c. Conduct an assessment using a patient safety assessment survey.

2. For Units/Teams:

a. Make sure your coworkers feel able to talk about their concerns

and dare to report incidents if they occur.

b. Demonstrate to your team the measurements used in your

hospital to ensure all reports are made openly and there is a

learning process and the right actions/solutions are implemented.

5.5.2 Leading and Supporting Staff

Establish a strong and clear commitment and focus on Patient Safety in

hospitals. The steps to implement anny are as follows:

1. For Hospitals:

a. Ensure there is a member of the Board of Directors or

Leadership responsible for Patient Safety

b. Identify in every part of the hospital, people who can be relied on

to be the "driving force" in the movement

Patient Safety

c. Prioritize Safety Patient deep agenda meeting

Board of Directors/Leaders and hospital management meetings

d. Include Patient Safety in all your hospital staff training programs

and ensure that this training is followed and measured for

effectiveness.

2. For Units/Teams:

a. Nominate "movers" in your own team to lead the Patient Safety

Movement

b. Explain to your team the relevance and importance and benefits

to them by running the Patient Safety movement

c. Cultivate a chivalrous attitude that values incident reporting.

5.5.3 Integrating Risk Management Activities

Develop risk management systems and processes, as well as conduct

identification and assessment of potentially problematic matters. The

steps to implement anny are as follows:

1. For Hospitals:

a. Review the structures and processes in clinical and nonclinical

risk management, and ensure they are inclusive and integrated

with Patient and Staff Safety;

b. Develop performance indicators for the risk management system

that can be monitored by the hospital directors/leaders;

c. Use the correct and clear information obtained from incident

reporting and risk assessment systems to be able to proactively

increase patient awareness.

2. For Units/Teams:

a. Establish forums within the hospital to discuss Patient Safety

issues to provide feedback to the relevant management;

b. Ensure that there is a risk assessment of the individual patient in

the hospital risk assessment process;

c. Conduct a regular risk assessment process, to determine the

acceptability of each risk, and take appropriate steps

appropriate to minimize such risks;

d. Make sure that the risk assessment is submitted as input to the

hospital's risk assessment and recording process.

5.5.4 Developing a Reporting System

Ensure staff can report incidents/incidents, and hospitals arrange

reporting to the National Committee for Hospital Patient Safety. The

implementation steps are as follows:

1. For Hospitals: Complete the implementation plan of the internal and

external incident reporting system, which must be reported to the

National Committee for Hospital Patient Safety.

2. For Units/Teams: Encourage your colleagues to actively report any

incidents that occur and incidents that have been prevented but still

occur, as they contain important lesson material.

5.5.5 Engaging and Communicating with Patients

Develop open ways of communicating with patients. The steps to

implement anny are as follows:

1. For Hospitals:

a. Make sure the hospital has a policy that clearly outlines ways of

open communication during the care process about incidents

with patients and their families.

b. Ensure that patients and their families are informed correctly and

clearly in the event of an incident. 3) Provide support, training

and encouragement to staff so that they are always open to

patients and their families.

2. For Units/Teams:

a. Make sure your team values and supports the involvement of

patients and their families in the event of an incident

b. Prioritize notification to patients and families in the event of an

incident, and provide them with clear and correct information

immediately

c. Make sure, immediately after the incident, the team shows

empathy to the patient and his family.

5.5.6 Learn and Share Experience About Patient Safety

Encourage staff to conduct root cause analysis to learn how and why the

incident occurred. The steps to implement anny are as follows:

1. For Hospitals:

a. Ensure that the relevant staff are trained to conduct an

appropriate incident assessment, which can be used to identify

the cause.

b. Develop a policy that clearly describes the criteria for

implementing a root cause analysis (RCA) that includes

incidents that occur and at least once a year conducts a Failure

Modes and Effects Analysis (FMEA) for high-risk processes.

2. For Units/Teams:

a. Discuss in your team the experience of the results of the incident

analysis.

b. Identify other units or parts that may be affected in the future and

share the experience more broadly.

5.5.7 Preventing Injury Through the Implementation of a Patient

Safety System

Use existing information about events/problems to make changes to the

service system. The steps to implement anny are as follows:

1. For Hospitals:

a. Use the correct and clear information obtained from reporting

systems, risk assessments, incident studies, and audits and

analysis, to determine local solutions.

b. Such solutions may include re-elaboration of systems (structures

and processes), adjustments to staff training and/or clinical

activities, including the use of instruments that ensure patient

safety.

c. Do assessment risk to every change

planned.

d. Socialize the solutions developed by the National Committee for

Hospital Patient Safety.

e. Give staff feedback on any actions taken on reported incidents.

2. For Units/Teams:

a. Involve your team in developing ways to make patient care

better and safer.

b. Review the changes your team has made and make sure they are

implemented.

c. Make sure your team receives feedback on any follow-ups on

reported incidents.

The seven steps for hospital patient safety are a comprehensive guide to

patient safety, so the seven steps must be implemented comprehensively

by every hospital. In implementation, the seven steps do not have to be

sequential and do not have to be simultaneous. Choose the most strategic

and easiest steps to implement in the hospital. If these steps are

successful, then develop the steps that have not been implemented. If

these seven steps have been implemented properly, hospitals can increase

the use of other methods.

NURSING SERVICE OBJECTIVES

6.1 Nursing Services

Nursing Services according to the Law of the Republic of Indonesia

Number 38 of 2014 concerning Nursing is a form of professional service

which is an integral part of health services based on nursing knowledge

and tips aimed at individuals, families, groups, or communities, both

healthy and sick. In addition, the foundation of nursing services is also

contained in the Regulation of the Minister of Health of the Republic of

Indonesia Number 26 of 2019 Nursing.

The Nursing Law is a state regulation that has binding legal force. At the

beginning of the explanation of the law, related matters are described.

The description is as follows: Health as a human right that is

constitutionally recognized in the 1945 Constitution of the Republic of

Indonesia as a citizen's right and state responsibility. This human right in

the health sector must be realized through health development directed to

improve the welfare of individuals, families, and communities by

instilling healthy living habits.

The implementation of health development is realized through the

provision of health services supported by health resources, both health

workers and non-health workers. Nurses in carrying out health services

play the role of organizers of Nursing Practices, providers of Nursing

Care, counselors and counselors for Clients, managers of Nursing

Services, and Nursing researchers. Nursing services provided by nurses

are based on knowledge and competence in the field of nursing that are

developed in accordance with the needs of clients, the development of

science, and the demands of globalization. These health services include

nursing services that are carried out responsibly, accountably, quality,

and safely by nurses who have obtained registration and practice

licenses. Nursing practice as a tangible manifestation of Nursing

Services is carried out independently based on delegation of authority,

assignment in certain limited circumstances, assignment in emergencies,

or collaboration.

6.1.1 Definition of Terms According to the Nursing Act

The definitions of various things related to Nursing have been

established in the Nursing Act. This is a reference in the professional

application of Nursing. Some of the terms related to services are as

follows:

1. Nursing is the activity of providing care to individuals, families,

groups, or communities, whether in a sick or healthy state.

2. A nurse is someone who has graduated from higher education in

Nursing, both in and out of the country that is recognized by the

Government in accordance with the provisions of Laws and

Regulations.

3. Nursing Services is a form of professional service that is an integral

part of health services based on nursing knowledge and tips aimed at

individuals, families, groups, or communities, both healthy and sick

4. Nursing Practice is a service provided by Nurses in the form of

Nursing Care.

5. Nursing Care is a series of interactions between Nurses and Clients

and their Clients to achieve the goal of meeting the Client's needs

and independence in caring for them.

6. Clients are individuals, families, groups, or communities who use

Nursing Services.

7. Health Service Facilities are tools and/or places used to carry out

health service efforts, both promotive, preventive, curative, and

rehabilitative carried out by the Government, Regional Governments,

and/or the community.

In addition, there is also a definition of the term in accordance with the

legality process as a prerequisite for performing nursing services

1. The Competency Test is the process of measuring the knowledge,

skills, and behavior of students at universities that organize the

Nursing study program.

2. Competency Certificate is a letter of recognition of the competence

of Nurses who have passed the Competency Test to practice Nursing

3. A Professional Certificate is a letter of recognition to practice

Nursing obtained by professional education graduates.

4. Registration is the official recording of Nurses who already have a

Certificate of Competency or Professional Certificate and have

certain other qualifications and have been legally recognized to carry

out Nursing Practice.

5. The Registration Certificate, hereinafter abbreviated as STR, is a

written proof given by the Nursing Council to registered nurses.

6. The Nurse Practice License Letter, hereinafter abbreviated as SIPP, is

written evidence given by the Regency/City Regional Government to

Nurses as granting authority to carry out Nursing Practice.

6.1.2 Principles of Nursing Practice

Nursing practice in accordance with the Nursing law is based on:

1. Humanity

Principles that must reflect the protection and respect of human

rights as well as the dignity and dignity of every citizen and resident

regardless of ethnicity, nation, religion, social status, and race.

2. Scientific value

Nursing practice is carried out based on the science and technology

obtained, both through research, education and practical experience.

3. Ethics and professionalism

The Nursing Practice Regulation must be able to achieve and

improve the professionalism of Nurses in carrying out Nursing

Practice as well as have professional ethics and professional

attitudes.

4. Benefit

Nursing must provide the greatest benefit to humanity in order to

maintain and improve the degree of public health.

5. Keadilan

Nursing must be able to provide services that are equitable,

affordable, quality, and non-discriminatory in health services.

6. Protection

The Nursing Practice Regulation must provide the greatest protection

for Nurses and the community.

7. Client health and safety

Nurse deep do Upbringing Nursing must

prioritize the health and safety of KIien.

6.1.3 Duties and Authorities of Nurses

The duties of nurses in organizing Nursing Practice in accordance with

the Nursing law are

1. Nursing Care Provider

2. Extension and counselor for Clients

3. Nursing Service Manager

4. Nursing Researcher

5. Executors based on delegation of authority 6. Executing duties in

certain limited circumstances.

Tasks can be carried out jointly or individually. The implementation of

Nurse duties as must be carried out responsibly and accountably.

The Authority of Nurses in carrying out their duties as caregivers

Nursing in the field of individual health efforts

1. Conduct a holistic nursing assessment

2. Establishing a Nursing diagnosis

3. Planning Nursing actions

4. Carrying out Nursing actions

5. Evaluating the results of nursing actions

6. Make referrals

7. Providing emergency action in accordance with competence

8. Providing Nursing consultations and collaborating with doctors

9. Conducting health counseling and counseling

10. Managing the administration of drugs to the Client in accordance

with the prescription of medical personnel or over-the-counter drugs

and limited over-the-counter drugs.

Authority of Nurses in carrying out their duties as providers of Nursing

Care in the field of public health efforts

1. Conducting a public health nursing assessment at the family and

community group levels

2. Determining public health nursing problems

3. Assisting in the discovery of disease cases

4. Planning public health nursing actions

5. carry out public health nursing actions

6. Refer a case

7. Evaluate the results of public health nursing actions

8. Empowering the community

9. Carry out advocacy in public health care

10. Forging partnerships in public healthcare

11. Conducting health counseling and counseling

12. Manage cases

13. Do Management Nursing complementary and alternatives.

The authority of nurses in carrying out their duties as counselors and

counselors for clients

1. Conduct a holistic nursing assessment at the individual and family

levels as well as at the community group level;

2. Empowering the community

3. Carry out advocacy in public health care 4. Establish partnerships in

public health care 5. Conducting health counseling and counseling.

Authority of Nurses in carrying out their duties as Service Managers

Nursing

1. Conduct assessments and determine problems

2. Plan, implement, and evaluate Nursing Services 3. Manage cases.

Authority Nurse deep Run His duties as

Researchers

Nursing

1. Conduct research in accordance with standards and ethics

2. Use resources at Healthcare Facilities with the permission of the

leadership

3. Using patients as research subjects in accordance with professional

ethics and the provisions of laws and regulations.

6.1.4 Rights and Obligations of Nurses

The rights and obligations of nurses have been determined in Law of the

Republic of Indonesia number 38 of 2014.

Nurses' Rights in Practicing Nursing

1. Obtain legal protection while carrying out their duties in accordance

with service standards, professional standards, operational procedure

standards, and the provisions of laws and regulations;

2. Obtain true, clear, and honest information from the Client and/or his

family.

3. Receive remuneration for services that have been provided

4. Reject the wishes of the Client or other parties that are contrary to

the code of ethics, service standards, professional standards,

operational procedure standards, or the provisions of laws and

regulations; and

5. Obtain work facilities in accordance with standards.

Nurses' Obligations in Carrying Out Nursing Practice

1. Completing Nursing Service facilities and infrastructure in

accordance with Nursing Service standards and the provisions of

Laws and Regulations

2. Providing Nursing Services in accordance with the code of ethics,

Nursing Service standards, professional standards, operational

procedure standards, and the provisions of Laws and Regulations

3. Refer Clients who cannot be handled to Nurses or other health

workers who are more appropriate according to their scope and level

of competence

4. Document Nursing Care in accordance with standards

5. Providing complete, honest, true, clear, and easily understandable

information regarding Nursing actions to the Client and/or his family

in accordance with the limits of his authority

6. Carry out actions of delegating authority from other health workers

in accordance with the competence of nurses

7. Carry out special assignments set by the Government.

6.2 Nursing Service Objectives

Nursing Services as a form of professional service which is an integral

part of health services based on nursing science and tips aimed at

individuals, families, groups, or communities, whether healthy or sick.

The Client is an individual, family, group, or community who uses

Nursing Services.

6.2.1 Client's Rights and Obligations

Client Rights in Nursing Practice

1. Obtain information in a true, clear, and honest manner about the

Nursing action to be carried out

2. Ask for the opinion of other nurses and/or other health workers

3. Obtaining Nursing Services in accordance with the code of ethics,

Nursing Service standards, prolesion standards, operational

procedure standards, and the provisions of Laws and Regulations

4. Giving approval or rejection of the nursing action that he will receive

5. Obtaining the confidentiality of their health condition

Client Obligations in Nursing Practice

1. Provide true, honest, and honest information about their health

problems

2. Comply with the advice and instructions of the Nurse

3. Comply with the applicable provisions at the Health Service Facility

4. Providing rewards for services received

The disclosure of the Client's health secrets is carried out on the basis of

1. Client's health interests

2. Fulfillment of requests by law enforcement officials in the context of

law enforcement

3. Client's own consent

4. Educational and research interests

5. Provisions of Laws and Regulations

6.2.2 Individual Clients

Humans are complex organisms, influenced by and responsive to the

internal and external environment. Our behavior, our feelings about

ourselves and others, our values, and the priorities we set for ourselves

are all related to our physiological and psychosocial needs. This need is

common to everyone, and meeting this need is essential for everyone's

health and survival; hence, they are labeled as basic human needs. Basic

human needs can be met or unmet in a variety of ways. A person can

fulfill some needs independently, but most needs require relationships

and interactions with others for partial or complete fulfillment. Satisfying

one's needs often depends on one's social and physical environment,

especially one's family and community (Taylor et al., 2011).

Basic Human Needs of the Individual

In nursing, the physical and psychosocial needs of the patient are

considered. Maslow (1968) developed a hierarchy of basic human needs

that can be used to consider the most important needs of a person at any

given time. Certain needs are more basic or essential than others and

must at least be met before other needs can be considered.

Maslow's hierarchy is useful for understanding the relationship of basic

human needs and for setting care priorities. The hierarchy is based on the

theory that something is a basic need if it has the following

characteristics (Taylor et al., 2011):

1. Its absence causes illness.

2. Its presence helps prevent diseases or signifies health.

3. The meeting restored health.

4. Preferable to other satisfactions when not met.

5. A person feels that something is missing when their needs are not

met.

6. A person feels satisfaction when their needs are met.

Maslow organized the hierarchy to show that certain needs are more

fundamental than others. Although everyone has all the needs all the

time, people generally strive to meet certain needs, at least to a minimal

extent, before meeting others. The levels from the bottom up are

physiologic needs, safety and security needs, love and belonging needs,

self-esteem needs, selfactualization needs (Potter et al., 2021).

Nursing care is often directed to meet unmet or threatened needs.

Maslow's hierarchy provides a framework for nursing assessment and to

understand patient needs at all levels, so that interventions to meet

priority needs become part of the care plan.

6.2.3 Family

Almost everyone is a member of a number of groups, such as friends, co-

workers, or school classes. Each of these groups involves a specific part

of a person's life and is important to the person. However, only one

group cares about all parts of a person's life and by meeting his basic

needs as a human being to improve health. That group is the family

(Taylor et al., 2011).

A family can be simply defined as a group of people who live together

and are emotionally bonded. Families exist in all sizes and

configurations and are essential for the health and survival of individual

family members, as well as society as a whole. The family is a buffer

between the needs of individual members and the demands and

expectations of society. The role of the family is to help meet the basic

human needs of its members as well as meet the needs of society

(Friedman, Bowden and Jones, 2003).

A family can consist of two or more people. Family members may not be

biologically or legally related, may be of the same sex, and/or may

belong to multiple generations (such as grandparents raising

grandchildren). Nurses must remember that there is no absolute "right"

or "wrong" about what makes a family, and one person's values should

not be imposed on others. Respect for all types of family members and

relationships is essential for holistic, holistic and individualized patient

care (Taylor et al., 2011).

6.2.4 Community

A person has several roles, as an individual, as a family member, as well

as being a member of society. The environment of society affects the

ability of individuals to meet basic human needs. A community can be

defined in a variety of ways, but the most basic definition is that a

community is a specific population or group of people who live in the

same geographic area under the same rules and have the same values,

interests, and needs. A community may be a small neighborhood in a

large city or a large rural area that includes a small town. Communities

are shaped by the characteristics of people, regions, social interactions,

and the same family, cultural, or ethnic heritage and ties. In a

community, people interact and share resources (Taylor et al., 2011).

Vulnerable Populations

In community settings, nurses care for patients from diverse cultures and

backgrounds and with a variety of health conditions. However, changes

in the healthcare delivery system have made high-risk groups the main

patients. Vulnerable populations are groups of patients who are more

likely to develop health problems as a result of excessive health risks,

who are limited in access to health care services, or who are dependent

on others for treatment (Potter et al., 2017).

Public and community health nursing and primary care providers share

health care responsibilities for health promotion, screening, and early

detection and prevention of disease for vulnerable populations. These

patients have intense healthcare needs that are not met or neglected or

require more care than can be provided in an outpatient or hospital

setting. Vulnerable individuals and their families are often members of

more than one of these groups. In addition, healthcare vulnerabilities

affect all age groups (Sebastian, 2014).

Some things related to the community (Taylor et al., 2011)

1. Social Support System

An individual's social support system is made up of all the people

who help meet financial, personal, physical, and emotional needs. In

most cases, family, friends, and neighbors provide the best social

support in a community. To understand the social support system of a

community, it is important to know who and what is providing

support (such as family, neighbors, friends, and organizations).

2. Public Health Structure

The health care structure of a community has a direct effect on the

health of the people living in it. The size and location of the

community often determine the type of services available. For

example, urban dwellers have various means of transportation to

various health care providers, while rural dwellers may have to travel

long distances to get treatment. In addition, district and state funding

for public health services also determines the type and amount of

health services institutions and institutions available.

3. Economic Source

Financial and insurance coverage affects individuals' access to health

services in society. As the cost of private health insurance continues

to rise, fewer and fewer citizens have it. Many part-time and

unskilled jobs do not provide insurance benefits at all, resulting in a

large number of citizens not having financial assistance for health

screenings or disease treatment. Although the issue is being

examined by state and federal policymakers, there is no clear

solution yet.

4. Environmental factors

The community environment in which individuals live and work may

have beneficial and harmful effects on health. Air and water quality

is different in every community. Large urban areas are often affected

by air pollution, while smaller communities may be at risk of water

pollution from chemical or livestock waste runoff. There are also

growing concerns about how global warming affects health.

Environmental barriers to accessing health services in the

community include lack of transportation, distance to services, and

location of services.

5. Effects on Individuals and Families

The community has a strong influence on health promotion activities

and disease prevention of individuals and families in the community.

Just as there are family risk factors for the health of individual

members, there are also community risk factors involving resources,

economics, and services. In order for nursing assessments and

interventions to be comprehensive and individualized, nurses must

also consider the influence of the community.

NURSING PROCESS

7.1 Introduction

The nursing process is a series of methods applied by nurses in nursing

practice. Initially, nurses only carried out tasks that became work

routines, without scientific guidelines for such actions. However, along

with the development of science, technology, practice and nursing

science also developed. The nursing process provides a structure for

nursing practice which is a framework for the use of science and

knowledge and skills carried out by nurses. The approach to solving

nursing problems also requires science, techniques and interpersonal

skills. The nursing process consists of five consistent, systematic and

interrelated stages, namely assessment, diagnosis, planning,

implementation and evaluation.

In the implementation of nursing care, the use of the nursing process is a

differentiator between professional nursing care and traditional nursing

care. Therefore, professional nurses are required to be able to carry out

the nursing process appropriately and correctly using a scientific

approach in solving the problems of the needs of clients, families and

society.

7.2 History of the nursing process

Currently, the five stages of the nursing process are used as the

framework, basis and introduction of the study of nursing. The term

nursing process was first introduced by Lidya Hall in 1955. At that time,

the nursing process still consisted of three stages, namely study,

planning, and evaluation. Then in 1967, Yura and Walls described it into

four stages, namely study, planning, implementation, and evaluation.

In the mid-1970s, authors such as Bloch, Roy, Mundinger and Jauron, as

well as Aspinal completed the nursing process into five stages: review,

diagnosis, planning, implementation and evaluation. In Indonesia,

around the 1980s, the nursing process began to be known, especially in

the world of nursing education.

7.3 Definition of Nursing Process

Since the 1950s until now, experts have described the nursing process in

various ways, but in general, the definition of the nursing process can be

divided into three dimensions, namely Objectives, Organization, and

Characteristics.

7.3.1 Objectives, Organization and Characteristics

The purpose of the nursing process is to use problem-solving methods so

that nurses can identify all the needs needed by the client both

individuals, families and communities. These client needs describe the

problems that occur to the client, both actual and risky.

The purpose of the nursing process will be met if nurses use standards

for nursing practice. The quality or nursing services provided use the

same standards, namely the nursing process. The nursing process also

aims to obtain a standard, appropriate, rational, and systematic method.

It can be concluded that the purpose of the nursing process is to produce

high-quality nursing care. Nursing process approach

help nurses more carefully carry out the task of mass identification and

scientific planning design.

The nursing process is organized into five stages, namely, assessment,

diagnosis, planning, implementation, and evaluation. Although it is

grouped into five stages, the nursing process must be carried out

consecutively, dependently and continuously. Each stage affects each

other, so that the performance of nurses who use the nursing process

approach becomes neat and structured. This makes the quality of nursing

care good and professional.

The characteristics of the nursing process include interactive, flexible,

and theoretical. The interaction between nurses, clients, families, and

other health workers makes the client's healing process will run quickly,

completely, and continuously. Interaction with other health workers in

the healing process of clients will form an attitude of mutual respect for

other professions. The flexibility of the nursing process means that it can

be used in the life span, from the fetus to the elderly, as well as the entire

health service order.

The nursing process is dynamic in that the nursing process can change

when the patient's condition changes. Changes in the patient's condition

both positively and negatively, so that nursing problems, plans, and

actions will also change.

7.3.2 Benefits of the Nursing Process

The application of the nursing process has implications and impacts on

the nursing profession, clients and nurses. The benefits of the nursing

process are first, improving the quality of nursing services through

comprehensive nursing care, so as to accelerate the healing process and

avoid mallpractice.

Second, the development of intellectual and technical skills for nursing

staff. The implementation of the nursing process in caring for clients will

provide opportunities for nurses to develop various knowledge and skills

as well as experience in cooperation with colleagues, clients, and their

families.

Third, improve the role and function of nursing in the management of

nursing care. By carrying out the stages in the nursing process means

carrying out management functions starting from problem assessment,

planning nursing care, organizing nursing activities, mobilizing nursing

staff, assessing and controlling the nursing care provided in achieving

the goals of nursing services that have been set.

Fourth, recognition of nursing autonomy. The community will recognize

the autonomy of the nursing profession if nursing care is provided with a

method based on responsibility and responsibility based on the

professional code of ethics and nursing practice standards.

Fifth: Increase job satisfaction and improve professional development.

The nursing process allows for the development of creativity so as to

prevent nurses from being bored in doing routine work and a task-

oriented approach.

7.4 Theories Underlying the Nursing Process

Various theories have been put forward by experts about nursing, both in

the form of concepts, philosophies, models and nursing theories

themselves. Here are some theories about the nursing process.

7.4.1 Systems Theory

In the nursing system, it is explained that nurses as individuals and

clients (individuals, families, communities) interact where each other

affects each other on the level of needs and satisfaction which is the

focus of nursing care.

Figure 7.1: Nursing Process System Theory (Nursalam, 2008)

The data set of the results of the assessment and the problems are, then

the right nursing plan and care are prepared, so that the results (output)

of the interventions that have been carried out are created. The feedback

process is a process in which the system is evaluated or reviewed to

determine the next intervention.

7.4.2 Theory of Human Needs

This theory initiated by Abraham Maslow frames humans as an integral

part of motivation to meet basic human needs (physiology, security,

compassion, self-esteem, and self-actualization). The application of the

nursing process is focused on the unique basic needs of human beings

Figure 7.2: Nursing Process System Theory (Nursalam, 2008)

7.4.3 Theory of perception

This perceptual theory states that in the fulfillment of basic needs, it is

influenced by the individual's perception of the stimulus obtained. in

nursing processes where nurses and clients are mutually collecting data.

Then the data will provide meaningful value and can be used to provide

nursing care.

Figure 7.3: Nursing Process System Theory (Nursalam, 2008)

7.4.4 Theory of Decision Making and Problem Solving

This theory states that every decision-making and problem-solving

requires a person to be able to accept new, different and more complex

aspects of the existing environment. The purpose of the nursing process

is to provide nursing care to clients is to help accelerate the resolution of

complex client problems.

Figure 7.4: Nursing Process System Theory (Nursalam, 2008)

7.5 Nursing Process Steps

The nursing process is used continuously in nursing care. Nursing care is

the core of the entire nursing process. Nursing care is the entire process

that is arranged in sequence that is directly aimed at the client in various

health service settings. Nurses consider clients as central figures in

nursing care plans so they always ensure the accuracy of all aspects and

observe the patient's response.

In fact, health professionals must master the process in nursing care so

that they can overcome client problems professionally. To better master

the nursing process, it's a good idea to look at the details of the stages of

the nursing process. Here is a simple table of the steps of the nursing

process.

Table 7.1: Nursing Process Steps

Process Stages

Assessment 1. Data collection through interviews,

observations, physical examinations and

studying

Supporting Examination

Diagnosis

Nursing

2. Data analysis

3. Problem Identification

4. Formulation of Nursing Diagnosis

Nursing Planning 5. Nursing Objectives

6. Outcome Criteria

7. Intervention Plan (nursing action)

Implementation 8. Implementation of nursing care

Evaluation 9. Implementation of Assessment

10. Determination of Follow-up

7.5.1 Nursing Review

Nursing review is the initial and basic stage in the nursing process and

determines the next process. The activities in the assessment are data

collection through interviews, observations, physical examinations, and

maintenance of supports. In the nursing assessment, four types of data

will be collected, namely basic data, focus data, subjective data, and

objective data. The data collected is sourced from the client's primary,

and secondary data sources are from family, closest people, or other

people who know the client's health status, including health workers.

Data collection techniques include anamnesis, observation. Anamnesis is

a question and answer or communication directly or indirectly with the

client to find out information about the client's health status. In

performing anamnesis, the nurse's ability to communicate and pay

attention to the client's verbal responses and non-verbal behavior is

needed.

In observation, nurses make direct observations that require skills,

discipline, and modern practice. Observation consists of physical

examinations carried out in four ways, namely inspection, percussion,

palapation and auscultation. Observation of supporting examinations is

carried out according to indications, for example observing thoracic,

laboratory and cardiac photos.

Nurses in conducting assessments sometimes experience obstacles or

obstacles, including (1) not being able to perform anamnesis

appropriately, (2) not being able to conduct physical examinations

appropriately, (3) not being able to organize data, (4) incomplete and

accurate data, (5) data that are contrary to each other, and (6) data

duplication.

Therefore, to carry out the nursing process comprehensively and

professionally, a nurse must have good knowledge, skills and

communication skills.

7.5.2 Diagnosis

In the provision of nursing care, nursing diagnosis is a vital part to help

patients achieve optimal health. A nursing diagnosis is a statement that

describes the human response, as well as the clinical assessment of that

response. The purpose of nursing diagnosis is to enable nurses to analyze

and synthesize data that has been grouped, identify problems, factors that

cause problems, and the client's ability to be able to prevent and solve

problems.

Analyzing data and drawing conclusions in the formulation of a

diagnosis requires cognitive and reasoning skills. The data found during

the nursing assessment process to be then concluded in the formulation

of nursing diagnosis requires nurses to develop thinking and reasoning

skills that are greatly influenced by the background of science and

knowledge (Dermawan, 2012). So it can be said that the determination of

nursing diagnosis is a process that is carried out simultaneously which of

course requires adequate experience by the nurse. Inexperienced nurses

need to get continuous training and habituation systematically so that

nursing diagnoses can be established accurately.

Figure 7.5: Stages of the Diagnostic Process (PPNI,

2016)

The process of diagnostic enforcement (process diagnostics) or diagnosis

is a systematic process consisting of three stages, namely (1) data

analysis, (2) problem identification, and (3) diagnosis formulation.

These steps to determine nursing diagnosis make it easier for nurses or

new students to accurately enforce nursing diagnoses (PPNI, 2016).

7.5.3 Planning

After identifying problems in the nursing diagnosis, the nurse then

develops a nursing planning design to prevent, reduce and overcome the

problem. In developing a nursing plan, nurses must determine the

priority of nursing issues. The first priority is interpreted that this

problem needs the attention of nurses because it can affect the general

health status and can slow down the resolution of other problems.

At this stage, various applicable steps will be prepared and planned. This

stage contains the objectives, outcome criteria and nursing action plan.

PPNI has compiled the Indonesian Nursing Output Standards book as a

guide for nurses in compiling the goals and outcome criteria in nursing

planning.

Nursing objectives or nursing outcomes are aspects that can be observed

and measured including conditions, behaviors, or perceptions of patients,

families or communities in response to nursing interventions. This

nursing output shows the status of nursing diagnosis after nursing

intervention.

Nursing outcomes have three main components, namely labels,

expectations and outcome criteria. Nursing output labels are conditions

that are behavioral or perceptual conditions that can be changed or

overcome by nursing intervention. External expectations are an

assessment of the expected results achieved. Expectations describe

conditions such as increasing, decreasing, and improving. Outcome

criteria are patient characteristics that are observed or measured by

nurses and are used as a basis for assessing the achievement of nursing

intervention outcomes. The result kiteria is also called an indicator

because it describes the change to be achieved.

The nursing intervention plan is prepared based on the Indonesian

Nursing Intervention Standards (SIKI). Based on the mandate of Law

No. 38/2014 concerning Nursing, it is stated that in carrying out their

duties as nursing care providers, nurses are authorized to plan and carry

out nursing actions, make referrals, provide emergency measures, give

consultations, collaborate, conduct consultations and counseling, provide

drugs according to a doctor's prescription or over-the-counter and limited

over-the-counter drugs, manage cases and manage complementary and

alternative interventions.

In the SIKI classification system, it consists of 5 categories and 14

subcategories. The classification of nursing interventions is carried out

based on similarity analysis and clinical judgement.

7.5.4 Implementation

Implementation is the realization of actions to achieve the goals that have

been set. Activities in the implementation include continuous data

collection, observing client responses during and after the

implementation of actions and assessing new data.

Professional nurses in carrying out implementation require several skills,

namely cognitive, interpersonal, and psychomotor. These skills are

needed for nurses to know the reasons for each intervention,

physiological and psychological responses, and recognize the promotive

aspects of the client's health. In interacting with clients, nurses must

communicate clearly in addition to having a perspective on the client's

verbal and non-verbal communication.

7.5.5 Nursing Evaluation

Nursing evaluation is to compare changes in the patient's circumstances

(observed outcomes) with the outcome goals and criteria made at the

planning stage. The purpose of the evaluation is to End the nursing

action plan, modify the nursing plan, and forward the nursing plan. The

evaluation process includes measuring the achievement of goals from

cognitive, affective, and psychomotor aspects as well as changes in body

functions. After being evaluated, the nurse makes a decision whether the

client has achieved the set results, the client is still in the process of

achieving the results, and the client cannot achieve the predetermined

results.

The types of evaluation include formative evaluation and summative

evaluation. Formative evaluation is an evaluation that is carried out after

each action. Meanwhile, summative evaluation is an evaluation that is

carried out after the end of the nursing procedure in full. To make it

easier for nurses to evaluate or monitor client progress, SOAP

components are used. S is subjective data, O is objective data, A is the

analysis or interpretation of subjective and objective data, and P is

continued nursing planning or planning.

NURSE CARE DOCUTATION

8.1 Introduction

Health Services are contained in the Law of the Republic of Indonesia

(UU RI) of 2014 Number 38 stating that nursing care is an integral

component in a health service, which is based on nursing science in the

form of counseling individuals, families, groups and communities in a

healthy or unhealthy state. The main responsibility of a nurse is to

provide professional care services in the form of nursing activities,

starting with a comprehensive investigation process, making diagnoses,

making plans, taking action and evaluating nursing activities. Section 1

of section 34 of the Act states that nurses are required to keep records

while performing nursing duties. 2) Record keeping according to

paragraph 1 must be held in accordance with the provisions of the law.

Nursing work is a stage of nursing work that is taught directly to patients

in the health system as a nursing profession according to the principles of

a nurse's knowledge, which pays attention to a sense of humanity and is

based on the needs of patients in solving a health problem. The most

important part of nursing jobs is documentation. Nursing documentation

is a comprehensive, systematic and structured record of the resident's

response to treatment actions, showing the caregiver's responsibility to

the resident during the nursing process (Prabowo, 2016).

8.2 Basic Concepts of Nursing Care

Law No. 38 of 2014 of the Republic of Indonesia Nursing work is the

interaction of the client and the environment to meet the needs and

achieve the goal of increasing the client's independence. Nursing is a

series of processes to meet the needs of clients through systematic and

scientific methods of the evaluation process, determination of nursing

diagnosis and determination of the achievement or goal of nursing care,

planning and implementation as well as evaluation (Suarli and Yahya,

2012). The basic concepts of nursing emphasize a holistic approach,

autonomy, partnership, individual and cultural context in the process of

review, planning, implementation and evaluation. This means that clients

must be actively involved and identify their goals for managing their

problems to be included in the treatment plan. The parenting process

must foster therapeutic relationships, provide counseling, education, and

evidence-based interventions by caregivers. In another sense, the concept

of nursing refers to preventive, treat, and rehabilitation services for

people suffering from diseases or health problems (Beard, 2021)

8.3 Nursing Care Documentation Concept

Concept of nursing documentation 8.3.1 Definition Documentation is

printed material or documents that can be relied on by the authorities as

evidence. Another source states that nurse records are evidence in the

form of writing that is useful for patients, nursing teams, and medical

personnel who carry out medical care based on accurate and complete

written information from nurses in nurses' records about the care of

Wahid and Suprapto, 2012).

8.3.1 Nursing Care Documentation Objectives

Nursing documentation is a communication tool between clients,

families, nursing teams and other health teams, the purpose of which is

to ensure good communication between nurses, protect clients in care

and assist nurses. start organizing nursing work. and responsible for

customer safety. As a statistical reference for rostering, planning of

future facilities and infrastructure, and staff needs, for educational

institutions, can be used as a learning environment and research material

for students in the development of nursing skills; as a data source for

nursing audits; as a measuring tool to evaluate the performance of health

services, documents are used as legal aspects and original evidence that

can be used by nurses in legal matters and to ensure the quality of health

services and care (Setiadi, 2012). The implementation of nursing

documentation is a measuring tool to record, monitor and complete

nursing services provided in hospitals. Indicators of the performance of

nursing staff in providing nursing services can be seen in the

implementation of nursing work documentation. Without nursing

documentation, any nursing care performed by nurses is meaningless in

terms of accountability and responsibility. Nursing documentation is also

one of the efforts to encourage and control the responsibilities of a nurse.

8.3.2 Benefits of Nursing Care Documentation

Documentation of nursing work is very important in many ways,

especially to answer questions about the quality of services based on

documentation, because documentation facilitates the delivery of

services and the resolution of customer problems, is an evaluation

benchmark to improve the quality of services, aspects of communication

and communication lines between nurses and clients or families, other

health workers, so as to form good coordination and avoid duplication,

which is legally invalid and effective as an official document and has

legal value or legitimacy in the nursing service system, so that when

legal problems arise, documentation is evidence that can be used in

court, educational training and documentation has educational value

because the content is the chronology of nursing practice, which is a

learning reference for nursing students. Documented information can be

used as a reference or reimbursement for clients, in terms of

documentation research serves as material or research objectives in the

development of the nursing profession, in terms of nursing documents

can be used as an indicator in accreditation as an indicator in the

evaluation of nursing services in hospital accreditation.

8.3.3 Principles of Nursing Care Documentation

The principle of documentation, recording is carried out immediately

after the initial assessment or at each stage of treatment, which records

the patient's response to important information or data and ensures the

accuracy of all recorded data so that the existing information or data

must be objective. Accurately document when a client's condition is in

place or when a patient's condition changes or a new issue arises. Avoid

the same documentation because every patient has different problems.

Avoid spelling ambiguous terms in nurses' notes. Write with ink, not

pencil. If there are typos, they must be crossed out and replaced with the

correct ones and signed on each document. Include the time, signature,

and real name of the author. Each nursing document must be readable by

all members or teams of healthcare workers.

8.3.4 Nursing Process Documentation

1. Study Documentation

The Assessment process is the first step in the nursing process and is

a systematic process of collecting data from various sources to

evaluate and identify the health status of clients. Records of nurse

assessment results are in the form of data consisting of current

patient health history, past patient health history, and family health

history. Data on patients' health conditions are comprehensively

reviewed including biological, psychological, social, spiritual and

cultural conditions. After the assessment results are collected, the

data is grouped and interpreted and documented.

According to Ermawati Dalami (2011), the type of assessment

consists of: a. Initial Assessment Documentation

Initial assessments are documented as data sources (databases)

developed for general use by an agency, for specific use in

specialized care units, or for specific types of client populations.

The form of data sources helps in structuring the client's Health

History and documenting the results of physical examinations.

b. Advanced Assessment Documentation

Follow-up assessments, reassessments, and reassessments are

documented in client development notes or on appropriate

sheets. This data can be categorized as supporting data or

developed data.

c. Supporting Data Documentation

Supporting data is data that has been reviewed or data that has

been collected previously and then documented to show

continuous monitoring of the client's health status and problem

solving.

d. Documentation Developed data

Nurses document relevant data developed in progress notes to

support nursing assessments of clients' health status.

e. Specific Assessment Documentation

Documentation of special assessments is carried out When

special measurement tools are incorporated into the clinical

decision-making process, their use should always be documented

in the clinical record.

2. Nursing Care Diagnosis Documentation

Nursing Diagnostic Documentation is the decision-making stage of a

nursing process. Writing a nursing diagnosis includes client

problems or problems that are actual, risky, or prosperous. Decision-

making in the form of nursing problems must be supported by data

available to the client, both in the form of major and minor data and

supporting data. The use of nursing diagnosis is a guide to make

progress records.

3. Action Plan Documentation

The Nursing Action Plan includes three things including: a.

Nursing diagnosis

Nursing diagnosis should be a priority for caring for clients. This

must directly concern the situation that threatens the client's life.

b. Outcome Criteria

Each nursing diagnosis must have at least one outcome criterion.

The outcome criteria can be measured with expected goals that

reflect the client's concerns.

c. Nursing Action Plan

The act of nursing is to obtain independent responsibility,

especially by the nurse who is carried out in conjunction with the

medical program based on the client's problem and the help the

client receives is the expected result. Each client problem and

expected outcome is at least two action plans.

4. Nursing Care Implementation Documentation

Nursing Planning and Action is a stage in the nursing process based

on the actual problems of the client. The purpose of the Action

documentation is to find exactly the picture of the nursing

intervention which includes: a. Therapeutic interventions

Therapeutic treatment is immediate nursing care according to the

client's circumstances. More than one nursing plan must be

worked on seriously according to the priority of the problem in

diagnosing nursing.

b. Monitoring/observation interventions

This process requires the nurse's observation acumen including

proper evaluation skills. A program that is more than a highly

determined client's health. Nurses must see more good and bad

developments from clients such as: maintenance of vital signs,

nursing diagnoses, nursing therapeutic measures, medical

therapy and others.

Intervention documentation identifies why something happened to

the client, what happened, when, how, and who intervened.

5. Nursing Care Evaluation Documentation

Evaluation statements need to be documented in progress notes,

revised in the treatment plan or included in specific summaries and

in implementation or planning. Guidelines for documenting

evaluations are as follows:

a. Before the conclusion of the evaluation with data that supports

the assessment of the nurse.

b. Follow the documentation of the nursing intervention with a

formative evaluation statement describing the client's rapid

response to the nursing intervention or nursing procedure.

c. Using statement Evaluation Summative When

The client is transferred to another facility or

discharged/the patient recovers.

d. Summative evaluation of each expected outcome is identified on

the client's nursing plan.

e. Write an evaluation statement that reflects the client's

developmental state against the objectives.

f. Through an assessment or modification of the intervention,

initiate and document the nurse's response to change the client's

condition.

MODEL OF NURSING PRACTICE MODEL

9.1 Introduction

Nursing is an effort to provide care that has a humanistic, holistic,

professional nature based on knowledge and tips, established service

standards and based on the code of ethics of the nursing profession,

where nurses can provide care independently and collaboratively

(Kodim, 2018). Nursing practice is a form of professional service that is

part of health services based on nursing tips and knowledge provided to

clients individually, families, groups and communities (Ariga, 2022).

According to Nursalam (2022), there are nursing practice models,

namely;

1. Hospital nursing practice, where nurses have the natural authority

and responsibility to carry out nursing practice in hospitals according

to their abilities and attitudes.

2. Home nursing practice is basically a nursing service that is an

extension of hospital services carried out by hospital nurses and

community nurses.

3. Group nursing practice, a 24-hour nursing service provided by nurses

who open practices with the approach and implementation of

hospital nursing practices in overcoming various nursing problems

faced by the community.

4. Individual nursing practice, nursing services provided by a senior

professional nurse during specific practice hours. This form of

practice is indispensable for people who are far from access to health

care facilities

Along with the development of the times, it is inevitable that there will

be an increase in the demands of client needs, so the nursing world has

also experienced developments in the model of implementing nursing

services. The nursing service model provided by professional nurses

provides satisfaction for both the client and the nurse itself. One of the

efforts made is to change the framework for providing nursing care by

implementing the Professional Nursing Practice Model (MPKP). MPKP

is a model for providing services to clients that provides safe, effective

and efficient services. (Kozier, B, Erb. G & Blais, 1997)

MPKP or professional nursing care model (MAKP) is a nurse framework

that defines 4 elements, namely standards, nursing processes, nursing

education and the MPKP system so that these four elements are

considered in determining a care model. (Dedi, 2020). The success of

nursing care to clients is highly determined by the selection of the

nursing practice model used so that the nursing practice model must be

effective and efficient. Each nursing unit has an effort to select the

appropriate nursing practice model to be used in its nursing unit, by

having consideration for the suitability of the client's classification and

the type of availability of existing nurses, infrastructure, hospital

policies. Where each of these models has advantages and disadvantages

that are considered for each nursing service unit.

9.2 Professional Nursing Practice

Word Health Organization (WHO) in 2010 launched the focus of nursing

practice on primary prevention, health improvement (client, family,

community), self-care, and confidence building. Kusnanto (2013), wrote

that nursing practice has five areas related to health, namely; Health

promotion, disease prevention, health maintenance, health restoration,

and care for clients before death.

9.3 Basis for Consideration for Selecting a

Nursing Practice Model

There are six main elements in the selection of a nursing practice model,

(Nursalam, 2022):

1. Vision and Mission

The first basis determines the model of nursing practice for clients by

adjusting to the vision and mission of the care unit and even the

vision and mission of the hospital.

2. Nursing process

The nursing process can be applied in providing care to clients,

where each unit or hospital has client characteristics and the type of

nurses needed that differ according to the client's characteristics.

3. Efficiency and effectiveness

The determination of the model must be based on the cost efficiency

and effectiveness of the smooth implementation of the selected

model in order to produce perfect results.

4. Customer satisfaction

Choose a nursing practice model that can provide satisfaction to

customers, in this case clients, families and the community.

5. Nurse satisfaction and performance

Choose a nursing practice model that can provide satisfaction and

improve nurse performance, not one that can increase the workload

and even have a frustrating impact on nurses in carrying out care.

6. Communication

Professional communication is in accordance with the roles,

functions and responsibilities of nurses to fellow nurses and other

health workers. The nursing practice model is expected to achieve

good interpersonal relationships.

9.4 Characteristics of Professional

Relationships

Professional relationships can affect the model of nursing practice that

will be used, there are several characteristics of these professional

relationships, namely;

1. Oriented to the needs of the client

2. Directed towards the achievement of goals

3. Responsible for resolving client issues

4. Understand the client's condition with its various limitations

5. Providing assessments based on the norms agreed upon between

nurses and clients

6. Obliged to help clients to be able to be independent gradually

7. Building relationships based on trust

8. Work by holding the principles of nursing ethics, one of which is

maintaining the confidentiality of the client's health, using

information only for the benefit and with the consent of the client

9. Using effective communication in meeting client needs

9.5 Models of Nursing Practice

9.5.1 Functional Nursing Practice Model

A nursing practice model that takes into account the division of tasks

according to the type of work performed. The person in charge in this

model is the nurse who is in charge of the specific action performed. A

nurse can perform two or more types for all clients present in the unit.

There is a lack of professional nurses, so many nursing assistants are

recruited. They are trained at a minimum on how to take care of them,

taught simple and repetitive tasks such as injecting, measuring blood

pressure, measuring temperature, treating wounds and so on. Example:

Nurse A is in charge of providing treatment and nurse B is in charge of

treating wounds, and Nurse C is in charge of preparing instruments or

carrying out the needs of the client (Nursalam, 2022)

Figure 9.1: Functional Nursing Practice Model (Nursalam, 2022)

Advantages:

1. Emphasis on efficiency, clear division of tasks and good supervision

2. Very good for hospitals that lack manpower

3. Senior nurses perform managerial duties and junior nurses perform

direct care to clients

4. Make it easier for the head of the room to supervise staff or students

who practice for certain skills.

Debilitation:

1. No satisfaction for clients or nurses

2. Nursing services are fragmented or not possible to perform nursing

holistically

3. Nurses only see nursing care as a skill.

9.5.2 Team Nursing Practice Model

A nursing practice model conducted by a group of nurses to a group of

clients (2-3 teams per group) led by registered and experienced nurses

who are knowledgeable in their field. The person in charge in this model

is the team leader. The division of tasks in groups is carried out by the

group leader or team leader who can use various leadership techniques,

the importance of effective communication to ensure the sustainability of

the nursing plan. In addition, the Team Leader is responsible for

directing his members before the task and receiving reports on the

progress of client nursing services and assisting team members in

completing tasks if they encounter difficulties. This model of nursing

practice is commonly used in inpatient, outpatient, emergency

departments. (Nursalam, 2022)

Figure 9.2: Team Nursing Practice Model (Nursalam, 2022)

Advantages:

1. Facilitate comprehensive nursing services

2. Enables the achievement of the nursing process

3. Conflicts or differences of opinion between staff can be suppressed

through team meetings

4. This is an effective way to learn

5. Enable the ability of different team members to be united safely and

effectively.

6. Providing satisfaction to team members

Debilitation:

1. Team meetings take time so that in busy situations team meetings are

canceled or rushed, so that communication and coordination between

team members are disrupted so that the smooth running of tasks is

hampered

2. Unskilled and inexperienced nurses tend to depend on or take refuge

in capable team members or team leaders

3. Accountability in the team is blurred

4. Less effective if poorly set up

9.5.3 Case Nursing Practice Model

The case method is a method in which the nurse is responsible for

providing care according to the needs of the client during his or her

service, the ratio of one nurse to one client. Clients are cared for by

different nurses for each shift and there is no guarantee that clients will

be cared for by the same nurse the next day. The person in charge in this

model is the nurse manager. In this model, the nurse provides

comprehensive nursing care to a client so that they know what to do with

the client well, so that the client feels satisfied and feels safer because he

knows the nurse who is responsible for him. With this model, all nursing

staff are required to have professional quality and require a large number

of professional nursing staff. This model is very suitable for use in

isolation rooms or intensive rooms such as ICCU rooms, ICU HCU,

hemodialysis and others. In this model, nursing care is carried out based

on the view that for the complete resolution of nursing cases based on

various available resources (Nursalam, 2022).

Figure 9.3: Case Nursing Practice Model (Nursalam, 2022)

Advantages:

1. Nurses better understand case-by-case (comprehensive nursing)

2. Managerial evaluation system made easy

3. Motivating nurses to always be with clients during their duties

4. Overall task satisfaction is achievable

Debilitation:

1. The nurse in charge has not been identified

2. It takes a lot of energy and has the same basic abilities

3. The workload is high especially if the number of clients is large so

that simple routine tasks are missed.

9.5.4 Primary Nursing Practice Model

Primary nursing is a method of providing nursing care in which

professional nurses are responsible and responsible for the client's

nursing care for 24 hours/day, from the time the client enters and leaves

the hospital. This model can encourage the practice of nurse

independence, there is clarity between the planner and the

implementation of nursing care. There is a very strong and continuous

relationship between clients and nurses (Nursalam, 2022). The person in

charge in this model is the primary nurse (PP). Responsibilities include

client assessment, planning, implementation and evaluation of nursing

care from the moment the client enters the hospital until the client is

declared home, this is the main task of the PP assisted by an associate

nurse (PA). PP coordinates all care activities provided to clients and

communicates them with fellow nurses and other health workers. In

addition, PP plays a role as a health educator, advocate, decision maker

and continuity in nursing care (Sumijatun, 2017)

This primary nursing will create an opportunity to provide

comprehensive nursing care, where nursing care is client-oriented.

Assessment and preparation of the client's nursing care plan under the

responsibility of the primary nurse, and the associate nurse who will

implement the nursing care plan in nursing actions. The Primary Nursing

Care Model requires certain qualifications because PP must be

professional nurses (Register Nurses) who take care of clients starting

from assessment, diagnosis, making plans, implementing and evaluating.

In the implementation of PP activities, it is assisted by PA. So the role of

PA is to assist during the implementation of actions. PP will take care of

4 – 6 clients/clients for 24 hours (Maria Bakrie, 2017)

Figure 9.4: Primary Nursing Practice Model (Nursalam, 2022)

Advantages:

1. Nurse autonomy increases, as motivation, responsibility and

responsibility increase

2. Ensuring continuity of nursing and holistic care

3. Increased nurse-client relationships

4. There are clear responsibilities and responsibilities

5. This method supports professional services

6. Creating good collaboration

Debilitation:

1. The required costs are expensive because more professional nurses

are used

2. Assistant nurses, feel that they do not have authority so that it can

cause misunderstandings in communication.

3. Nurses may not have enough control of the case so they cannot

conduct a proper assessment or prepare a treatment plan

appropriately.

9.5.5 Modular Nursing Practice Model

This practice model is a combination of the primary model and the team

model. The organization of nursing services or care carried out by

professional nurses, namely PP and non-professionals, namely PA for a

group of clients from admission to the hospital until they go home, is

called total or total responsibility. For this method, a nurse who is

knowledgeable, skilled and has the ability to lead is needed. Ideally, 2-3

nurses for 8-12 clients (Maria Bakrie, 2017). All of the above models can

be used to organize nursing services/care according to the situation and

conditions of the room, the number of nurses and the ability of existing

nurses. The number of nurses must be balanced according to the number

of clients. In addition, the existing categories of nursing education need

to be considered in accordance with the duties and responsibilities that

will be imposed (Dedi, 2020).

Team activities as a unit have a holistic view of each client's needs, care

is provided from the time the client enters the hospital until the client

goes home. The advantage of the modular method is that the quality of

nursing services increases because clients receive comprehensive nursing

services according to the client's treatment needs. Not many registered

nurses (nurses) are used so that costs become more effective. Even if the

provision of nursing care using this method is carried out by two to three

nurses, the greatest responsibility remains on the professional nurse.

Professional nurses have an obligation to guide and train non-

professionals. If a professional nurse as a team leader in modular nursing

does not enter, the duties and responsibilities can be replaced by another

professional nurse who acts as a team leader.

Figure 9.5: Modular Nursing Practice Model (Maria Bakrie, 2017)

Advantages:

1. The team supports group development and productivity

2. Nursing care is provided comprehensively

3. Improved continuity and coordination of care

4. Increased client satisfaction

5. Cost-effective

Debilitation:

1. Few registered nurses are used to address unexpected client

conditions.

2. Experience and skills of a team leader are required.

3. The right mix of skills is required.

9.6 The Four Pillars of MPKP

9.6.1 Pillar 1 with a nursing management approach

Planning; formulation of vision, mission, philosophy, policies and short-

term, daily, monthly, and yearly plans); organizing by compiling

organizational structures, service schedules and client allocation lists;

Direction of delegation activities, supervision, creating motivation, time

management, effective communication throughout nursing service

activities to clients.

9.6.2 Pillar 2 with HR reward system

This pillar focuses on human resources; the process of receipt, job

selection, orientation, work assessment and nursing staff.

9.6.3 Pillar 3 with a professional relationship approach

This third pillar is professional relationships, both internal and external.

Internal professional relationships, namely between health workers,

between nurses themselves. External professional relationship, namely

the relationship between the giver and the recipient of the service

(client).

9.6.4 Pillar 4 with a nursing care management approach

Pillar four focuses on providing nursing care by implementing the

nursing process.

9.7 Activities in MPKP

Nurse activities in the nursing care model room with a team model

(Ali Maghfuri, 2015)

9.7.1 Weigh Accept or Pass Client

Weighing or passing is a routine activity as a form of client handover

managed between one shift and another before and after the nurse carries

out her duties. Weighing and accepting is carried out to find out the

client's condition carefully according to the current client's condition. In

the pass, some important information will be conveyed about the actions

that will be and have been taken, and can provide a broader clarity that

cannot be described in writing in the report writing activity.

The pass activity should be carried out after the nurse reads the previous

guard shift report or resume report, so that when the pass activity is

carried out, the nurse already has an idea of the condition of the client

being delivered. Client pass activities should be carried out by nurses

who are directly responsible for providing nursing care to nurses who

will be responsible for providing care on the next shift. This is intended

to avoid forgetfulness or mistakes in the service activities that will be

provided to the client. In the team assignment method, passes can also be

made by the team leader to the next team leader.

The pass activity should be followed by the head of the room, the team

leader and all nurses who are on duty at that time and who will be on

duty. This is intended to be able to provide clear (real) information about

the client's situation and conditions and make it easier to receive the

overflow of tasks, as well as as input material when carrying out the pre-

conference. In addition to the activity of weighing and receiving clients,

it is generally also followed by weighing and receiving goods/tools,

medicines, money and so on. At the time of this activity, what needs to

be conveyed is the number and condition of goods or tools at the time the

pass is carried out. In order for the weighing and acceptance activities to

be accounted for, there must be written evidence signed by both parties.

9.7.2 Pre Conference

Pre Conference is an activity carried out to prepare for service activities

at the beginning of the service shift. This activity is very effective in

discussing activity plans that require feedback or special responses,

meaning that the response is less ethical if delivered in front of the client

when the consideration is carried out. During the pre-conference

activities, all participants can freely express their opinions. This activity

should be carried out briefly so as not to interfere with the smooth

running of nursing services. This activity is under the responsibility of

the head of the room or the team leader who has been determined.

9.7.3 Middle Conference

Middle conference is an activity to discuss activities that have been

carried out in the middle of the service time, this activity is intended to

get an early evaluation of the nursing care that is being carried out and

improve planning if necessary. This activity is usually carried out briefly

on the sidelines of activities attended by the team leader and its

members.

9.7.4 Post Conference

At this stage, the activity focuses on the discussion of the actions that

have been implemented and the next program plan. Generally, this

activity is carried out before the weighing and receiving activity in the

next shift. This activity was attended by all nurses and room heads as the

person in charge.

9.7.5 Implementation of Foster Care Activities

At this stage of the activity, nurses carry out nursing care activities

starting from assessment, planning, implementation to evaluation

activities. At this stage, the team leader or room head can carry out his

managerial activities, such as supervision of the implementation of care,

coordination with other health teams. Furthermore, one of the existing

assignment methods will be discussed, on this occasion the team nursing

care will be discussed, considering that this method is widely applied in

several hospitals, especially hospitals in the regions.

9.8 Characteristics of Professional Nursing

Practice

There are 6 characteristics of professional nursing practice (Ariga, 2022):

1. Otoritas

A nurse has authority according to her expertise. This will affect the

parenting process through professional roles.

2. Accountability

A nurse has responsibilities to clients, herself, and the profession,

and has responsibilities in accordance with applicable legal

provisions. Making decisions related to parenting.

3. Independent Decision Making

A nurse according to her authority can make decisions based on solid

knowledge and use a scientific approach. This is expected to solve

the client's problem.

4. Collaboration

A nurse can collaborate, both cross-sectoral and cross-program, by

establishing working relationships across various disciplines. This is

done to help solve the health problems that the client is experiencing.

5. Defense or support

A nurse can act to fulfill the client's right to quality nursing care by

intervening for the client's benefit in addressing her health problems.

Nurses can also deal with other parties more broadly.

6. Facilitate

A nurse has the ability to empower clients in an effort to improve

their health by maximizing the potential of the organization and the

client system with families in nursing care.

EVIDENCE-BASED NURSING PRACTICE

10.1 Concept of Evidence-Based Practice

In the last few decades, nurses have been part of a movement of change.

The direction of nursing education since the 1960s has established

nursing as an applied science and brought this profession to the era of

knowledge. In the 1990s, knowledge was just seen as insufficient to

influence better patient outcomes. It is necessary to change the new

knowledge into a form that is more clinically useful and can be applied

effectively in the context of the nursing system and has an impact on

health (Stevens, 2013).

Evidence-based practice is a problem-solving approach to health care

that integrates the best evidence from a study with clinical expertise and

patient preferences and values to make the best decisions about patient

care (Melnyk & FineoutOverholt, 2023). Evidence-based nursing

practice has been described as an ideal problem-solving approach as well

as the best evidence-based practice resulting from a well-designed

research project (Abuadas, 2021).

Evidence is a collection of facts that are believed to be true. External

evidence is obtained through rigorous research (e.g. randomized

controlled trials [RCTs] or predictive studies) and is intended to be

generalized and used in other settings. An important question when

implementing this external evidence is whether clinicians can achieve

the same outcomes as their patients achieved in the studies they

reviewed. In other words, whether the research findings can be translated

into a real clinical setting with the same outcomes.

Instead, internal evidence is obtained through the initiation of practices

such as QI. Researchers generate new knowledge through rigorous

research and EBP provides clinicians with processes and tools to

translate external evidence into clinical practice and integrate it with

internal evidence collected from patients in a hospital or health system to

improve healthcare, patients, and out-of-cost outcomes (Melnyk &

Fineout-Overholt, 2023).

The evidence-based form of nursing is important for nurses as well as the

nursing profession because this practice provides several broad benefits

such as assisting nurses in building a body of science, minimizing the

gap between education, research, and nursing practice, standardizing

nursing practice, increasing patient clinical output, improving nursing

quality, and lowering healthcare costs (Abu-Baker et al., 2021).

Several research studies in various countries show that the application of

evidence-based approaches is a complex activity and the implementation

of evidence-based practices is slow and inconsistent (Abuadas, 2021).

For Indonesia, the application of evidence-based nursing practice for the

time being is still not optimal or still relatively low even though quite a

lot of nursing research results have been produced from both educational

and service institutions (Irmayanti, Malini & Murni, 2019).

10.2 Perbedaan Evidence-based Practice,

Research, dan Quality Improvement

Evidence-Based Practice (EBP) is different from research or Quality

Improvement (QI). Research uses a rigorous scientific process to produce

new knowledge. QI or quality improvement is a systematic approach to

understand the processes towards the desired patient outcome. In

general, QI uses the Plan Do Study Act (PDSA) model to try to

implement new processes to evaluate how they affect outcomes in the

health care system.

EBP uses a seven-step process that includes a combination of rigorous

critical appraisal and synthesis of a Body Of Evidence (BOE), clinical

expertise, and patient and family preferences or values, to make the best

decision regarding patient care (Melnyk & Fineout-Overholt, 2023).

The following is a brief description of the seven steps in the EBP

(Melnyk & Fineout-Overholt, 2023) and will be explained in more detail

in the next section:

1. Fostering a spirit of inquiry (questioning) in an EBP environment

and culture

2. Asking clinical questions in PICOT format

3. Systematically searching and gathering the best and most relevant

evidence

4. Critically evaluate evidence

5. Integrate the best evidence with clinical expertise and valuable

preferences from patients/families to make the best clinical decisions

6. Evaluate outcomes from practice decisions or changes based on

evidence

7. Disseminate externalities

10.3 Stages of Evidence-Based Practice

Evidence-based practices or better known as EBPs contribute to

improving patient care and outcomes. There are seven stages in EBP

where the first stage is referred to as stage zero because this stage is the

foundation of EBP, so the numbering of stages will start from zero (0) to

six (Melnyk et al., 2010).

1. Step 0 (Zero)/Beginning: Cultivating a spirit of questioning

(inquiry).

At this stage, the nurse has started asking something related to

treatment. Nurses begin to have curiosity about something that needs

to be studied more deeply. An example of a question is for example

in a patient with head trauma, how the supine position affects

intracranial pressure compared to raising the head of the bed 300.

Without this spirit of inquiry, the next stage in EBP is impossible.

2. Step one: Ask clinical questions in PICOT format.

The inquiry or question in this format takes into account the patient

population (P), the intervention or area of specialization (I), the

comparison group or intervention (C), the outcome (O), and the time

(T). The PICOT format provides an efficient framework for

electronic database searches to find relevant articles for the clinical

question.

One example question in PICOT format is as follows: "In acute care

hospitals (patient-P population), how does the presence of a rapid

reaction team (intervention-I) compared to the absence of a rapid

reaction team (comparator-C) affect the number of cardiac arrest

events (O-outcome) over a three-month period (T-time)?

3. Step two: Find the best proof.

The use of questions in the PICOT format will make the search for

evidence more efficient. The PICOT format helps identify key words

or phrases in a row and then combine them.

For the example above, the key word is "rapid reaction team",

followed by "cardiac arrest", and then it can be followed by other

words in the PICOT question. The final step in the search is to

combine the search results and make the search effective with certain

criteria such as "human subject" or "Indonesian" to limit the final

search results.

4. Step three: Critically assess the evidence.

After obtaining selected articles for review, they are assessed to

determine which ones are most relevant, valid, reliable, and reliable,

and applicable to clinical questions. Some questions that can help in

evaluating the value of a study, for example whether the results of

the study are valid. The validity of the study centers on whether the

research method is rigorous enough to make the findings as close to

the truth as possible. For example, whether the researcher uses

random techniques, whether he uses valid and reliable research

instruments.

The next question in assessing the evidence is what the results of the

study are and whether the results are important. For the intervention

study, the reliability question of this study answered whether the

intervention worked and had an impact on the outcome, and how

likely it was to achieve the same outcome in other similar clinical

practice settings. For qualitative studies, this includes assessing the

research approach in accordance with the study objectives as well as

assessing other aspects of the research such as whether the results

can be confirmed.

Another question that can be used in assessing the evidence is

whether the results of the study helped me (in this case the

researcher) in the care of my patients (in this case the researcher's

patients). Questions related to the implementation of this study

include clinical considerations such as whether the subjects in the

study are similar to the researcher's current patients, whether the

benefits outweigh the risks, feasibility or feasibility, cost-

effectiveness, and patient preferences and values. After assessing

each study, the next step is to synthesize the studies to determine

whether they lead to similar conclusions, which then supports a

decision or change in the EBP.

5. Step four: Integrate the evidence with clinical expertise and patient

preferences and values.

Research evidence alone is not enough to justify a change in nursing

practice. Clinical expertise, based on patient assessments, laboratory

data, and data from the outcomes of management programs, as well

as patient preferences and values are important components of EBP.

There is no magic formula for how to weigh each of these elements,

the implementation of EBP is greatly influenced by clinical and

institutional variables.

A simple example is the strong evidence that the incidence of

depression can decrease in patients with burns if the patient attends a

specific therapy session before being discharged from the hospital.

Nurses want to implement it, but the hospital states that there are

constraints in the budget for this. This kind of thing can hinder the

implementation of an EBP.

6. Fifth step: Evaluate the outcome of a practice decision or change

based on evidence.

It is important to monitor and evaluate any changes in outcomes after

the implementation of the EBP so that positive impacts can be

supported and negative impacts can be remedied. Interventions based

on rigorous experimental studies do not necessarily have the same

impact. Monitoring the effects of an EBP change on nursing quality

and outcomes can help clinicians identify gaps in implementation

and more precisely identify which patients benefit the most.

Monitoring can help find the cause why the results differ from what

was reported in the research literature review.

7. Sixth step: Disseminate the EBP results.

Clinicians are able to achieve excellent outcomes for patients with

EBP, but often this success experience is not shared with colleagues

or healthcare organizations. This can result in duplication of

unnecessary efforts. Some ways to disseminate or disseminate

successful change initiatives are through presentations within

internal institutions, at the regional level, national conferences,

journal publications, and also professional newsletters.

10.4 Evidence-Based Practice Model

Nurses and other healthcare professionals have developed several EBP

models that help in the implementation of EBP. These models serve as a

guide that integrates the latest research to create the best patient care

practices. In addition to assisting nurses in integrating credible evidence

into their care practices, these EBP models can help ensure the overall

implementation of EBP projects and the optimal use of time, including

the use of existing resources.

It must be understood that there is no single EBP model that meets the

needs of every hospital or every patient condition. Nurses need to

understand how to identify the EBP model that best suits their individual

EBP needs. Below is a brief explanation of some of the existing EBP

models (Christenbery, 2017).

10.4.1 Model Iowa

The Iowa model focuses on the entire health care system including

patients, practitioners, infrastructure, to implement, and guide practice

decisions based on the best available research and evidence. This model

is widely used in the United States and was developed about 27 years

ago and has passed significant reviews and revisions in 2017.

10.4.2 Model Stettler

The Stetler model was first developed in 1976 and was updated in 1994

and in 2001. This model allows practitioners to assess how research

findings and other relevant evidence are implemented in clinical practice.

This model examines how to use evidence to create change that drives

patient-centered care.

10.4.3 Ottawa Research Usage Model

The Ottawa Model is an interactive model that describes research as a

dynamic process of decisions made and actions taken by interconnected

stakeholders.

10.4.4 Promoting Action on Research Implementation in Health

Services (PARiHS) Framework

The PARiHS framework provides a method for implementing research

into practice by exploring the interactions between three key elements:

evidence, context, and facility.

10.4.5 ACE (Academic Center for Evidence-based practice) Star

Model of Knowledge Transformation

As a framework, the ACE Star model helps to systematically integrate

the best evidence into practice. The model includes five main stages that

describe the forms of knowledge in relative order. Research moves

through a cycle combined with other forms of knowledge before

interaction into practice occurs.

10.4.6 Advancing Research and Clinical practice through Close

Coordination (ARCC)

ARCC increases the use of EBP among advanced practitioner nurses as

well as nurses who provide direct care. The model can also identify a

network of stakeholders that support the EBP project. In addition, this

model emphasizes the readiness of health service organizations and the

identification of facilities and barriers.

10.4.7 Model Johns Hopkins Nursing Evidence-Based Practice

(JHNEBP)

The JHNEBP model applies a problem-solving approach to clinical

decision-making. This model is designed to meet the EBP needs of the

nurse provider directly by using a simple three-step process, known as

PET, including: Practice question, Evidence, and Translation. Practice

questions are the identification of EBP questions using a team approach.

Evidence in this case is a team that searches, assesses, provides a value

for the strength of the evidence, and explains the quality of the evidence,

as well as makes a recommendation for practice based on the strength of

the evidence. At the translation stage, feasibility or feasibility is

determined, action plans are prepared, and changes are implemented and

evaluated. The findings were presented to health organizations and the

wider nursing community.

This model places emphasis on individual use. A well-developed toolkit

provides nurses with guidance on question development, evidence

assessment scales, and assessment guides for various forms of evidence.

10.4.8 Knowledge-To-Action Process (KTA) Framework

The KTA model is a model of knowledge creation and knowledge

integration through several important stages. This model can be well

adapted for individual, team, and healthcare organization use. The model

is also based on the theory of planned actions, which makes it adaptable

to a variety of settings. In addition, this model also breaks down the

knowledge-action process into manageable parts.

10.5 Evidence-Based Practice Model

The results of the study by Speroni et al. (2020) show that more than

90% of nursing research leaders in America state that their hospitals have

used the EBP model and put its findings into practice. The most

commonly used models are the Iowa model, the Johns Hopkins Nursing

Evidence-based Practice model, and the Advancing Research and

Clinical Practice Through Close Collaboration model. EBP models are

most commonly used for education and training, nurse residency

programs, and research. EBP findings are implemented through policy

and procedure processes, shared governance structures, and EBP

processes.

Evidence-based practice or EBP directs practice towards better patient

outcomes. Therefore, EBP is an important aspect of nursing care. EBP is

widely encouraged at the organizational, national, and international

levels. Nurses need to understand important contextual knowledge about

EBP to be able to produce the best evidence in practice. All nurses,

especially leaders in nursing, are responsible for evaluating the EBP and

how the findings of nursing research are implemented and translated into

practice.

Some of the factors for the success of implementing EBP in health care

include the competence and understanding of nurses regarding the basic

principles of EBP. Opportunities for improvement and improvement

should be provided to nursing staff so that they can take part in

development tasks such as evidence synthesis and implementation of

projects that facilitate EBP, as well as improve practices and other

activities that affect patient outcomes.

The World Health Organization (2017), said that there are 10 factors for

the success of implementing and maintaining EBP infrastructure. Six of

them are related to management, including organizational culture,

governance, mentorship, results feedback, visible and supportive

leadership, and continuous evaluation. The success of EBP's

infrastructure includes library resources, clinical librarians,

dissemination tools, multidisciplinary cooperation and educational

programs.

NURSING EDUCATION SYSTEM

11.1 Introduction

Nursing has a very broad essence because it touches almost all segments

of humanity and humanity as an impact on the health status experienced

both actual and potential. Nursing must be able to view human beings as

a whole and unique, in addition to that nursing must have the ability to

apply complex science and technology as an effort to meet the needs of

patients/individuals. Nursing itself is a profession that has a strong

educational foundation with a clear "body of knowledge" so that it can

be developed as high as possible. Thus, the nursing profession will be

able to actively participate in the Health Service System in Indonesia in

an effort to advance health services in the community which will

ultimately also improve nursing professionalism. To achieve all this, a

nursing education system is needed that is expected to be able to produce

human resources, namely professional health workers (nurses). To meet

quality nursing resources, nursing education institutions have a very

important role in producing quality graduates and meeting the set

standards.

11.2 General Provisions/Terminology in

Nursing Education

Some general provisions/terminology in the academic text of nursing

education are as follows:

1. Nursing is a form of professional service/care that is an integral part

of health services/care, based on nursing knowledge and tips aimed

at individuals, families, groups, and communities, both healthy and

sick which covers the entire process of human life.

2. Nursing is a science that studies the fulfillment of basic human

needs. Nursing science is a synthesis of biomedical, psychological,

social, behavioral, anthropology, and transcultural sciences. The field

of work and the phenomenon that is the object of nursing study is the

deviation or unfulfillment of basic human needs (bio-psycho-social-

cultural and spiritual) starting from the level of the whole individual

covering the entire life cycle, which is also reflected in the

unfulfilment of basic needs at the level of functional organ systems,

to the molecular level, to the level of society.

3. Nursing education is an educational process organized in Higher

Education to produce various graduates of Associate Nursing

Experts, Nurses, Masters in Nursing, Specialist Nurses, and

Doctorates in Nursing.

4. Types of nurse education are academic, vocational, and professional

education. Academic education is an education that is directed

mainly at mastering science. Vocational education is an education

that is directed mainly at the readiness to apply certain skills as a

nurse. Professional education is education directed to achieve

nursing professional competence.

5. A nursing education student, hereinafter referred to as a nursing

student, is someone who has been registered and participated in

professional academic activities at Higher Education.

6. Professional services are professional nursing services that use

scientific methods to meet basic human needs due to physical and

mental weaknesses, limited knowledge, and lack of willingness to

carry out daily life activities independently. It is given holistically

and comprehensively, covering physiological, psychological, social,

spiritual, and cultural needs in a humane and caring manner.

7. A nurse is someone who has graduated from higher education in

nursing both at home and abroad that is recognized by the Indonesian

government in accordance with laws and regulations and is

registered.

8. Associate Expert Nurses are nurses who have completed Diploma

Three (D III) Nursing education.

9. Nurses are professional nurses who have completed professional

education in the field of general nursing and have the ability to be a

first professional degree nurse.

10. Master of Nursing is a first professional degree nurse who has

completed a Master's degree in the Master of Nursing program.

11. Specialist nurses are Nurses who have completed Nursing Specialist

education

12. A Doctor of Nursing is a professional Nurse who has completed a

doctorate of nursing education.

13. Lecturers are professional educators and scientists whose main task

is to facilitate, develop, and disseminate science, technology, and the

arts through education, research, and community service in the field

of nursing.

14. Nursing education standards are the minimum criteria for

educational components that must be possessed by nursing higher

education institutions consisting of nursing professional education

standards.

15. Competency standards are the minimum competencies that must be

achieved in nursing education that include knowledge, attitudes, and,

skills.

16. Competence is a set of intelligent actions full of responsibility that a

person has as a condition to be considered capable by the community

in carrying out tasks in a certain field of work. Competencies consist

of main competencies, supporting competencies, other competencies

that are special and related to the main competencies (Decree of the

Minister of National Education No. 045/U/2002). The elements of

competence consist of a) Personality foundation, b) Mastery of

knowledge and skills, c) Ability to work, d) Attitude and behavior in

working according to the level of expertise based on the knowledge

and skills mastered, and e) Understanding the rules of social life in

accordance with the choice of expertise in work.

17. The competence of Indonesian nurses consists of the competence of

nurse practitioners (associate expert nurses and specialist nurses), the

competence of nurse managers and the competence of nurse

researchers.

18. A Certificate of Competency is a letter of recognition of a nurse's

ability to practice nursing throughout Indonesia after passing the

competency test.

19. Nursing Higher Education Institution is an institution that organizes

nursing education in the form of faculties, departments or study

programs that are part of higher education/university/high

school/institutes and academies.

20. The nursing education curriculum, hereinafter referred to as the

curriculum, is a set of plans and arrangements regarding the

objectives, content, and learning materials, as well as the methods

used as guidelines for the implementation of learning activities to

achieve the goals of nursing education.

21. The Indonesian National Qualifications Framework for Nursing is a

leveling of nursing learning outcomes that equalizes formal, non-

formal, informal educational outcomes, or in accordance with the

nursing work structure.

22. Competency Test is a process to measure the knowledge, skills and

attitudes of nurses in accordance with the standards of the nursing

profession.

23. The Registration Certificate is hereinafter abbreviated as STR is

written evidence provided by an authorized institution.

24. Registration is the official recording of nursing staff who already

have a nurse competency certificate and have certain other

qualifications and are legally recognized to carry out their

professional practice and/or work

11.3 Development of Nursing Education in

Indonesia

The development of nursing education is currently directed in line with

the development of science and technology, demographic changes in

population in Indonesia, global trends and complex health problems as

well as the demand for complete and quality health services. The 1983

Indonesian National Nursing Workshop was an important momentum for

the development of nursing in Indonesia which established Nursing as a

profession and mandated that all nursing development activities be

directed towards fulfilling professional criteria, including: having

knowledge, being grown in higher education, carrying out

professional/professional services using scientific methods. This

agreement was followed by a shift in various nursing education

regulations that were originally set by the Ministry of Health and

regulated by the Ministry of Education and Culture. Likewise, education

that originally existed at the SPK and D III levels was developed into

higher education at the Strata 1/profession level.

The first provider of higher education was the Nursing Study Program,

Faculty of Medicine, University of Indonesia in 1985. The opening of

the study program was followed by several state universities such as

Padjadjaran University Bandung in 1994, in 19971998 it was established

at Gadjah Mada University, Airlangga University, Diponegoro

University, Hasanuddin University, Brawijaya University, University

North Sumatra; as well as other private universities such as the

University of Muhammadiyah Jakarta and STIK St. Carolus Jakarta.

Meanwhile, the education of the Nursing Academy with the third

diploma education program is still a large number to date. At the

beginning of its development, the S-1 Nursing education curriculum was

a unity and integration between academic education and professional

education, whose graduates were given a Bachelor of Nursing degree

abbreviated as S.Kp and recognized as professional nurses.

In 1994, the Ministry of Education and Culture of the Republic of

Indonesia issued Decree Number 310/U/1994 concerning the nationally

applicable curriculum for undergraduate health science programs. In this

curriculum, learning academic and professional aspects are integrated

into a single unit. This curriculum was perfected through Decree number

129/U/1998 which made the Bachelor of Nursing education program

implement the nursing professional education curriculum in 2 (two)

stages, namely the academic stage and the professional stage which are a

unit. At the academic stage, graduates get a Bachelor of Nursing degree

abbreviated as S.Kep., and at the professional stage, graduates get a

professional title of Nurse abbreviated as Ns. Thus, the Bachelor of

Nursing (SKp.) degree as a result of the 1985 and 1994 curriculum, has

the same meaning as the Bachelor of Nursing and Nurses (S.Kep. Ns)

degree as a result of the 1998 curriculum. Meanwhile, SPK education

was gradually closed in 1996. This is a follow-up to the implementation

of the 1982 National Health System and the 1983 national workshop

agreement. The arrangement of types and levels of nursing education that

is good and directed is expected to be used as reference material in

developing the nursing profession in the future. The development of

nursing education levels includes the academic level of master's level

education (S-2), namely the Master of Leadership and Management

Nursing, as well as types of specialist level professional education in

various fields of specialized services that have started since 1998 which

include: Maternity Nursing and Community Nursing, Nursing

Medical Surgery Nursing Soul and

Pediatric Nursing. The development of Doctor of Nursing education for

the doctoral level (S-3) began in 2008 at the Faculty of Nursing,

University of Indonesia and is currently being followed by other nursing

institutions.

Since 2008 PPNI, AIPNI and support and collaborate with the Ministry

of National Education through the Health Profession Educational Quality

(HPEQ) project, updating and rearranging the Indonesian Nurse

Competency Standards, Indonesian Nursing Education Academic

Manuscripts, Nurse Education Standards, Indonesian Nurse Education

Accreditation Form Standards. and all of these standards refer to

Presidential Regulation No. 8 of 2012 concerning the Indonesian

National Qualifications Framework (KKNI) and have been completed

into state documents related to the direction and policy on Indonesian

nursing education. The standards referred to above also refer to the

development of nursing science, the development of the ever-changing

world of work.

11.4 Standards of Nursing Education

The diversity of the quality of nursing graduates nationally encourages

the Association of Indonesian Nurse Education Institutions (AIPNI), the

Association of Indonesian Diploma Three Nursing Education Institutions

(AIPDiKI), and the Indonesian National Nurses Association (PPNI), to

develop educational standards for the fulfillment of quality nurse

resources in fulfilling standardized and quality nursing services. This

activity was facilitated by the Directorate General of Higher Education

of the Ministry of Education and Culture through the Health

Professional Education Quality-Project (HPEQ-Project).

The Indonesian Nursing Education Standards consist of Diploma Three

Education Standards, Nurse Education, Master's Education, Nursing

Specialist Education and Doctoral Education Programs. The Indonesian

Nursing Education Standard is an equalizer of the quality of education

that must be met by Nursing Education Institutions in Indonesia, covering

seven standards, namely:

1. Standard 1 Vision, Mission, Goals, Objectives, and Achievement

Strategies This standard is a reference for excellence in the quality of

the implementation and strategy of the nursing education program to

achieve future goals.

2. Standard 2 Governance, Leadership, Management System, and

Quality Assurance

This standard is a reference for the excellence of the quality of

governance, leadership, management system, and quality assurance

system of nursing education programs as an integrated unit which is

an important key to the success of nursing education programs.

3. Standard 3 Students and Graduates

This standard is a reference for the quality excellence of students and

graduates. Nursing education programs must have a selection system

that is reliable, accountable, transparent and accountable to all

stakeholders. This standard is an effort by the program to provide the

competencies needed by students to become graduates who are able

to compete.

4. Standard 4 Human Resources

This standard is a reference for excellence in the quality of human

resources, as well as how the nursing education program should

obtain and utilize human resources and provide excellent service to

realize the vision, carry out and carry out the mission, and achieve

the goals of the nursing education program.

5. Standard 5 Curriculum, Learning, and Academic Atmosphere This

standard is a reference for excellence in the quality of curriculum,

learning, and academic atmosphere to ensure the quality of the

implementation of nursing education programs.

6. Standard 6 Financing, Facilities and Infrastructure, Clinical Learning

Facilities and Information Systems

This standard is a reference for excellence in the quality of financing,

facilities and infrastructure, including clinical learning vehicles, as

well as information systems that are able to ensure the quality of the

implementation of nursing education programs.

7. Standard 7 Research, Community Service, and Cooperation

This standard is a reference for excellence in the quality of research,

services and/or community service, and cooperation held related to

the development of the quality of nursing education programs.

11.5 Type, Level and Burden of Nursing

Education Study

Nursing education in Indonesia refers to Law No. 20 of 2003 concerning

the National Education System.

1. Types of nursing higher education include:

a. Vocational Education; That is the type of diploma education

according to the level which is directed mainly at the readiness to

apply and master certain nursing skills as a vocational nurse.

b. Academic Education; namely higher education for undergraduate

and postgraduate programs (masters, doctors) which is directed

mainly at mastering and developing the discipline of nursing.

c. Professional Education; namely education directed to be able to

solve science and technology problems in the field of nursing to

be able to make strategic decisions with accountability and full

responsibility for nursing actions under their responsibility.

2. The level of nursing education includes:

a. Diploma Education Three Nursing

b. Nurse Education

c. Master's Education in Nursing

1) Nursing Leadership and Management

2) Nursing Science

d. Nursing Specialist Education consists of:

1) Maternity Nursing Specialist

2) Pediatric Nursing Specialist

3) Medical Surgical Nursing Specialist

4) Psychiatric Nursing Specialist

5) Community Nursing Specialist

6) Critical Care Specialist

7) Geriatric Nursing Specialist

8) Family Nursing Specialist

9) Occupational Health Nursing Specialist

The specialist education mentioned above will develop in

accordance with the needs of the community for nursing services

and the need for knowledge development.

e. Nursing Doctoral Education

3. Study Load

Nursing education is carried out with a semester credit system as

mandated by Law number 20 of 2003 concerning the National

Education System. The burden of nursing education studies for all

levels according to the Decree of the Minister of National Education

No.

232/U/2000 as follows:

a. Diploma Three in Nursing has a study load of 110-120 credits

b. Nurse education has a study load at the academic stage between

144-160 credits, and at the Profession stage has a study load

between 36-50 credits

c. The Master of Nursing has a study load of between 36-50

credits.

d. Nursing Specialists have a study load between 36-50 credits

e. The study load of the doctoral program for participants who have

a master's degree (S2) in the same field is at least 40 credits

scheduled for four semesters with a study duration of ten (10)

semesters. The study load of the doctoral program for

participants with a master's degree (S2) is not in the same field of

at least 52 credits scheduled for five semesters with a maximum

study duration of eleven (11) semesters.

So the nursing higher education system can be described with the

following scheme:

Figure 11.1: Nursing Higher Education System

11.6 Nursing Competencies Based on

Education Level

The competence of nursing higher education graduates is in accordance

with the KKNI level. The following describes the relationship between

the type of education, the type of education, the graduate degree and

competence. Table 11.1 is competencies based on the current level of

education. Meanwhile, table 11.2 shows the relationship between the

level of education, the Indonesian National Qualifications Framework

(KKNI) in the field of nursing and the length of education.

Table 11.1: Competencies Based on Current Education Levels

(Standards

Nursing Profession, 2020)

Types of

Education

Level of

Education

Graduate

Degree Competence

Vocational Diploma

Three

Nursing

Expert

Associate

of Nursing

(Amd.Kep

)

After completing diploma

three, graduates are able to

carry out their work activities

in accordance with the 3

domains of competence of

Diploma Three in Nursing

Profession Nurses Nurses (ns) After completing

professional education,

graduates are able to carry

out their work activities in

accordance with 3 areas of

competence

Nurses

Specialist

Nursing

Ns. Sp.

Kep

After completing the

professional education of

Nursing Specialist, graduates

are able to carry out their

work activities in accordance

with the 3 domains of Nurse

competence

Specialist

Academic Magister

Nursing

(*)

M.Kep After finish

education

Master's degree, graduates

are able to carry out their

work activities in accordance

with 3 domains of

competence

Master of Nursing

Doctor

Nursing

Dr.Kep After completing doctoral

education, graduates are able

to run

Activities

his work is in accordance with

the 3 domains of Doctoral

competence

Nursing

Table 11.2: Levels and Levels of the Indonesian National Qualification

Framework (KKNI) in Nursing (KKNI, 2012)

Level of

Education

KKNI Level

Field

Nursing

Study

Load

Vocational

Academic

Study Load

Study

Load

Profession

Diploma

Three

Nursing

55 110-120

credits

- 36-50

credits

Nurses 7 144-160 credits

Nurses

Specialist

Nursing

8 36-50 credits

Magister

Nursing

(*)

8 36-50 credits

Doctor

Nursing

9 50 credits

(matriculation

credits/semester

for 2 semesters

The education providers mentioned above must meet the education

implementation standards which include 7 standards including 1) Vision,

Mission, Goals, Goals and Achievement Strategy; 2) Governance,

leadership, management system and quality assurance: 3) Students and

Graduates; 4) Human Resources; 5) Curriculum, Learning and Academic

Atmosphere; 6) Financing, Facilities and Infrastructure, Information

Systems; 7)

Research, service/Community Service and Cooperation (as described in

point 11.4).

11.7 Vocational, Academic and Professional

Education Degree

Indonesian Nursing Higher Education levels and degree designations

include:

1. Graduates of the third diploma education program get the title of

Associate Nursing Expert (AMd. Kep.)

2. Graduates of the Nurse education program get the title of Nurse (Ns.)

3. Graduates of the Master of Nursing education program get a Master

of Nursing degree (M.Kep.).

4. Graduates of the Nursing Specialist education program get a Nursing

Specialist degree (Sp. Kep. according to the branch of nursing)

5. Graduates of the doctoral education program get an academic degree

of Doctor of Nursing (Dr.Kep.).

11.8 Nursing Education Graduate Certification

Certification is a sign of proof of the validity of the end of the process, in

this case the nursing education process. Certification of nursing

education graduates is given in the following forms/types:

1. Diplomas are given by universities to graduates who have completed

certain levels including: triple diploma nursing education, nurse

education, Master of Nursing education, nursing specialist nurse

education and nursing doctoral education.

2. A certificate of competence as proof of the completion of the

continuing education program, is given by the Nurse certification

body as a sign that it has passed the nurse competency test.

To provide assurance to the community, that nurse services are provided

by competent nurses need to be proven through competency tests that

have been carried out by authorized institutions. Since 2007, the

competency test system has been developed by professional

organizations (PPNI) for nurses, especially those who will work abroad

and new graduates where the implementation is carried out by the

National Committee for Nurse Competency Tests (KNUKP). With the

issuance of the Ministry of Health Number 1796 of 2011 which regulates

the Registration of Health Workers, including Nurses, every new

graduate must take a competency test to get a Registration Certificate

(STR). STR is a requirement for nurses to practice began in 2013. The

implementation of the competency test based on the regulation of the

minister of health is the authority of the Indonesian Health Workers

Council (MTKI). In carrying out its duties, MTKI collaborates with the

Competency Test Development Institute (LPUK) to develop a system

including competency test questions. Evidence of a nurse's graduation in

the competency test in the form of a Registration Certificate (STR) is

identical to Registered Nurses (RN) abroad.

11.9 Quality Assurance of Nursing Education

In maintaining the quality of graduates (intake, process and output),

every nursing education provider must carry out a good education quality

assurance program Quality assurance programs can be carried out

internally and externally. Internal quality assurance is carried out by

forming an internal quality assurance body, while external quality

assurance can involve independent quality assurance institutions

recognized by the government.

1. Internal audits by educational institutions through the development

of higher education standards at the institutional level refer to

SNPT/SNPTK (for nursing) and SPMI programs.

2. External accreditation by the independent accreditation institution for

health higher education (LAM PTkes) Accreditation by LAM-PT

Kes is carried out by assessing the process and performance as well

as the relationship between the objectives, inputs, processes and

outputs of a university or nursing study program through formative

assessment. The principle of accreditation is Continuous Quality

Improvement.

Meanwhile, the utilization of graduates in various health service and

educational facilities is based on competence, which is then arranged in

the professional nurse career path system.

PROFESSIONAL STANDARDS IN NURSING

PRACTICE

12.1 Introduction

Nursing is a professional service/care is a humanistic, comprehensive

approach based on nursing knowledge and tips, based on the real needs

of patients, by mentioning professional standards and nurse ethics as the

main requirement (Nursalam, 2014). According to the Ministry of Health

of the Republic of Indonesia in 2005, nurses play an important role in the

provision of quality health services in clinics/hospitals, because the care

they offer is sourced from a specific bio-psycho-social-spiritual approach

and is applied for 24 hours a day continuously, which is a clear

advantage compared to other health service professions (Christiana,

2019). One of the health services provided by health workers is medical

assistance services, where part of nursing duties also includes nurse work

(Hidayat, 2011). Nurses as a profession, both in terms of quantity and

interaction with patients, have existed longer than other professions, so

their role in improving the quality of services, especially in the field of

nursing, is very crucial (Mubarak, 2009). Nursing care is an approach to

problem-solving that enables nurses to organize and deliver nursing care.

The standards of care listed in the Standards of Clinical Practice of

Nursing consist of five phases of nursing care: 1) Assessment; 2)

Diagnosis; 3) Planning; 4) Implementation; and 5) Evaluation. One of

the benefits of good nursing implementation is to improve the quality

and quality of nursing care (Kozier, 2010). In this study, we will discuss

how to compare the application of nursing care in the evaluation step.

12.2 Professional Standards in Nursing

Practice

The definition of Nursing Standards is: minimum expectations in the

provision of guaranteed, efficient and ethical nursing care. The standard

of care is the responsibility of the nursing profession, to protect residents

from the actions of the nursing profession (Hidayat, 2011).

Nursing work standards are guidelines and measures for the

implementation of nursing work, in order to be in accordance with

professional values, ethics and the principle of responsibility. Standards

are dreamed and achievable levels of performance that are compared to

real work. This is guided by guidelines on what activities are

inappropriate or unacceptable. The Standard of Nursing Practice is a

statement of what a registered nurse needs to practice nursing. Overall,

this standard reflects the values of the nursing profession and explains

what is expected of its members in the nursing profession.

12.2.1. Professional Practice Standards I Assessment

Nurses collect data on the health status of clients in a systematic,

thorough, accurate, concise and continuous manner.

Rationale

Nursing assessment is a fundamental part of the nursing process that

aims to obtain primary information about patient health that is used to

develop nursing diagnoses and nursing interventions.

Structure Parameters

1. The data collection methods used can ensure:

a. A systematic and complete data collection.

b. Completeness of records.

c. Information is easily obtained.

d. Guaranteed Confidentiality.

2. Training centers have maintained data collection tools are an integral

part of the patient data collection system

3. The form of recording is based on the nursing process. Be concise,

thorough, precise and continuous.

4. Patient medical records are part of the nursing data collection

system.

5. In practice, there are data checking tools and can be used if needed

6. In practice, there is a special place to store data that can be used to

retrieve it again if needed.

7. Availability of supporting resources and the environment.

Process Standards

1. Collection data Done through interview

observation, physical examination and additional data

(laboratory results and diagnostic tests) and other document studies.

2. Sources of information are clients, family members or close people,

health teams, patient records and other information.

3. The client actively assists at the time of the assessment.

4. The information collected focuses on identifying:

a. Patient's current condition

b. Previous patient condition

c. State of body function (Physical)

d. Circumstances at the time of the problem (coping)

e. State of cultural culture

f. Mental state

g. Reactions to treatment

h. Hope for maximum health

i. Possible case risk

5. Evaluation Standards

a. Data is stored and analyzed according to existing standards and

formats.

b. The information generated is accurate, up-to-date, and meets the

needs of the client.

Standard II Nursing Diagnostics

Nurses analyze assessment data to formulate nursing diagnoses.

Rationale

The development of nursing interventions to realize the cure, prevention

and improvement of abnormalities as well as the rehabilitation of

patients' health is the basis of nursing diagnosis.

Structure Parameters

The environment in which the practice provides opportunities;

1. For colleagues, exchange information to enforce nursing diagnoses

2. There are rules regarding the transfer of knowledge from survey

results to determine the correct diagnosis of nursing.

3. Exist source power and program development

Professional tenaga

4. The patient's diagnosis is recorded systematically.

Process Standards

1. Analysis and presentation of processed data, discovery of problems

in patients and enforcement of nursing diagnosis are diagnostic

processes.

2. The nursing diagnosis section includes Problem (P), Etiology (E),

Symptom (S) or includes Problems with Etiology (PE).

3. Collaboration, establishing communication with patients, other

health workers to validate nursing diagnoses.

4. Review and improve diagnoses sourced from the latest data.

Evaluation Standards

1. If possible, the nursing diagnosis is confirmed by the patient

2. Important and significant nursing diagnoses made jointly with peers

3. To facilitate intervention, the implementation, evaluation and

research of nursing diagnosis must be documented.

Standard III Nursing Intervention

Intervention Nursing Compiled by nurse use

solve problems and improve patient health.

Rationale

Nursing intervention is a follow-up based on a nursing diagnosis.

Structure Parameters

Practice places available:

1. Tools will be needed to intervene.

2. The availability of data storage devices, therefore, can be discussed.

Process Standards

1. Intervention is the determination of priorities, goals and plans of

nursing action.

2. Collaborate together patient to Preparation

nursing interventions.

3. Nursing planning is individual (as individuals, groups and citizens)

that is the same as the patient's circumstances or needs.

4. Record all action interventions.

Evaluation Standards

1. Patient care intervention preparation

2. The plan describes the solution of nursing diagnosis problems.

3. The outline is written briefly and is easily accessible.

4. Interventions reflect improvements to achieve goals.

Standard IV Implementation of Actions (Impediments)

Nurses implement the actions that have been identified in the nursing

care plan

Rationale

Nurses carry out nursing interventions to obtain the goals that have been

guided by the profession and patient cooperation in nursing activities

affects the desired results.

Structure Parameters

Places of treatment activities include:

1. Nursing activity implementers 2. The

working relationship model is adapted to the

circumstances.

3. Activity procedures as a reference to review and improve activities.

4. Development and ability skill at field Nursing

clinic.

5. Form of referral for nursing services.

Standard Procedure

1. Work with patient moment do Nursing

implementation.

2. Collaborate with other health workers to improve the health status of

patients.

3. Carrying out nursing activities in solving patient problems.

4. Supervise nurses who are under their obligations.

5. To be a service coordinator and advocate for clients to achieve their

health goals.

6. Inform clients about the health status and available healthcare

services.

7. Provide self-care concepts & skills training to clients and families

and help clients modify the areas they use.

8. Assess and monitor the implementation of nursing based on patient

reactions.

Assessment standards

1. Records of nursing actions and client responses are systematically

easily searched.

2. Nursing implementation is acceptable to clients.

3. Measurable evidence according to the target objectives.

Standard V assessment

The nurse assesses the client's health development against actions in

achieving goals, according to the plan and improves the data from the

plan.

Rationale

Nursing is a dynamic process that involves various changes to data,

diagnoses or previous plans. The effectiveness of treatment depends on

repeated evaluation.

Structure Parameters

1. The place of practice ensures: the evaluation process is supported by

the place and the environment.

2. The existence of data as a reference for nurses to improve action

interventions.

3. There is effective monitoring and discussion of nursing cases to

improve accurate intervention options.

Process Standards

1. Organize a comprehensive, timely and sustainable performance

evaluation plan.

2. Utilize basic data and patient responses to measure achievement

towards goals.

3. Validate and analyze new information with colleagues and patients.

4. Collaboration with clients, families to change nursing care plans.

5. Record the results of assessment and planning.

6. Clinic supervision and consultation.

12.2.2 Professional Performance Standards Standard I: Quality

Assurance

Nurses are structured to evaluate the quality and effectiveness of nursing

activities.

Rationale

Assessing the quality of nursing work through job evaluation is a

professional method of duty, i.e. ensuring quality care for clients.

Structure Parameters

1. There are institutional rules in the implementation of quality

assurance.

2. There is an evaluation system between peers and interdisciplinary

that is used in activities.

3. Nurses are part of peer review and assessment design of various

disciplines to assess the results of treatment for actions.

4. There is a program to improve quality assurance and quality that

refers to the benchmark for maintenance activities and is legalized

for the quality of care for service users.

Process Standards

1. The continuous and organized activities of nurses participate in

assessing nursing work:

a. Determine critical indicators and monitoring tools.

b. Data collection and analysis.

c. Make conclusions, feedback and recommendations.

d. Data transmission

e. Make subsequent interventions.

f. Make interventions and conduct periodic evaluations.

2. Nurses apply appropriate and accurate feedback according to the

nursing evaluation program.

Evaluation Standards

1. Evaluation of quality commitment

2. There are stages to eliminate the deficiencies observed by design

valuation nurse against individual part of the

community or existing institutions.

Standard II: Academic knowledge

The responsibility of nurses as a profession must always be updated with

the latest science in nursing activities.

Rationale

The advancement of science and technology, social, economic, political

and educational society expects nurses to always acquire knowledge to

improve professional development.

Structure Parameters

1. Rules that remain provide opportunities and moments for nurses to

participate in activities related to nursing work development.

2. The availability of educational opportunities and spaces in the work

environment.

3. There is an opportunity to collaborate through organizational

activities for the development of the nursing profession.

Process Standards

1. Nurses have an independent learning initiative to keep up with the

development of science and develop their skills.

2. Nurses participate in additional activities such as scientific meetings,

nursing sections.

3. Nurses participate in education and training, scientific meetings or

consultations with other professions.

4. Nurses teach colleagues to find something needed in learning.

Evaluation Standards

1. The more advanced and the increase in the science and expertise of

nurses in applying nursing science and technology.

2. The application of the department's clinical practice utilizes the latest

science and technology.

Standard III: Evaluation

Nurse activity assesses their work according to professional measures

and other linked regulations.

Rationale

Nursing performance evaluation is a way to ensure compliance with

nursing standards and other related regulations.

Structure Parameters

1. There are rules regarding the evaluation of nurses' activities.

2. There is a nurse assessor as a member of the work assessor.

3. There are performance evaluation parameters

4. There are activity evaluation interventions based on standard criteria.

Process Standards

1. The participation of nurses in accordance with the rules and

organized in the work evaluation includes:

a. Standard rules and work evaluation

b. Performance assessment based on standardized standards

c. The formulation of the work evaluation assessment consists of

various areas that are good and those that are lacking

d. Providing feedback and follow-up

2. The use of assessment results to improve and develop the work

ability of nurses.

Evaluation Standards

1. Availability of performance assessment results

2. There were revisions found to the shortcomings during the

performance evaluation.

Standard IV: Equality (Collegial)

Participation in the role of nurses during professional development from

peers.

Rationale

Cooperation between peers with good communication improves the

quality of health services for patients.

Structure Parameters

1. There is a peer review method for work rule regulations.

2. There are nurses who act as peer evaluators who assess the results of

nursing care.

3. The activeness of the role of nurses to cooperate between professions

Engineering Standards

1. The active participation of nurses in carrying out cross-disciplinary

cooperation through a peer review mechanism.

2. The use of the results of cooperation by nurses in carrying out

services.

Evaluation Standards

1. There is an agreement with colleagues

2. Improvement in nursing implementation is based on a meeting

evaluation with peers.

Standard V: Culture

The decisions and actions that nurses take on behalf of clients are

determined based on cultural principles (norms, cultural values, with

professional modules and expectations)

Rationale

Cultural rules in nursing are a benchmark for nurses when making ethical

decisions.

Some special ethical issues that must be of concern to nurses include:

patients refusing treatment, "informed-consent", withdrawal of treatment

to maintain survival, regarding patient confidentiality.

Structure Parameters

1. Nursing ethics delegates available

2. Availability of ethical parameters

3. There are rules about decision-making on ethical issues.

4. There is a professional ethical civilization plan for nurses.

Process Standards

1. Rules of ethics that govern Nursing practice.

2. Patient confidentiality is always maintained by nurses

3. As a defender/companion of the patient is a nurse

4. Provision of nursing care by nurses without judgment, without

discrimination

5. Protect the independence, human dignity and authority of patients

that must be given by nurses in nursing care.

6. Nurse ethical decisions are made with available resources.

Evaluation Standards

1. With the availability of evidence of client records, ethical issues are

identified and discussed at a joint meeting

2. The purpose of continuous development of nurses' work illustrates

the realization of the concept of ethical rules.

Standard VI: Collaboration

Nurse activities always collaborate with clients, the community and all

components of multidisciplinary health groups in patient care.

Rationale

The complexity of care requires a multidisciplinary approach when

dealing with clients. Multidisciplinary collaboration is essential to

improve the effectiveness and efficiency of treatment and to achieve

optimal client health. The collaboration leverages the healthcare

provider's specialized skills to communicate, plan, problem-solve, and

evaluate services.

Structure Parameters

1. When providing health services to clients, a teamwork policy is

followed.

2. Nurses are involved in the formulation of policies related to client

services.

3. Availability of regular meeting schedules.

4. There is a mechanism that ensures patient participation in the team's

decisions.

Process Standards

1. Nurse consultation with representatives of other professions, if

necessary in providing maximum care to patients.

2. The knowledge and expertise of nurses between nurse colleagues can

be integrated into patient care.

3. Nurse activities always involve patients in multidisciplinary groups

4. The nurse acts as a defender/companion of the service recipient.

5. Cooperation between nurses and groups from various disciplines is

very necessary in education, supervision and research programs.

6. 6. Mutual recognition and respect between colleagues for each

contribution.

Evaluation Standards

1. There is a legal aspect that nurses are an integral component of a

group of various disciplines

2. There is evidence of multidisciplinary collaboration on care

interventions.

Standard VII: Research

Nurses utilize research findings in the application of nursing science.

Rationale

The work of nurses who have been recognized as professionals has a

responsibility for the development of the latest approaches in nursing

practice through research.

Structure Parameters

1. There is an institutional policy related to scientific research.

2. There are guidelines for scientific research.

3. Nurses have the opportunity to carry out and participate in existing

research activities at the academic level.

4. There is an opportunity to use facilities related to research results.

Process Standards

1. Nurses determine problem-solving related to activities in research

2. The results of the research obtained are taken into consideration in

investigation efforts.

3. Nurses' obligations to conduct research

4. The application of research results is utilized by nurses

5. Legal protection is prioritized for individuals when conducting

research. Nurses develop, carry out and assess scientific research in

line with the academic level.

6. If necessary, discuss the process of guidance from a specialist, the

nurse will obtain.

7. Nurses are obliged to inform the evaluation of scientific research.

Evaluation Standards

1. Client problems are found and solved with research efforts.

2. There is a fact that nurses' knowledge is continuously tested and

complemented by the results of related research.

3. Nursing practice reflects the use of the latest and existing research

results in the region.

4. The contribution of nurses makes public developments in theory,

practice and research.

Standard VIII: Utilization of Resources

Nurses consider factors related to safety, effectiveness, and cost when

planning and delivering patient care.

Rationale

Nursing activities require efforts to develop more effective and efficient

nursing programs. Nurses collaborate in mapping the use of patient

resources.

Structure Parameters

1. There are rules for the amount of production used in maintenance

services and sub-maintenance

2. Exist source Funding that Approved

appropriate with budgeting.

3. There are clear Standard Operating Procedures for action and

conflict resolution mechanisms

4. There is a record-keeping information applied at the nursing

management level in planning nursing work, managing nursing staff,

directing nursing work, and admission, organization, analysis,

transfer, and mediation to store information needed to assess research

results and work for nurses.

5. There is an Occupational Safety and Health (K3) plan made by the

company.

6. There are important cost control rules.

7. Availability of facilities and infrastructure needed by customers.

Process Standards

1. The nursing department creates and maintains the design of the share

cost.

2. Nurses must have the responsibility to place professional resources

as efficiently as possible and minimize the amount of waste.

3. Nurses control the use of funds from the facility in charge of nursing

for care

4. Nurses analyze monthly budget reports to assess expenditure patterns

and know how adapts its use to changing situations.

5. The nursing department equalizes the total dependents of the

section's activities through the collaboration of other professional

disciplines.

6. Nursing protocols are set based on goals (building a nursing work

support network and responding appropriately to all complaints and

conflicts between nurses and other professions, family mismatches

with work schedules, unfair work tasks and lack of work

orientation).

7. The nurse is responsible for the operation of the equipment.

8. Nurses are responsible for ensuring the level of K3 facilities/health

service units.

Evaluation Standards

1. Availability of routine budget documents for activities can be used as

an illustration of the form of expenditure and changes in cost

estimates

2. The form of employee loyalty to the work group is realized because

performance satisfaction is recognized and evaluated.

3. Management of power that society receives autonomously

4. The management of health care resources is at the community level.

5. Service activities aimed at safety, efficiency and common expenses.

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