Outpatient nursing care implementations in Indonesian regional public hospitals

Abstract

Objective

This study aimed to describe the nursing care implementations in the outpatient installations of several hospitals.

Method

A descriptive study design was used with purposive random sampling. A total of 292 patients were included based on the following criteria: treated at the internal, neurological, ear, nose, and throat, pulmonary, surgical, skin, sex, and heart disease polyclinics, able to read and write, and attended more than one visit. This study was conducted in three central referral hospitals in the Bogor, Depok, and Jakarta areas of Indonesia.

Results

The outpatient care implementation was not optimal in the three regional public hospitals (56.8%). The nurses minimally performed the outpatient nursing processes, namely diagnosis enforcement (63.7%) and implementation (62%).

Conclusion

The implementation of care that is not optimal can result in a decrease in patient satisfaction and safety. The support of hospital management is needed to facilitate the availability of adequate nursing resources (both quantity and quality) and to provide equipment, facilities, and logistics to optimize nursing care.

Introduction

Outpatient facilities are designed for medical, nursing, and other services that do not require hospitalization.^1,2 Hospital outpatient services consist of various medical and nursing services, including health counseling, which should be provided to patients when needed as a form of outpatient care.³ Nursing is a professional service that is the backbone of healthcare facilities because nurses constitute the majority when compared to the other healthcare workers, so they can dramatically determine the quality of healthcare services.^4,5

Nurses who work in outpatient units frequently have short meetings with patients and their families; however, there is a lack of communication between the healthcare personnel, the patients, and the medical personnel participating in training.⁶ The duties of the majority of the nurses who work in the outpatient rooms are to help the doctors prepare equipment, weigh the patient, check the patient's blood pressure, and provide therapy according to the doctor's instructions.⁷ However, the problem often faced by nurses working in outpatient rooms is their inability to perform nursing care because of the short time that they have, their increasing administrative demands, and patient visits that are not yet in line with the outpatient care. Unfortunately, this situation does not follow outpatient care standards, which state that nurses are doctor's partners, and they are tasked with holistic nursing care.

The nurse is in charge of providing nursing care that improves the health status of the patient and their family, as well as patient safety. While providing care, nurses use a five-stage nursing process because care is comprehensive.^8,9 These stages are described as a related theory in the nurse's process for managing patients as individuals, families, and communities.¹⁰

Research conducted in Brazil has stated that all stages of the nursing process are challenging to implement due to the nurses’ lack of knowledge, an excessive number of tasks, poor professional educational quality, and minimal ability to systematically conduct patient assessents.¹¹ Other factors were found in the Hagos et al. study, including the demographic status (age, educational level, length of working, certificate), nurses’ attitudes, nursing process knowledge level, training, and reinforcement factors in the form of promotions and motivation.¹² These various factors came from private hospitals, and they have an impact on the quality of the services received by the patients.

With regard to the general outpatient hospital areas, many conditions, from the time that the patient arrives until the final discharge, have received less attention and less optimal services. The results of the observations and interviews with the room head and the nursing facility also confirmed that the nurses had not carried out their care roles. Nurses should be placed in all healthcare areas while carrying out their roles and functions. Therefore, it is essential for researchers to identify the factors involved in the implementation of outpatient nursing care so that appropriate improvements can be made to create quality services that are both excellent and professional.

Methods

This research used descriptive studies to illustrate the implementation of nursing care in outpatient facilities. The location of the study included the outpatient installations at Hospital X, Hospital Y, and Hospital Z. These three hospitals are regional reference hospitals in Jakarta, Bogor, and Depok in Indonesia, and they have the same characteristics and number of visits (700–1100 per day).

A purposive random sampling technique was used, and the total sample included 292 outpatients. The inclusion criteria were those patients who had been treated at the internal, neurological, otolaryngology, lung, surgical, skin, genital, and cardiac polyclinics for more than one visit, and who were able to read and write. The exclusion criteria were those patients who were treated at the psychiatric, midwifery and oral/dental polyclinics. The researchers took sample data over four weeks. With regard to the research ethics, this study passed the ethical test from the Faculty of nursing Universitas Indonesia committee (No. 63/UN2.F12.D/HKP.02.04/2018). The ethical principles of self-determination, privacy, and anonymity, confidentially, protection, and discomfort justice were also used in this study.

The research instrument consisted of 20 questions used to describe the patient's care delivery perceptions modified from the Inayah Outpatient Nursing Care model.² The assessment was carried out using the Guttman scale with assessment categories of 1 = not implemented and 2 = implemented. The measurement results were grouped based on the mean implementation of the outpatient care with categories of <32 = not optimal = 0 and >32 = optimal = 1. The questionnaire tested the validity (>0.361) and reliability (Cronbach's alpha = 0.91) of 30 patients in regional public hospital A.

Results

The results of this study indicated that the nursing care implementation in all three hospitals, according to the patients, was not optimal (56.8%). The care implementation was optimal (54.4%) and not optimal (45.6%) in regional public hospital Z, and it was optimal (54.8%) and not optimal (25.9%) in regional public hospital Y (Table 1).

Table 1.

Overview of the implementation of the nursing care in the outpatient departments of the regional public hospitals in 2018 (n = 292).

Category	Hospital X		Hospital Y		Hospital Z		Third hospital
	n	%	n	%	n	%	n	%
Not optimal	86	74.1	28	45.2	52	45.6	166	56.8
Optimal	30	25.9	34	54.8	62	54.4	126	43.2
Total	116	100	62	100	114	100	292	100

The nursing process consists of various stages: assessment, diagnosis, planning, implementation, and evaluation. Each stage is interrelated, and they should be carried out continuously. The patient assessments were carried out by the nurses, but several parts were not carried out, including double-checking the birth date (58.9%), double-checking the patient's name (61.3%), and assessing the fall risk (52.1%) (Table 2).

Table 2.

The implementation assessment of the nursing care in the outpatient departments of the regional public hospitals in 2018 (n = 292).

Assessment item	Implementation
	No		Yes
	n	%	n	%
Greetings to patient	118	40.4	174	59.6
Calling patient's name	27	9.2	265	90.8
Double check patient's name	179	61.3	113	38.7
Ask the patient's birth date	172	58.9	120	41.1
Assess patient's health problem	29	9.9	263	90.1
Assess fall risk	152	52.1	140	47.9
Assess medicine allergy	123	42.1	169	57.9
Measure the body and body temperature of the patient	99	33.9	193	66.1
Measure the patient's blood pressure	26	8.9	266	91.1
Assess the signs and symptoms of the patient's health problems	146	50	146	50

The determination of the diagnosis and patient care plan was not carried out optimally; 63.7% of the nurses had not established a nursing diagnosis, and 62% had not been informed of the patient's treatment plan (Table 3).

Table 3.

The implementation of the diagnosis and intervention of the nursing care in the outpatient departments of the regional public hospitals in 2018 (n = 292).

Diagnosis and nursing intervention category	Implementation
	Yes		No
	n	%	n	%
Determination of nursing diagnosis	186	63.7	106	36.3
Planning of nursing diagnosis	181	62.0	111	38.0

The actions carried out by the nurses are not yet optimal. This nursing implementation was based on the fact that 65.1% of the nurses did not provide active education and demonstrations for the patients, 60.3% did not provide precise information according to the patient's needs before returning home, and 64.7% did not train their patients according to their care needs (Table 4).

Table 4.

The implementation of the nursing care in the outpatient departments of the regional public hospitals in 2018 (n = 292).

Nursing implementation category	Implementation
	Yes		No
	n	%	n	%
Answering patient's question	27	9.2	265	90.8
Ask patient to sit and wait for the queue	70	34	222	76
Provide information after a doctor's consultation	125	42.8	167	57.2
Explain to patient and family	190	65.1	102	34.9
Provide information for caring for the patient at home	176	60.3	116	39.7
Train the patient/family if the treatment is at home	189	64.7	103	35.3
Encourage family to motivate the patient to recover	129	44.2	163	55.8
Tell the patient the follow up schedule	54	18.5	238	81.5

Discussion

Ideal nursing care consists of an assessment, diagnosis, intervention, implementation, self-care education, and evaluation. The nursing care process uses client-focused data, provides nursing actions, and provides self-care education for the clients and their families.^13–16 The description of the nursing care implementation in this study consisted of an assessment, and most (56.8%) of the patients rated the nursing care as not optimal in all three of the outpatient hospitals.

Nursing care can be an essential part of the improvement in hospital services because nursing care can be an illustration and indicator of patient satisfaction.^17–19 While being cared for, a patient will receive lots of information, and the nurses will take action to help the patients and their families overcome health problems. If this is done optimally, the patient's satisfaction will increase. The quality of the care implementation can be assessed based on the patient's perception through each process carried out by the nurse from when the patient first arrives until their treatment is completed in the hospital area.

This study was carried out to evaluate nurses when patients are admitted to outpatient care. An assessment is an essential beginning for patients to confer with nurses before receiving medical attention, diagnostic investigation and other investigations.¹⁷ A nursing assessment includes greeting the patient, confirming the patient's identity (name, birth date), determining patient complaints, assessing the patient's vital signs, noting the illness and allergy histories, and determining the fall risk. This section can be described in 10 questions. Overall, studies have been conducted on nurses, but not with regard to optimal care implementation. The majority of the patients stated that the nurse had not double-checked the patient's birth date (58.9%), double-checked the patient's name (61.8%), and asked about the fall risk (52.1%). These should be done when the patient first meets the nurse at the outpatient nurses’ station. The next step should be an assessment in order to diagnose, plan, and carry out the procedures and to evaluate the patient's condition and describe the service quality. Improving the quality of hospital services continues to be necessary, and one of the ways to do this is through the accreditation process. The hospital accreditation standards for the patient safety objectives include six targets that must be implemented in order to improve the quality of services, minimize medication errors, and treat the patient.²⁰ Reassessments, such as verifying the patient's identity, allergy history, and medical history, should be done because these conform to the hospital's patient safety standards.

Hospitals should consider the fact that hospital care is an integral role of care providers, and this is stated in the patient-focused service standards.²⁰ Assessments are carried out not only when the patient meets the nurse, but, as stated in the chapter on hospital access and service continuity, the patient should become the service focus from reception through registration, during medical team services and therapy, and finally, until the patient is discharged from the hospital.

Outpatient care includes the patient's initial access to services, and ongoing services should be implemented in all parts of care. For example, a study carried out by nurses should be a medium for doctors to continue to further explore the patient's condition and treatment planning. If this is done, then access to the hospital is sound, and service continuity has taken place.

The next stage is determining the diagnosis and nursing action plan. The results of this study found that 63.7% of the nurses did not convey the nursing problems that they found to the patients, and they did not plan nursing care (62%). Patients assess the lack of communication and interaction between the nurses and themselves. In addition, the nurses should educate the patients with regard to prevention and handling the information needed by the patients and their families at home. They should communicate in order to provide a controlled schedule of information. In this study, 65.1% of the patients stated that the nurses did not provide examples of the nursing actions if needed, and the nurses rarely communicated with their patients to provide the information/education. As many as 60.3% and 64.7% of the patients stated that the nurses had not trained the patients or their families, respectively, if they required hospital actions.

The community's ability to provide care did not seem to go as it should. If the patient still perceives that their outpatient care is not optimal, it can lead to dissatisfaction and reduce patient confidence in the quality of the hospital. This happened in several hospitals studied in 2012, in which it was stated that the patients were not satisfied with the outpatient care services provided by the nurses because of the lack of information received from the nurses regarding their health problems. The professional nurses’ roles had not been implemented with regard to the quality of the nursing care.² The accreditation standards for the patients’ rights and obligations have explained that the hospital should build trust and open communication with the patients, involve the patients in decision making, and obtain complete information.²⁰

Excellent communication between the patients, their families, and the multidisciplinary hospital team is beneficial for the success and effectiveness of the treatment plan. Communication is built to create the patient's trust in their healthcare team. Patients require information, support, and attention from their families and healthcare workers, including both the nurses and the doctors. Communicating in outpatient clinics can be done by optimizing the way that the patient's condition is monitored after treatment and reminding them about the follow-up schedule via the telephone. This is one option to improve patient satisfaction and the quality of care while using technological advances and outpatient care information.^21–23 Carrying out the caregiver role by improving communication and direct support and providing information will optimize the service quality.

The implementation of non-optimal care occurred in the three hospitals evaluated in this study, and while previous research has been conducted on this subject, it took place in government hospitals.^11,24 According to the American and Canadian practice standards in Pokorski et al., nurses should carry out their practice based on professional nursing processes throughout all healthcare institutions, without differentiating between the nurses’ scopes of work.¹¹ However, in practice, not all of the steps in the nursing process are carried out and applied systematically, especially in the outpatient service areas. Therefore, more attention is needed so that outpatient nursing care implementation can be optimal because these nursing services are seen as the backbone determining the quality of the hospital.^4,12,25

The field conditions were cited when identifying the nurses’ problems, underlying the lack of the optimal implementation of care, such as not understanding the caregiver role, the imbalance between the workforce and the patient visits, not knowing about nursing care, rarely being reminded to attend nursing care training, being stuck with administrative routines, lack of documentation, and incomplete support facilities.

Labor has a significant influence on a hospital's services. The effectiveness and efficiency of nursing labor strongly support the provision of appropriate nursing care in the amount, quality, and method used.⁸ Workforce development in the form of increased knowledge needs to be done in order to improve the implementation of the nursing processes and daily nursing care planning²⁶.

The majority of the nurses in all three hospitals had diploma educational levels. Hagos et al. stated that the educational level was very influential in nursing care for the patients.¹² Likewise, the study by Baraki et al. reported that education has significant value that influences the implementation of nursing care for hospitalized patients.⁹ These results were supported by other researchers who explained that nurses without a consistent theoretical basis for applying the nursing process were 95.1% less likely to apply it than those nurses with a good theoretical understanding.^9,10,12,27 Quality improvement is needed so that nurses understand their roles and have the comprehensive knowledge to carry out the proper level of care.

In addition to increasing the nurse's resources at the educational level, it is necessary for the management to distribute the personnel according to the patients’ needs in both outpatient and support facilities. Moreover, it is the role of the room head to take care of the nursing management and coordinate with them to improve the quality of care. Managers also influence the nursing care results, because they are sources of indispensable information for the care implementation carried out by the nurses, which can impact a nurse's job satisfaction.^28,29 Finally, the director's role is to motivate, foster organizational communication, handle conflicts, facilitate service delivery cooperation, and improve satisfaction.

The implementation of care that is not optimal can result in a decrease in patient satisfaction and safety. It takes the support of the hospital management to facilitate the availability of adequate nursing resources in both quantity and quality while providing equipment, facilities, and logistics to optimize nursing care.

Improvements in the quality of care can be implemented by improving the quality of outpatient nursing resources. This includes the development of knowledge and education, work motivation, direct communication with the patients, and adequate facility support.

The research questionnaire did have some limitations because it did not include nursing care evaluation components, and it lacked a proportionate number of questions for each nursing care stage.

Conflict of interests

The authors declare no conflict of interest.

Acknowledgements

This work is supported by Hibah PITTA 2018 funded by DRPM Universitas Indonesia No. 1853/UN2.R3.1/HKP.05.00/2018.