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International Journal of Nursing Practice 2013; ••: ••–••
RESEARCH PAPER
Person-centred care in the Indonesian health-care system Wan Nishfa Dewi RN BN MNg PhD Student, School of Nursing and Midwifery, University of South Australia, Adelaide, South Australia, Australia Lecturer, School of Nursing, University of Riau, Pekanbaru, Riau, Indonesia
David Evans RN DipN BN MNS PhD Senior Lecturer, School of Nursing and Midwifery, University of South Australia, Adelaide, South Australia, Australia
Helen Bradley PhD MEdSt GrCertIntHlth BEd RN RM Senior Lecturer, School of Nursing and Midwifery, University of South Australia, Adelaide, South Australia, Australia
Sandra Ullrich PhD BSc (Hons) Grad Dip (Gerontology) BN RN Researcher/Consultant, School of Nursing and Midwifery, University of South Australia, Adelaide, South Australia, Australia
Accepted for publication April 2013 Dewi WN, Evans D, Bradley H, Ullrich S. International Journal of Nursing Practice 2013; ••: ••–•• Person-centred care in the Indonesian health-care system Person-centred care (PCC) is defined as the health-care providers selecting and delivering interventions or treatments that are respectful of and responsive to the characteristics, needs, preferences and values of the individual person. This model of care puts the person at the centre of care delivery. The World Health Organization suggests that PCC is one of the essential dimensions of health care and as such is an important indicator of health-care quality. However, how PCC is implemented differs between countries in response to local cultures, resources and consumer expectations of health care. This article discusses person-centred care in the Indonesian health-care system. Key words: health-care system, Indonesia, nursing, person-centred care.
INTRODUCTION Person-centred care (PCC) is defined as health-care providers, such as nurses, selecting and delivering interventions or treatments that are respectful of and responsive to the characteristics, needs, preferences and values of the person or individual.1–5 The essence of PCC is to shift the person from having a passive role in the health care that
Correspondence: Wan Nishfa Dewi, School of Nursing and Midwifery, University of South Australia, GPO Box 2471, Adelaide, SA 5001, Australia. Email:
[email protected] doi:10.1111/ijn.12213
he or she receives to becoming actively involved in decisions about his or her care. It moves away from an emphasis on disease to a model that integrates the biological, psychological and social dimensions of illness.6,7 The application of PCC in a clinical setting implies that nurses will assess the person’s needs, values and preferences, and then select and implement interventions that are considered and responsive to their client’s needs. PCC has become an established approach to the delivery of health care, and a growing number of organizations are starting to adopt a PCC model of care.8,9 In the UK, Australia, Europe and the USA, there has been substantial development of the PCC model of care. In the USA PCC © 2013 Wiley Publishing Asia Pty Ltd
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is considered to be a health-care priority,10 and in the UK PCC has been embedded in many policy initiatives.9 However, PCC is not widely used in the health-care systems of developing countries. It is likely that PCC is contrary to some of the current approaches to care delivery in these countries.1,11 It might also be that the philosophy that underpins PCC is different from those that inform health care in some developing countries. In addition, different countries and institutions have different understandings of what PCC means and different ways of translating it into care delivery. This article will explore the nature and characteristics of PCC with a particular focus on its introduction into developing countries and specifically to the Indonesian health-care system.
The Picker Institute defines PCC as a partnership between informed and respected patients and their families and the health-care team to achieve quality health care.22 The nursing literature is consistent in the view that being person-centred requires the formation of a therapeutic relationship between care professionals and patients and other significant persons. McCormack and McCance proposed a definition of person-centred care within a nursing context: Person-centredness is an approach to practice established through the formation and fostering of therapeutic relationships between all care providers, older people and others significant to them in their lives. It is underpinned by values of respect for persons, individual right to self-determination, mutual respect and understanding. It is enabled by cultures of empowerment that foster continuous approaches to practice development.13
TERMINOLOGY In the literature, the word person in person-centred care is used interchangeably with patient, client, individual and resident.12 The variation depends on the context in which care is provided. In the hospital setting the term patientcentred care is most commonly used, whereas in aged care it is resident-centred care. Different terms are used interchangeably in the literature to reflect the concept of PCC. These include client-centred care, individualized care, self-directed care, patient-centred care, relationship-centred care and family-centred care.1,13–16 However, the intent of the care delivery is consistent across all of these terms: that PCC care should be individualized and responsive to the needs of the client.
DEFINITIONS Definitions of PCC in the literature differ. McCormack defines PCC as ‘the formation of a therapeutic narrative between professional and patient that is built on mutual trust, understanding and a sharing of collective knowledge’.17 Suhonen, Leino-Kilpi, and Välimäki18 define PCC as being comprehensive care that fulfils patients’ physical, psychological and social needs. Kitwood describes it as a status that is given to one person by another and involves recognition, respect and trust.19 From a slightly different perspective, Nolan et al.20 considers it to be relationship-centred care because all parties involved in the care must experience relationships that promote a sense of security, belonging, continuity, goals and achievements.20 One of the first international organizations to introduce PCC into the health-care system to improve care by considering the totality of the experience through the ‘eyes of the patient’ was the Picker Institute.21 © 2013 Wiley Publishing Asia Pty Ltd
PCC makes the client and his or her family an integral part of the care team, and as such they collaborate with health-care professionals in the decisions that impact on the care that they receive.
CHARACTERISTICS It is not just the terminology and definitions that are open to interpretation; the characteristics of this model of care are also viewed differently. There have been many attempts to characterize the attributes of PCC. Contemporary views of PCC are based largely on research conducted by the Picker Institute.23 This early work identified seven characteristics: Respect for patient values, preferences and expressed needs Coordination and integration of care Information, communication and education Physical comfort Emotional support relieving fear and anxiety Involvement of family and friends Transition and continuity Some authors, such as Mead and Bower,24 Radwin25 and Poochikian-Sarkissian et al.,26 have also attempted to describe the characteristics of PCC. Although there are some differences in the characteristics reported, three common themes emerge: Participation and involvement of patient and relatives Respect for patient values, preferences and needs Information and education and sharing knowledge
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Importantly, these three characteristics emerge as the principles of PCC and are in line with the concept that nursing care is individualized.4,25,27 Patient and family participation and involvement is an important component of delivering PCC, particularly in nursing care.28 In PCC, the traditional view of caring has been substituted with one that actively engages patients in their own care. Sharing information and shared decisionmaking in PCC is a dynamic process in providing better care. Information, education and counselling are needed in the PCC model of care, as is health-care practitioners’ providing trustworthy information that is responsive and tailored to the patients’ individual needs.29
IMPACT ON HEALTH CARE There are a number of benefits related to the implementation of PCC into health-care practice, including increased satisfaction with care, improved independent self-care, better team performance, organizational effectiveness and efficiency, and an enhanced quality of health care.2,3,7,27,30–32 PCC can also increase consumers’ satisfaction with outcomes of health-care delivery.30 A study by Stewart et al.2 on the impact of PCC in healthcare showed PCC contributed to improved recovery and a reduction in diagnostic tests and referrals.2 Hook examined the relationship between PCC and quality of care and found that a good partnership between patients and health-care providers supported patients having a greater say about their care and improved outcomes such as patient independence in self-care and improved health-care utilization.31 Sidani27 and Wolf et al.7 found PCC contributed to increased self-care ability, improved functional status, satisfaction and quality of care received. These authors suggest that patient satisfaction and quality of care in wards using a PCC model of care rated more highly than wards that did not use PCC. Few developing countries have implemented PCC. However, the impact of PCC in countries such as Lebanon and Jordan has been investigated.32,33 PCC improved patient satisfaction, efficiency, competence and attitudes in both countries.32,33 Implementing PCC also brought a range of benefits for patients by enhancing their independence18 and improving quality of care.27,34
INTERNATIONAL EXPERIENCES Recent policy developments across developed countries have highlighted the importance of a PCC approach within
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health-care services.9,35,36 In the UK, USA, Canada, Australia and some European countries such as the Netherlands and Denmark, PCC has become an expected dimension of high-quality care. In 1997, the National Health Services in the UK started to develop a PCC environment. From that time the implementation of this model became an agenda to be delivered and achieved by all health services in the UK.36,37 In the USA, the concept of PCC has become more popular since the Institute of Medicine in 2001 reinforced this concept of care in the new health system for the 21st century. This new model of care delivery considers that good quality care should be safe, effective, patientcentred, efficient and equitable and considers PCC a fundamental practice for high-quality care in the USA.38 In Canada and Denmark PCC provides highly accessible care for patients and families by health professionals.8 Both Australia and the Netherlands have also implemented a PCC model of care. The Dutch associate PCC with responsiveness,8 whereas in Australia PCC is grounded in mutually beneficial collaboration among health-care professionals, patients and families.39
THE HEALTH-CARE SYSTEM IN INDONESIA Indonesia is one of the world’s most densely populated countries, consisting of 33 provinces and home to many different cultures, religions and racial clusters, resulting in many different views of health. The diversity of Indonesia’s environment and population poses enormous challenges to effective health-service delivery.40,41 The health-care system consists of two sectors: public (or state) and private. The government funds public hospitals and Puskesmas, or primary health-care clinics, across Indonesia, and private hospitals and clinics are run by private companies and individual organizations.42 The public system has different levels of care, from Class 1 to Class 3. Class 1 patients usually have some health insurance and receive the maximum resources that a public health system can provide. Class 2 patients receive a lower level of service but still incur costs. Class 3 covers the poorest people, who have free health care but minimal access to resources. This group is covered by the central and local government health-care cards, or jamskesmas and jamkesda. Currently, most health-care services in Indonesia are based on a conventional model of care. Conventional care is related to the delivery of care based on routine activities and tasks.43 The conventional care implemented in most © 2013 Wiley Publishing Asia Pty Ltd
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of the hospitals is such that the caregivers expect that their patients will be compliant—that is, follow their instructions according to Indonesian social norms. Health-care providers do not normally consult patients, nor do they deliver care that is based on individual patient preferences. Socially, patients do not expect that their concerns will come first or that they will have a voice in decisions related to their care delivery. In Indonesia, health-care professionals are highly respected and commonly come from the higher class of society. Doctors have a higher status than nurses. This difference in social status can serve as a barrier between the provider and the recipient of health care. Patients have little opportunity to discuss or consult with medical practitioners, who hold a higher social status than themselves.43 This hierarchy of social status also influences nursing practice in Indonesia, because nursing has a social status that is lower than that of other health professions. As a consequence, nurses have little independence in how they deliver nursing care and determine patient needs.43 Introducing PCC into the Indonesian health-care system could challenge this traditional approach to care with a new and unfamiliar model that could also challenge health practitioners.
PERSON-CENTRED CARE IN INDONESIA There is very little information about the use of PCC in Indonesia. One study on family-centred care (FCC) found that implementing FCC in Indonesia encountered difficulties related to an insufficient number of health workers.44,45 However, there is little further evidence related to PCC in the Indonesian healthcare system. While PCC is a new concept to Indonesian nurse practitioners and researchers, it is possible to identify barriers to and enablers of PCC.
which are poorly prepared for planning new health policies, and some public health institutions and hospitals now have a focus on profit.46 As stated, workforce issues are also considered an important barrier to the implementation of PCC in Indonesia. Human resources for health have been affected by the decentralization policy. Health workforce issues are grounded in long-standing policies about central planning and deployment, budget limitations and ceilings on workforce numbers in Indonesia.41,48 Existing civil service regulations constrain central and local governments in addressing the problems.40 These workforce issues might serve to limit any further changes to care delivery because the system is already struggling to come to terms with the changes related to decentralization. Although PCC has been introduced through the nursing curriculum, nurses have not been able to influence its introduction into the clinical area because of their lack of clinical authority. However, the existing nursing and medical workforce have a limited understanding of PCC. A lack of education about PCC in this group has been identified as a barrier in the literature.5,49,50 Therefore, this is likely to be an important barrier to the implementation of PCC in Indonesia. Social and economic differences between the healthcare professionals and patients are also a barrier to PCC. As previously discussed, in Indonesia health-care professionals have a higher social status than their patients. This difference in social status can serve as a barrier between the health-care professionals and the patients. Similarly, the social status of nurses within the health system in Indonesia is lower than that of other health professionals, especially medical doctors, so this impacts on their autonomy in clinical practice. As a consequence, these two factors have acted as barriers to PCC implementation.
ENABLERS BARRIERS Although there has been an investment in resources to improve the quality of health-care delivery in Indonesia, some barriers still exist. These include decentralization, workforce issues, health education and social stratification.5,8,37,41,45–47 These barriers all influence the implementation of PCC in the Indonesian health-care system. The general decentralization process implemented in 2001 has had many impacts on the health system. New responsibilities have been given to local governments, © 2013 Wiley Publishing Asia Pty Ltd
There are also enablers that could support the implementation of PCC in Indonesia. Decentralization has also had a positive impact because it has accelerated change in the health sector and in the nursing profession. Decentralization can increase the responsiveness of a system to local conditions by encouraging the growth of decision-making capacity and by developing the skills, abilities and motivation of local officials who work in the health sector.51 Therefore, local governments can be more flexible in determining health sector priorities to better meet the needs of their region.
Person-centred care in Indonesia
The need to have nursing recognized as a profession in Indonesia has prompted the Indonesian National Nurses Association to request the government to acknowledge their identity as a health profession. They are developing a credentialing system which will provide a legislative framework within which nurses will practice. Efforts are currently underway to develop and implement competencies to strengthen nursing as a self-regulating, accountable and professional body with a code of ethical conduct and a ‘Nursing Act’.48 Professional nurses play an important role in promoting quality of care in health systems. Having more qualified, skilled and scholarly nurses is likely to foster the transformation of nursing in Indonesia, not only in practice but also in education.
DISCUSSION Studies have demonstrated the many benefits that accompany a person-centred approach to health-care delivery. However, there are few studies of PCC in the developing world and none in Indonesia. To improve the provision of health care and to implement PCC as a new model of care in Indonesia there are challenges still to be addressed. The challenges for PCC in Indonesia identified in this paper are the lack of nursing authority, decentralization, workforce issues and social stratification. Nursing has a lack of authority and has been unable to influence the use of PCC in the hospital or clinical setting. Although education of nurses will assist in the change to care delivery processes, more is needed to ensure a sustained implementation of PCC. The workforce issue can be resolved by refining the deployment of staff and analysing the skill mix to support the implementation of this new model of care.52 Consequently, skilled, qualified and scholarly nurses would improve care and help support the implementation of the PCC model in the Indonesian health-care system.
CONCLUSION A person-centred approach to health care can improve the quality of patient care and increase satisfaction and adherence to care programs. PCC is now considered by many to be an important dimension of quality in health care. However, its implementation internationally might be impeded by a lack of understanding. Implementation of PCC in the health systems of developed and developing nations might encounter quite different challenges reflecting the unique cultural views, health-care practices and
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social norms of individual countries. Implementation of PCC in a developing country such as Indonesia will require changes in attitudes and skills to accommodate the differing view of health that PCC demands.
ACKNOWLEDGEMENT The first author would like to thank the Directorate General of Higher Education, Ministry of Education and Culture, Republic of Indonesia, for her PhD scholarship.
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