As part of my research about promoting and maintaining wellness of the elderly in community, I travelled from one health centre to another to visit health integrative post for the elderly in some villages (Posyandu Lansia). The Posyandu in this village for me is extraordinary as the health worker who conducts the health service is supposed to be a community health nurse, however in this village (and some other villages in this municipality) employed village midwife to provide this service. When I asked the reason why, they explained that they lack health staff in the Community Health Centre (Puskesmas) so the health staff who is responsible for Posyandu for children (midwife) was also assigned in Posyandu for elderly.
It is understandable however, the village midwife who provided the service at that day only graduated from diploma 1 midwife course, which is one year study after high school. She was already appointed as the village midwife. She’s still very young and I assume she still lacks experience. When I checked the control book to see how many elderly visit the Posyandu and their purpose of visit, I was a bit shocked to see the report of the blood pressure on that book was written incorrectly. To report someone’s blood pressure you need to report the sistole/diastole, e.g. 110/70, but in this book she only reported the sistole. I clarified with her the reason she didn’t put the diastole number, she said that it was because there were so many patients who came, around 50, and she didn’t have time to write the complete figures as she needed to serve quickly.
It is very sad, because the figures should show the real condition of the elderly, whether they have high blood pressure or not, but the figures were not able to be used to treat the elderly.
As many industrialised countries have moved their health care systems from treating sick individuals in hospitals to community-based management, Indonesia has similarly moved towards that direction. Over the past decade, a number of important reforms and transitions have taken place in Indonesia and in the health sector in particular. These include the decentralization of responsibilities for service delivery care to the district level. Moreover, staffing responsibilities have evolved with decentralization, the number of nursing training institutions has steadily risen, and important human resource policy changes have been introduced in the health sector. Increasingly, the community health nurse is one health care provider in the health workforce who plays an important role in providing services for the community. Such nurses are challenged to advance their knowledge about theoretical foundations of community practice. To achieve this, they need to receive appropriate education and skills to deliver health services in the new emerging health care environment. According to the World Health Organization (WHO) knowledge and many diverse skills are required for community health nurses to function effectively, both in clinical content and practical knowledge. In Indonesia, many effort have been made to improve knowledge and skills needed to deliver services at the community level such as established specialty programs in community health (CH) nursing.
Roles of Community Health Nursing
CH nurses perform many roles as part of their everyday practice such as clinician, educator, advocate, manager, collaborator, leadership, and researcher. In theory, CH nurses should be able to fulfil those roles as nurses are valuable resource in communities. Thus, they need good skills and appropriate education to perform as expected. To be effective practitioners, CH nurses must have a clear understanding about community health nursing and also about their roles and responsibilities. Without recognising their role in the community, it is assumed that CH nurses may perform their work poorly. It is important for CH nurses to have a clear idea who they are and know what they have to do in a community health setting. Nurses need to develop their skills so they can work effectively with individuals, groups and communities. In addition, to work in the community, CH nurses need to apply knowledge of a specialty area based on which organisation they work for.
Although the aim of community health nursing work is generally similar, the work depends somewhat on the issues a particular country faces at that time. Every country tries to emphasise the main framework of CH nurse that is to promote health and illness prevention rather than to focus on curative and rehabilitative as guided by the Ottawa Charter. However, the work of CH nurses in developed countries to some extent is different to that of community nurses in developing countries. In developed countries health care is focused more on health promotion based on the Ottawa Charter where responsibility for healthcare is shifted from a top-down approach to one that supported individuals, groups and communities to make decisions and plan public policy. While in some developing countries, such as in Indonesia and Pakistan, the government funding on health still emphasises on curative technology. In Indonesia, although the government already declarde the focus of health care is health promotion and prevention, majority of CH nurses’ work in Puskesmas are still focused on curative or even administrative work. This is due to the lack of human resources and knowledge regarding their roles in a community setting. The example from the Posyandu that I visited showed me the nurses only focused on providing medication to the elderly without trying to make an effort in educating health promotion and illness prevention.
Factors influencing practice of CH Nurses
Nurses need to know the community and have knowledge on how to address the needs of individuals, groups and/or the community. Knowledge can be defined in several ways: perception, the range of information, and the condition of knowing something through experience. Knowledge can be obtained through formal and informal education. To prepare CH nurses to be able to work effectively in partnering with individuals, groups and communities, they need to receive appropriate education and gain professional skills which takes both time and commitment. Unfortunately, in some countries such as Indonesia, not every nurse has a chance to continue or gain their knowledge and skills in their relevant area due to lack of support and funding.
In order to improve practice, the CH nurse must be able to increase their knowledge and skills to meet practice context needs. Many nurses employed in practice environments lack the necessary education and skills for that area. This may be related to a number of factors, including the lack of time to engage in professional development and supervised practice and access to support such as study time and fiscal support to participate in educational activities. Continuing education is one option that assists CH nurses gain required knowledge and skills in their area of practice. In community health, continuing education must strengthen a broad range of critical competencies and skills for CH nurses. However, to be professional, nurses must possess appropriate qualifications, contemporary knowledge and skills that are necessary to practice in their speciality and context and to accept the need to engage in ongoing professional development. American Community Health Nursing Education (ACHNE) suggests that the practice of community/public health nursing (C/PHN) requires a comprehensive set of knowledge and skills competencies acquired through educational experiences in a generalised baccalaureate curricula. Thus, as a professional nurse practising in community settings, the CH nurse should hold appropriate education and all the competencies acquired at baccalaureate level. Nurses need to combine nursing and public health in promoting the health of communities through holistic approaches for individuals, families and groups in community. The position requires not only a focus on patients, but also on community health problems. Thus, that level of education, combined with experience as well, is likely to provide better results for community health programs.
Community Health Nursing in Indonesia
The political, social and economic conditions of developing nations are different to those of developed countries. The resource base of every nation is a significant influence on the health services available and ultimately the role of health professional including community nurses. In Indonesia, although the CH nurses implement new public health approaches, there are still some differences in fulfilling their functions in public health services. In Indonesia, from my experience in supervising students and CH nurses in hospital and community health centres, some nurses still deliver nursing care based on what they were told or observed from their seniors, not because they understand or have knowledge about it. Thus nurses in developing countries, who are still practising in traditional roles, cannot always meet the challenge of providing health care although the aim of community health care may be similar to developed countries. This situation also occurs in Indonesia, where CH nurses practice is focused on curative interventionist and administrative functions, rather than preventative health activities that include the promotion of health and wellbeing. Many CH nurses still also performed non-nursing roles, such as taking patient registration in the centre. CH nurses in Indonesia are still not working properly according to their function and role because of lack of knowledge and skills related to community health nursing, as well as a lack of understanding about their roles as CH nurses.
Role of CH Nurses in supporting Elderly health in community
The examples about health services provided for elderly in community previously show that the health service for the elderly is still far from the theory. They are still focusing on curative intervention than health promotion activities. Interestingly, practices such as prescribing and administering medication still exist and are provided more by health staff working in rural and remote areas compared with those in urban-rural settings. This was not surprising, as in these areas, the number of physicians is limited, thus those nurses act as extensions of medical staff. Unfortunately, the educational background of these nurses (or other health staff) is often insufficient to prepare them for performing those activities, as they must hold at least a bachelor degree. It is very rare for CH nurses, who work in community health centres especially in rural Indonesia, to hold bachelor degrees or higher as more qualified nurses tend to work in large metropolitan based hospitals, community centres located in urban areas or in the educational sector. Thus, they have limited knowledge related to their current tasks and have not upgraded their skills and knowledge for their current roles. In addition, unfortunately, there is no specific education or training for nurses who will work in the community area. This creates barriers for Indonesia’s CH nurses to perform their role satisfactorily.
Conclusion and Recommendation for Research, Practice and Policy
Nursing in Indonesia, although not as advanced as in developed countries, is developing as a profession. Due to lack of information related to nursing in Indonesia, there is a need for more research to explore the actual working conditions of nurses, especially CH nurses. The results of such studies can be used to inform evidence-based practice and improve the health care service provided by nurses. The Indonesian government is working towards improving the quality of nurses by improving the standard of nursing education. However, implementation of accreditation is still undeveloped. In addition, the implementation of a registration system for nurses needs to be improved in Indonesia. Currently, the government has implemented a new system of registration where the nurse will be required to sit for a competency exam before they can be registered as registered nurse. In addition, the role of community health nursing association is necessary in helping to guide and improve the quality of CH nurses in Indonesia. In Indonesia’s case, there should be more socialisation about the scope of practice and community health nursing (CHN) program from the CHN association towards all CH Nurses in all regions. Hence, there will be at least one guideline for CH nurses who work in communities and this guideline can be applied across Indonesia.
Improving the standard of nursing education and implementing a registration system for nurses in Indonesia has the potential to produce more qualified nurses who can provide better health care to the community. For CH nurses, there is a need for appropriate education related to their work as their scope of service is broader. A key assumption is that a baccalaureate nursing degree is the minimum requirement. As the nursing situation in Indonesia is different to that in developed countries, the government should seek to provide additional training for CH nurses who are not baccalaureate graduates in order to fulfil requirements as professional CH nurses.
Kusrini Kadar PhD is a lecturer at the Faculty of Nursing, Hasanuddin University, Makassar. She is an alumni of Monash University. This article was written as part of the Makassar International Writing Class supported by Australia Award Alumni Grant Scheme 2017.