The search for nurses with a better bedside manner

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.