The search for nurses with a better bedside manner

Ratih Sayidun and Santi W.E. Soekanto, Contributors/Jakarta

Rahma has worked for the past two years at a small medical clinic in Depok, south of Jakarta, as well as taking patients at home, despite not having a license to open a practice of her own.

The mother of three has nothing but complaints about her even younger colleagues.

"Those new midwives don't even know how to insert an IUD (intrauterine device, a contraceptive)," she said scornfully.

"They leave a half-naked patient for so long without tending to her!"

Rahma expected her inexperienced colleagues to finish tending to the patient without leading them or explaining the standard.

"Of course they have to do it. Otherwise, they'll never learn!"

Mrs. Ningsih, a mother of seven grown children in Jakarta who has been fighting cancer for the past three years, does not have a good impression of the nurses who cared for her.

"They are so cold-hearted, so unsmiling and even rough," she complained. "It's humiliating enough to ask for a bedpan, but when the nurses help me with that in a rough manner, I feel like I'd be better off dead."

Rita, a nurse in a Jakarta hospital, has her own complaints.

"Who has the time and energy to smile when you have to spend all working hours at the beck and call of busy, arrogant doctors, and whining patients, in addition to mopping the floor?"

The experiences of the three women highlight the problem of nursing in this country.

As we rush to the hospital, do we ever think that we must place the lives of our loved ones, or our own, in the hands of a young woman in a white uniform who is mopping the floor?

Would we really think of entrusting the care of our pregnant daughter to a midwife at the Puskesmas (village health centers) whom we last saw carrying out the garbage?

Certainly not, we may think indignantly, but that is what millions have to do all the time.

A large number of the approximately 250,000 nurses and midwives here are poorly educated or trained. They work without a clear job description and standards to guide, so that the actual work that they do often goes beyond the scope of nursing.

Add to that the poor image of nurses and midwives as unsmiling and rude caregivers, and many patients would share the sentiments of Mrs. Ningsih.

Ani Suryani, a midwife and official at the provincial health office of Yogyakarta, admitted that nurses, who are on the front line of the health service, were often unprofessional.

"They are deemed the lesser decision-maker despite spending more time with patients than doctors," she told The Jakarta Post in Yogyakarta recently.

"Midwives often become complacent because their job is often monotonous, and they still have inadequate support from the health system."

Another challenge for them is dealing with teenage reproductive health and high maternal and infant mortality rates.

"Studies conducted here have found that a large number of teenagers, who make up 30 percent of the population in Yogyakarta, are involved in premarital sex," she said.

"Unless help is being given and solutions found, the outcomes are usually even worse, including unsafe abortions and sexually transmitted diseases. Can you imagine having an unskilled nurse giving advice to your pregnant teenager?"

Elly Nurachmah, a professor of nursing at the University of Indonesia, said many nurses were inadequately equipped with theories and concepts of nursing, with a lack of interest on the part of the health centers' managers to envisage good nursing practices.

Other experts believe that nurses and midwives must also have good clinical skills and the standards to guide their practice.

"Nurses lack understanding about their patients as human beings. Often they are insensitive to their patients' feelings," Elly said. "This is because they are often trained to merely carry out tasks given by doctors."

Most nurses and midwives carried out tasks beyond their professional boundaries, had no clear job description and had not received any professional updating in the previous three years, according to a 2001 study carried out in North Sulawesi, North Sumatra and East Kalimantan by the Directorate of Nursing and Medical Technicians of the Ministry of Health, in cooperation with the World Health Organization (WHO).

A 1997 WHO report on nursing in Southeast Asian countries, citing studies carried out since 1987, found that less than 50 percent of the working hours of nurses in hospital were actually spent on nursing.

Experts and practitioners such as Elly agree that the key to improving the quality of nursing and midwifery is training and education geared to accommodating the socioeconomic characteristics of the profession in Indonesia, where nurses are often paid a meager salary.

Also vital is to improve the performance management system.

Based on the 2001 study, the health ministry, WHO and Gadjah Mada University in Yogyakarta developed a system to assess and improve the clinical performance of nurses and midwives. They ran a pilot project to implement the concept in Sleman in Yogyakarta and Magelang, Central Java in 2001, and in Tabanan regency in Bali and Semarang and Grobogan, both in Central Java, in 2002.

In 2003, the Clinical Performance Management Development System (CPDMS) was expanded to another five provinces.

Suhartati from the Directorate of Nursing and Medical Technician of the health ministry said the system was intended to improve the clinical performance of nurses and midwives in the health care sector.

The system developed from the realization that health care here, as in many other developing countries, suffers from poor quality, poor clinical performance and that the health system fails to make the best use of its human resources.

The world is changing, and is moving toward the understanding that a health care system should protect patients from injury and bad advice during the actual health care treatment.

The public wants care that is effective, efficient, patient- centered and punctual -- and of constantly good quality. Nurses and midwives in Indonesia need to improve their skills to keep up with increasing demands for quality health care.

In CPDMS, nurses and midwives are encouraged to review all aspects of the care they give, use operational standards in accordance to the official job descriptions and participate in group learning process.

Dr. Tri Djoko Hadianto, a consultant to the CPDMS in Yogyakarta, recounted how participants showed improvement in the quality of their services by becoming more oriented toward patients' needs and standard operating procedures.

More importantly, the nurses and midwives liked their job better -- and were thus more positively focused on their patients.