Better nurses means better health care

The meeting hall of the orphanage in the Yogyakarta district of Gunung Kidul -- one of the poorest districts of the country only a decade ago -- was full of men and women in brown uniforms.

They were doctors and health officials, directors and heads of the local hospitals and public health centers (Puskesmas), gathered to be informed by several experts that their nurses and midwives were woefully below professional par in their standard of service.

"Remember the woman from Bogor who fell into a coma following a caesarean and whose husband is now asking that she be euthanized?" a district administration officer asked rhetorically when opening the event, designed to endorse the concept of the Ministry of Health and the World Health Organization (WHO) of quality assurance for nurses and midwives.

It was his teasing way of chiding the participants into changing.

Dr. Arida, an official at the Yogyakarta provincial health office, who was attending the meeting in her capacity as guest lecturer, told the audience: "I would have taken offense had the chiding been directed toward me."

Stifled laughter and some sniggering met her remarks.

"Don't you want to be known for good quality service in your clinics and hospitals?"

More uneasy laughter was heard.

Arida and Dr. Tri Djoko Hadianto, another lecturer, recounted how campaigns to convince health officials to provide training sessions for their nurses and midwives often meet with resistance from among managers of clinics and hospitals.

"Change is difficult," Arida said. "You want to upgrade the nurses and midwives, but in order to do that you have to convince their superiors first, and this is where resistance often appears."

The CPDMS training sessions for nurses and midwives have the full support of the health ministry and the WHO and donor agencies because they have been proven to improve nursing quality, but dissemination of the concept takes a lot of effort on the part of its consultant and trainers.

"We often meet nurses and midwives who are eager to learn and participate in training, which means time away from work, but we need a commitment and managerial support before they can be carried out," Tri said.

"We need a special training in CPDMS for leaders (of health clinics and hospitals) so they could, in turn, lead their subordinates to achieve in certain training programs."

When CPDMS education and training for nurses and midwives has taken place, however, the progress more than makes up for the hard work.

"Education can change the mindset and attitude of the nurses and midwives, so the quality of health care in general can improve," said Dr. Sunartono, the head of Sleman district health office in Yogyakarta.

One of the Yogyakarta village health clinics (Puskesmas) applying CPDMS has just been awarded an ISO compliance certificate for quality service.

Sleman is a good example of how attitude change means improvement in health service and economic returns.

"People used to think that you went to Puskesmas because you had to, because you did not have the money for better care," said Sunartono.

"We are slowly changing that perception. We are trying to convince the public that Puskesmas is an alternative health care provision to hospitals. Patients come to the cheaper Puskesmas despite having the means to pay for more expensive care."

One of the ways to introduce the change, Sunartono said, is by returning 100 percent of a Puskesmas' income so it develops into a self-sufficient business unit which will suffer financially unless it provides quality service. More funding and equipment is allotted.

Financial and human resource management is improved, including the participation of nurses and midwives in CPDMS training.

"Nurses and midwives are more focused on their work following the training and stick to operational standards, which even includes the simple but important routine of washing hands before and after tending to a patient," he said.

More residents of Sleman chose to seek the services of Puskesmas, and it meant better income for staff members of the because more money comes in.

"We time our service, from the moment a patient is received up until they leave the clinic," said Markus Subadio, a nurse for 13 years. "We try to remember that we should smile when tending to the patients!

"We also have this weekly session where we discuss difficult cases and how they are handled, where we fail and where we succeed. It gives us a sense of keeping up with health care developments."

Tri Djoko is optimistic that training for the nursing profession such as CPDMS will in the longer term help introduce improvement in the overall health sector in Indonesia.

"I'd like to think that one day patients, even relatives of doctors, would feel safe and sure of a quality service wherever they go, Puskesmas or hospitals," he said.

-- Santi W.E. Soekanto and Ratih Sayidun