Whether Clinical Nurses (PK) III placement in the outpatient unit is in accordance with its functions and responsibilities?

Abstract

Objective

Most Clinical Nurses (PK) III are commonly assigned in the Outpatient Unit, but the assigning of nurses in each unit has not yet been in line with their skill and detail of their authority as a clinical nurse.

Method

This study used employed qualitative design with a phenomenological approach. It focused on the description of the importance and significance of PKs III experience in the Outpatient Unit. The participants were 10 PKs III in the Outpatient Unit aged 36–52.

Results

This study results in five themes which describe the experience of PKs III in undergoing a career path in the Outpatient Unit which are formed from eleven categories.

Conclusion

PKs III in the outpatient unit does not function according to their responsibilities. Unless it is taken care of seriously, the losses arising from this phenomenon will be repeated.

Introduction

Clinical Nurse (PK) III is a nurse who has a career level as a clinical nurse with competent-clinical detail and authority in providing nursing service for patients. Clinical nurse is a nurse who provides direct nursing care to clients as an individual, family, group, and community in accordance with her career level as a clinical nurse. A PK III is also a competent nurse who is aware of her long-term goal and gains perspective from the awareness in planning independent action as well as analysis thinking to achieve better efficiency and organization.^1,2

The assigning of PKs III in the Outpatient Unit by the nursing manager in the Nursing Division is a form of workforce function or staffing in career plan, development, and management of nursing in a hospital. The nursing manager should understand workforce pattern and manage the staff fairly and economically so that the employment of nursing resources becomes more efficient. This management also involves an active nursing organization to develop and plan a career.^3–5

Outpatient Unit in one of the government's vertical hospitals, 90% of the nurses are PKs III while there are not as many of them in other units as in the Outpatient Unit. It shows that the mapping proportion by nursing management in carrying out the workforce function has not been managed evenly to meet the needs of clinical nurses in all nursing service units. Whereas, one of the functions of nursing management is staffing performed by placing the nurses evenly in units by considering the work environment, definition of responsibilities, skills, and strategies for maximum achievement in nursing services.^6,7

Of 517 nurses, 189 of them are PK III (31%). Nursing HR map shows that the PKs III distribution in every room is varied, 32 rooms from a total of 33 rooms have already had PKs III. However, the uneven mapping is seen from the presence of 27 PKs III in the Outpatient Unit, and this is the highest number of PKs III of all units in the hospital. The nursing service in the room has not been done properly, so that there are still nurses who do mixed jobs which are not in line with their clinical authority, so that the benefits of the career path have not been optimized yet. Nurses’ working assignment should be in line with their practice areas, so nurses can carry out their duties in providing nursing care in accordance with the Clinical Assignment Letter that has been determined.^8,9

The Outpatient Unit is one of the leading services in the hospital which conducts various types of nursing service actions, but the types of these services are not as many and complex as the service actions in other units. Assigning PKs III with competent skills in this unit is not in accordance with the objective of implementing clinical nurse career level programs in the hospital, which is assigning the nursing resources in each unit according to the level of authority and clinical skill. The existence of a career path to assess nurses’ skills is a chance to improve their abilities, skills, career levels, and to form their careers according to their potentials and abilities.^10,11

Method

This study used a qualitative research method with a descriptive phenomenological approach. The objective of research using qualitative method is to understand life experience, phenomena, the relationship between concepts and perceptions to be raised, and emphasize on exploring and understanding the meaning of individual or group which is considered as a social or human problem.^12–14

The participants of this study were 10 nurses with clinical career level III in the Outpatient Unit, which is selected through purposive sampling technique. The data collection process through in-depth interview was conducted from April 2018 to May 2018. The process of managing and analyzing data used the Collaizi method because this method provides clear, systematic, detailed and simple steps. The data were directly analyzed by the researcher after interviewing each participant one by one. What is found from the data analysis of one participant shaped the researcher's decision in determining the context of the next participant interview.^12,15,16

Results

Using in-depth interviews with participants, this study has identified five themes with 11 categories. The themes are:

(1) PKs III mapping in the Outpatient Unit due to the request, health status and age of the clinical nurses themselves, as revealed by the following participants:

“... I went to the poly department because I proposed this ee to resign from the head of the room position because there was something...” (P1)

“... because of HNP (hernia nucleus pulposus), so I proposed to move to the clinic... because of I ee because my health did not allow me to be in OK anymore...” (P2)

“... the request has been made three times this year, it was just approved, three times because of the age problem, my age ee health problem...” (P6)

(2) PKs III's lack of understanding related to the level of clinical nurse career, as revealed by the following participants:

“... what is the career path? Is this from the boss, is that what it means?... someone who has ee what, high, high credibility...that he can be placed anywhere? Like that?” (P1)

“... I think, (what happen) here is that if someone is active and close to the boss or wants to do everything, he will be quickly promoted...” (P10)

(3) The workload as PKs III in the Outpatient Unit is lighter than in the other units, as revealed by the following participants:

“... the burden is reduced...in energy, and emotion too...” (P1)

“... the workload in poly is not that heavy, so why it becomes favorite, Inpatient Unit is more difficult, more tiring, it is different from here, it's less tiring...” (P2)

(4) PKs III feel more comfortable in the Outpatient Unit, as revealed by the following participants:

“... I’m just happy because there isn’t such night shift, it's happier, I meet a lot of different people, yeah, I’m just happy...” (P6)

“... it's nice here, (working) from half past seven to half past three, the Inpatient Unit is too tiring for our body, it hurts, it is nicer here hehehe, it's also better to relax at home, working in the morning and going home as a usual worker, as scheduled...” (P8)

(5) The role of PKs III in the Outpatient Unit as the in-charge person and educator, as revealed by the following participants:

“... (the education for) heart failure is every Monday, Wednesday, and Friday, every patient are given education (about heart failure), from Monday to Friday I will also visit the patients’ room (of heart failure), I give education about bedside teaching to patients and families...” (P3)

“... as I am in charge of TB DOTs (directly observed treatment short/short term treatment with direct supervision) when I took it in 2013, it has started to run, I have just taken care of this, this TB program is running now, so it's so good now, Alhamdulillah...” (P4)

Discussion

PK III mapping in the Outpatient Unit due to nurses’ requests, health status, and age

The mapping of human resource in the field of nursing aims to distribute the nurse's clinical expertise and authority in their appropriate places according to their levels in order to support the goals of the nursing care program in the hospital. Conceptual mapping is a graphical strategy that uses schematic representation to hierarchically organize a concept. In nursing, the mapping is a distribution strategy to develop and improve the ability of nursing service, reasoning, critical thinking, to support long-term learning, and strengthen nurses’ confidence in providing nursing services.^17,18

The mapping location for nurses with clinical career level III, which can be said as a competent nurse, is shown that PKs III mapping in the Outpatient Unit is due to request from the nurses themselves, considering their specialization, age and individual health status which make them not be able to perform nursing services in units with higher work pressure and also the night shift. Working in shift rotation for nurses (including the night shift) gives a greater risk of causing a health problem. Higher job pressure can affect job satisfaction and nursing services to the patients. Thus, nursing management in the hospital has to pay attention to the health and safety of their nurses and patients, by considering the nurse's age and health status.^19,20

The nurse mapping that is not in accordance with nurses’ specification will affect one of the nursing management strategies in developing nurse skills, which is the mentorship strategy. The existence of a competent PK III who has skill and experience in the clinical service unit can be one method of learning for the juniors through mentorship activity. Mentorship can improve individual skill because the process involves the formation of interpersonal relationship which is oriented professionally. In the Minister of Health Regulation No.40 of 2017, there are several competencies a clinical nurse should have in order to give a mentoring session to new nurses (PK I) by conducting mentorship on a specific area.^21,22

PKs III's lack of understanding in the Outpatient Unit related to detail of clinical authority

The results of this research show that PKs III in the Outpatient Unit does not fully understand the detail of their clinical authority. This condition makes them cannot optimally apply the knowledge and ability they have. It affects the patients’ satisfaction of nursing services in the Outpatient Unit. The variable of a nurse's competence is related to the patient's satisfaction. This nurse competence can be seen in they way they handle the patients, including good assessment techniques, a nursing intervention which is carried out according to the diseases, and complete comprehension about the actions given to the patients.^22,23

The implementation of clinical nurse's career path is conducted to fulfill one of the hospital accreditation requirements. The Nursing Committee and Nursing Division work together in establishing the nurse's career levels. The socialization of the details of the nurse's clinical skill and authority by the Nursing Committee is thought to be less active by PKs III, thus PKs III still carry out mixed jobs and authorities which are not related to the preliminary focus. As a consequence, PKs III have not fully understood the clinical authority and have not felt the benefits of applying the clinical nurse's career levels. The nursing profession requires the development and establishment of a career path in order to foster the professional progress, including triggering the improvement in knowledge, developing potential and clinical skills as well as promoting the development of nurses as active participants in the nursing profession.^24,25

The role of nursing as a hospital nursing manager in improving PKs III's understanding about the details of clinical authority can be done by providing support to nurses to continue improving their understanding of their clinical authority and providing supporting facilities to achieve this goal. It can be given through evaluation and consultation with the PKs III related to the obstacles which cause a lack of understanding of clinical authority. The position of the nursing manager is important in providing support and facilitating positive change in order to harmonize the responsibilities and the authorities of the nurses through consultation program under the control of expert practitioners. Because it supports the working environment and the quality of nursing services, it can maximize the significant contribution of nurses in the field.^26–28

The lighter workload as PKs III in the Outpatient Unit than in other units

The limited type of nursing service actions done in the Outpatient Unit affects the workload there, which is felt to be much different compared to other units. The minimum invasive action such as giving injection is one of the actions taken by the PKs III in the Outpatient Unit and it is seemed to be incomparable compared to the invasive action given in other units, which put more pressure and burden on the PKs III's work and give impact on their service to patients. This job pressure, such as physical and emotional exhaustion problems due to various work activities, affects the mental health and welfare of the nurses which likely lead to decreasing productivity, performance, and quality of nursing services toward the patients.^29,30

This lighter workload in the Outpatient Unit happens because the nursing service given by the PKs III is not in accordance with the detail of their clinical authority. So compared to the high skill and knowledge they have, the services they provide have not represented their status as a PK III. Considering the details of PKs III's a clinical authority which all require high ability and intensity in service, this condition may lead to the nurses’ physical and emotional burden. A competent nurse must be able to perform various health care treatments which are needed by individuals, families, and communities, as well as to be committed to performing services as a competent nurse which requires full concentration, energy, thought, presence, and contribution.^31,32

The hospital nursing manager in the Nursing Field can consider applying the model of care service intensity to create a fair workload for nurses, which focuses on different aspects of care service but are all integrated into direct care elements toward the patients for all clinical nurses in the hospital. In this case, the aspect of workload can become a consideration in assigning nurses with certain levels of competence into the appropriate units. Half of the nurses in the hospital always have a lower or higher workload than the average workload in each unit which then raises a problem of not ideal nursing service intensity with the workload in the hospital. This workload problem needs to be solved by the hospital authorities in order for the nursing and hospital organizational system function smoothly and to increase job satisfaction, nursing services quality, nurse job satisfaction, and patient satisfaction.^33,34

PKs III feel more comfortable working in the Outpatient Unit

Generally, the PKs III in the Outpatient Unit has previously worked in other units which have more complicated types, activities, and patterns as well as irregular working time. The comfortable feeling felt by the PKs III in the Outpatient Unit is due to the type of patients, who are independent, so the services given are generally simple and administrative without reducing the function and purpose of the service itself. A nurse represents a professional work group on health services. A nurse with irregular working time behaviors, activities, and patterns indicates the working pressure which leads to a loss. On the other hand, a nurse who works eight hours in a permanent shift in the Outpatient Unit has a good mental health and good self-performance in her working place and environment. The comfortable working condition is due to a simple service system, supporting facilities, and easy technical work of nursing services to be carried out by the nurses.^35–37

The detail of the clinical authority of the PKs III is stated in the Regulation of the Minister of Health No. 40 of 2017 which describes all obligations and responsibilities of a PK III as a high-level or competent clinical nurse. When compared to actual nursing services provided in the Outpatient Unit which mostly about the administrative matter, the comfortable feeling felt by the nurses does not indicate the achievement of a PK III based on her clinical authority, this condition becomes a dilemma for the nursing manager who wants to create a conducive working atmosphere for PKs III who have obstacles in providing services due to age and health status. When the purpose of a PK III according to the details of clinical authority is not achieved, it will block the achievement of organizational goals in hospital nursing. A nurse are the largest sector of health workers and represent a dynamic opportunity to change the service environment at the point of practice. The regulation of service implementation which is based on the responsibility of an innovative clinical nurse will be useful for organization. The nursing manager can set the implementation strategy that creates a proper working environment which is in line with clinical responsibility and able to support the nurses as well as maximizes the services given to the patients.^38,39

A comfortable working environment in the Outpatient Unit does not provide benefits and contributions of the PKs III in achieving nursing organizational goals at the hospital because of the disproportion of the PKs III distribution in the Outpatient Unit and other units. Other units of clinical nursing services which have less competent nurses can give a disadvantage to the patients because they are handled by nurses whose competence is not in accordance with the patient's condition. There is a relationship between the number and type of inadequate nurses and negative effects of service for the patients, such as a fault in giving medication, ulcers, mistreated patients, and falling patients.^40,41

The role of PKs III in the Outpatient Unit as the in-charge person and educator

The role of PKs III as the in-charge person in one particular area of service can be conducted by providing and managing individual nursing services, clinical population, and community. In this role, a PK III is responsible for the management of comprehensive patient nursing services throughout the series of services for patients in the Outpatient Unit. The nurse as a leader is responsible for planning contact with the health care system, coordinating and planning the team function activities, having knowledge and authority to delegate tasks to other nursing personnel, and taking the initiative to design and implement nursing services.^42,43

There are various types of services provided in the Outpatient Unit, one of them is giving education. One type of education provided here is an education for cardiac patients given by the higher skilled nurse. The nurse who gives this education is required to have a non-formal education certificate for cardiac care as proof that the nurse is competent to give this education. The formal and non-formal education programs are one of the learning strategies to improve optimal competencies, knowledge, and skills in the form of design, implementation and evaluation of certain nursing services so that they can reflect themselves to educate patients on nursing practice.^44,45

Of the four roles a PK III has, the PKs III in the Outpatient Unit only has two roles, which are as the in-charge person and educator. Based on scientific evidence, the role as clinical nurse practitioner and service developer cannot be conducted due to lack of knowledge of the PKs III and lack of support from nursing manager (the Nursing Division and the Nursing Committee) who have not socialized the role and detail of the clinical authority of the PKs III, so that the PKs III have not been able to fully play the PK III's role. The availability of clinical nurses along with their roles and functions in the patient nursing service unit is a better way to give support during the implementation of the change for the better, and this requires support and promotion from the organization's leaders. The nursing organization has the authority to determine the application of the nurse's role according to the level of knowledge, skill and authority to triggering changes in nursing services and improving service quality so that all nurses will have strong knowledge of nursing practices based on scientific evidence and can work collaboratively in teams.⁴⁶

Conclusion

This study results in five themes which describe the experience of PKs III in undergoing a career path in the Outpatient Unit which are formed from eleven categories, the five themes obtained are related to each other; including the reasons for assessing the PKs III due to their own request, health status and age, PKs III's lack of understanding related to career level, lighter workload, comfortable feeling felt by PKs III, and roles of PKs III as the in-charge person and educator in the Outpatient Unit.

PKs III in the outpatient unit does not function according to their responsibilities because the details of assignment in the unit have not required nurses to perform services according to their expertise. With the number of nurses in the outpatient unit, our suggested the collaboration of the Nursing Division and the Nursing Committee in developing programs to improve understanding of function and responsibilities among nurses and makes details of nurses’ responsibilities that are appropriate for implementation in the outpatient unit.

Conflict of interests

The authors declare no conflict of interest.

Acknowledgments

This work is supported by Hibah PITTA 2018 funded by DRPM Universitas Indonesia No. 1848/UN2.R3.1/HKP.05.00/2018.