Management strategy for management of independent practice nursing in Badung District, Bali Province, Indonesia

INTRODUCTION

Nurses are the largest health workers in Indonesia, amounting to 32.8% of the total health workers available. Based on data from the Health Profile in 2013 the number "1" of nursing staff in Indonesia was 288,045 nurses.

In the Regulation of the Minister of Health of the Republic of Indonesia Number 17 of 2013 concerning Amendments to the Regulation of the Minister of Health Number HK.02.02/Menkes/148/I/2010 concerning Licensing and Implementation of Nurse Practices, it is stated that nurses can practice in health service facilities which include health service facilities in outside of independent practice and / or independent practice.^2,3

Based on the results of the literature study at the moment there is no exact data on how many nurses have established independent nursing practices in Indonesia. In addition, there are no valid data on the number of independent nursing practices in each province. However, based on the results of the analysis, the Province of Bali is one of the regions in Indonesia that at present the practice of independent nursing can develop. The results of interviews with the Indonesian association of independent nurse practices (APMP) at present there are approximately 50 independent nursing practices in Bali Province.

Life experience or the experience of developing independent nursing practice management strategies is very important to study, because as is well known that nurses in Indonesia currently need a role model and concrete examples of how to establish and develop independent nursing practices in accordance with the provisions and can develop with business value, the concept of organizational growth and get a good reception from the community.

METHODS

Study design

The research method used in this study is a qualitative method with a phenomenological approach.

Study place and period

The research site was carried out in independent nursing practice in Badung Regency, Bali Province. Bali Province. The time of the study was carried out on June 2015 -July 2015.

Selection criteria/inclusion and exclusion criteria of samples

Research informants were taken by purposive sampling method. In This study there were 9 informants consisted of 5 main informants (independent nursing practice owners and 4 evaluation or triangulation informants.

Procedure

Researchers come to the respondent and give some deep interview questioner.

Statistical analysis

The analysis technique used is based on the Constant Comparative Method according to Glaser & Strauss.

RESULTS

Characteristics of respondents

In this study 9 informants consisted of 5 main informants (independent nursing practice owners and 4 evaluation or triangulation informants.

Triangulation respondents consisted of the Chairperson of the Indonesian National Nurses Association (PPNI) of Badung Regency and 3 patients who used the independent nursing practice services. The following is a description of the characteristics of the main respondents:

Place of practice planning

Planning a place of practice is one of the important things in opening an independent practice of nursing.

Facility planning

The facility is an infrastructure that supports services in independent nursing practice.

Organizing services

Based on the data obtained from the informants, there are some important things from the experiences that have been carried out by nurses as a strategy in organizing independent practice services.

Human resources management

There are nurses who handle themselves in the practice with the reason that patients can still be treated by themselves and there are those who already have nurses who help in the practice. For independent practice that has nurses, the recruitment process will be done by looking at aspects of the curiculum vitae, experience that has been followed, the ability of the patient's history, a perception for practice and handling emergency conditions.

DISCUSSION

This is consistent with the results of research on the marketing mix at Faisal Makassar Islamic Hospital which aims to find out the factors that are considered by patients to choose a health service, that place factors influence the decision to choose the health service. Thus, to be able to realize good health services, the regulation of distribution of health facilities is very important. Health service center or hospital from the community's residence will reduce the demand for health services.⁴

Most respondents feel comfortable with the inpatient room at Faisal Islamic Hospital according to their respective classes. Cleanliness of the room is always maintained by a janitor who comes to clean the patient's room.⁵

The same thing was conveyed by The College of Registered Psychiatric Nurses of British Columbia (CRPNBC), nurses in opening independent nursing practices have domain coverage of clinical practitioners providing nursing care, providing education or health education, conducting research in developing practices and administering services practice.⁶

The results of the study also showed that the organizing of independent practice carried out by informants had referred to legislation in carrying out their duties as a provider of Nursing care, make referrals, provide actions in emergencies according to competence, provide nursing consultations and collaborate with doctors, conduct health education and counseling and conduct management giving medicines to clients in accordance with the prescription of medical personnel or over-the-counter drugs and limited over-the-counter medicines.

After the recruitment process is carried out, an orientation phase is carried out for new nurses using the mentoring model and gradually teaching the existing services. Staffing arrangements require a lot of planning from managers. Planning staff arrangements is influenced by the mission and goals of the institution and is influenced by personnel policies.⁷

This shows that to be able to implement good health services, the relationship between staff and patients must be well established and it is hoped that every health care worker can and is willing to give adequate attention to his patients personally, provide friendly service, accommodate and listen to all complaints, and answer and provide clear information - clearly about everything the patient wants to know.⁸

The results are in accordance with the results at the Medan Helvetia Hariantary Clinic that health workers are a significant factor affecting patient satisfaction. This is consistent with the results of a study conducted by Rantz et al. Stating that the outcome of the quality of home care services performed by nurses is influenced by the quality of the attributes of facilities and staff or health service providers. These two factors are staff factors being the main key to the quality of home care.⁹

Implement the formulation of an independent practice nursing strategy

Service delivery in practice

Based on the research results obtained information from informants, there are several types of services available in independent practice, including curative measures such as basic treatment, complementary therapy (acupuncture, acupressure, jade ceragem, cupping, etc.), home care, and wound care, actions promotive (providing education to patients and families) and preventive measures (checking blood sugar, cholesterol and blood pressure checks).

The results showed that increasing nursing care in psychological aspects would be able to improve the quality of care in the independent practice of nursing. The efforts of psychological nursing care are based on increasing empathy and knowledge to patients.¹⁰

The development of these types of services in accordance with the level of need for independent nursing practice can also be seen in the curative aspect, namely the paradigm shift starting from the increasing community demand for complementary health services, where one of the authorities of independent nursing practice is to provide alternative medicine.¹¹ Based on the Permenkes the authorized person to carry out complementary medicine is a determined health worker and based on scientific principles.¹²

Community demands for health care needs are also increasing and changing from the concept of care and treatment in hospitals or clinics to home care needs as well as an alternative for families with elderly (elderly) who tend to experience diseases with chronic conditions that require care and treatment long term.¹³

This is certainly very beneficial for clients and their families, when considering the comfort and safety aspects of clients and families more intense and more free interaction when in their own homes, and financing therapy at home care is relatively cheaper when compared to hospital care (cost effective).¹⁴ These various phenomena indicate that independent practice of nursing is currently needed in the Indonesian national health system.

The results also showed that nurses who opened independent practices had also begun to pay attention to the psychological aspects of patients. This means that service to patients is not only on the physical aspects, but also includes psychological aspects.

Marketing services

Word of mouth communication is communication that is done through word of mouth by telling the experience or excellence of a product. Word of mouth has been considered as one of the most powerful forces on the market. In reality, consumer choice is usually influenced by word of mouth. Word of mouth promotion carried out by friends or relatives has high credibility, so it is more persuasive or influential than promotion through advertising.¹⁵

In the use of these products will arise a sense of satisfaction if the company can create products and services provided that are able to meet consumer expectations, and vice versa will feel dissatisfied if the use of the product is not in accordance with previous expectations.¹⁶

Challenges and obstacles in service

Based on data obtained from informants, in the course of opening independent nursing practices there were several challenges and obstacles encountered. These challenges and obstacles include the perception that there are still practices of doctors or midwives, difficulties in finding workers who help, limited time and physical fatigue, completeness of regulations for developing nurses' practices, which are still not good from the government or PPNI, competition with other health practices and cannot do BPJS insurance clamps.

Efforts to increase patient visits

Based on the experiences that have been done by the informants, to increase the number of visits at the place of practice there are several strategies that can be done, including: (1) always innovating and looking for differentiation with other practices for patient satisfaction, (2) doing caring services.

Health service user satisfaction is influenced by several factors including: (1) Understanding of service users about the type of service they will receive. In this case the communication aspect plays an important role because health services are high personal contact. (2) Empathy (caring attitude) shown by health workers. This attitude will touch the emotions of the patient. This factor will affect patient compliance. (3) Costs. High service costs can be considered as a source of moral hazard for patients and their families (4) Physical appearance (neatness) of cleanliness and comfort conditions of the room, (5) Safety guarantees addressed by health workers. The accuracy of the examination schedule and also the doctor's visit also includes factors that affect patient satisfaction, (6) Reliability and skills of officers in providing care and (7) Speed of officers providing services. The same thing is in accordance with the results of research which states that there is a relationship between product, promotion, place and customer service with the decision to choose treatment and there is no relationship between price and human resources with the decision to choose treatment in the Hajj Outpatient Subdivision, Jakarta.¹⁷ Seeing the results of these studies, patient satisfaction in choosing independent nursing practice will also be affected by product, promotion, place and customer service.

The results also showed that one of the efforts to increase the number of visits is caring for patients by providing education. This is consistent with the results of research from Salminen, which states that education is one part of the efforts of entrepreneurs in health services. Therefore, nurses must have good educational skills to patients as one part of improving the quality of entrepreneurship independent nursing practice.¹⁸

Control the implementation of independent nursing practice

Evaluate the implementation of independent practices

Evaluation of the implementation of independent practices has been carried out by informants to find out the implementation of practices. Based on the experience of the informants, the evaluation of independent practice is seen from the aspects of: (1) patient satisfaction, by looking at the patient's return rate if sick or asking directly because there is no separate satisfaction evaluation system, (2) seeing the number of visits and (3) seeing the benefits obtained.

Control or evaluation is a continuous function of nursing management that occurs during planning, organizing, and mobilizing activities. This means that measuring the level of patient satisfaction must be an activity that cannot be separated from the measurement of the quality of health services.¹⁹

Patient satisfaction will be achieved if optimal results are obtained for each patient and health services pay attention to the ability of patients and their families, pay attention to every complaint of the physical and energy environment conditions and prioritize patient needs so as to achieve the best possible balance between the level of satisfaction or the results and the pain have and must be experienced in order to obtain these results.²⁰

Efforts to improve quality

Based on the results of the interviews, the informants have made a number of efforts to improve the quality of service. Efforts to improve quality include raising insights and experiences through training activities, seminars, workshops and lectures, perfecting existing independent practices, in terms of facilities and types of services (towards holistic and SPO development services), and not providing a therapy if Not certified or attended previous training.

Good health services if in accordance with the needs of users of services can be reached by those in need (both in terms of distance or location, as well as financing), and in accordance with the principles of medical science and technology (quality health services guaranteed).²¹

Education and training are fundamental factors. Every nurse is expected and encouraged to continue learning in carrying out an independent practice of nursing. Learning is an endless process and knows no age limits. Therefore, the existing system in the independent practice of nursing needs to be improved continuously so that the quality produced can improve.²²

Independent practice development plan

The results obtained information that nurses who have opened practices already have plans to develop existing independent practices. The following are several independent practice development plans identified from the informants: (1) Planned to become a joint practice clinic, open 24 hours, or inpatient without leaving the practice of independent nursing as the main service, (2) Planned to be added in terms of service towards holistic and complementary services more complete, (3) Independent practice training center, and (4) practical land for students to learn the concept of independent practice. The following statements from several respondents reinforce this:

The aspect of the substance of planning is setting goals and establishing alternative actions. Planning in principle revolves around two things, the first, is the determination of conscious choices about the concrete goals to be achieved within a certain period of time based on the values held by the community concerned and the second is the choice between alternative and rational ways to achieve these goals.

The development of independent nursing practices must be developed using entrepreneurship models. It means that it is developed with innovation in accordance with the opportunities of market needs. In developing the concept of a nurse entrepreneur, it is developed based on two main principles, namely the principles of entrepreneurship and the principles of nursing. Starting from the two principles above, it is then integrated with legal aspects and economic aspects which include market demand, public sector conditions or a combination of both.²³

CONCLUSION

In the stages of the formulation of the formulation of a strategy to implement an independent practice that has been carried out includes planning a strategic place selection and setting the appearance of a comfortable place of practice, organizing a structured service, planning the provision of facilities and practice setting personnel.

At the stage of the implementation of the practice strategy formulation it includes the types of services available at the independent practice place consisting of nursing care services, promotive activities, preventive and complementary medicine and effective communication in the introduction of independent practice is to use word of mouth marketing.

Recommendations

For the Indonesian Independent Nurse Practices Association (APMPI), it is increasingly active in fostering efforts to improve the quality of independent nursing practice, through training, preparation of quality standards for independent nurse practice services and nurse assistance that opens independent practices.

For nursing education institutions to use independent nursing practices that already exist as one of the clinical practice areas of students, so students can learn directly the management of nursing care at the nurse's independent practice.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Health research ethics commission. Medical School. Diponegoro University

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