Person-centred care in the Indonesian health-care system

R E S E A R C H P A P E R

Person-centred care in the Indonesianhealth-care system

Wan Nishfa Dewi RN BN MNgPhD 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 PhDSenior Lecturer, School of Nursing and Midwifery, University of South Australia, Adelaide, South Australia, Australia

Helen Bradley PhD MEdSt GrCertIntHlth BEd RN RMSenior Lecturer, School of Nursing and Midwifery, University of South Australia, Adelaide, South Australia, Australia

Sandra Ullrich PhD BSc (Hons) Grad Dip (Gerontology) BN RNResearcher/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 thatare respectful of and responsive to the characteristics, needs, preferences and values of the individual person. This modelof care puts the person at the centre of care delivery. The World Health Organization suggests that PCC is one of theessential dimensions of health care and as such is an important indicator of health-care quality. However, how PCC isimplemented 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.

INTRODUCTIONPerson-centred care (PCC) is defined as health-care pro-viders, such as nurses, selecting and delivering interven-tions or treatments that are respectful of and responsive tothe characteristics, needs, preferences and values of theperson or individual.1–5 The essence of PCC is to shift theperson from having a passive role in the health care that

he or she receives to becoming actively involved in deci-sions about his or her care. It moves away from an empha-sis on disease to a model that integrates the biological,psychological and social dimensions of illness.6,7 Theapplication of PCC in a clinical setting implies that nurseswill assess the person’s needs, values and preferences, andthen select and implement interventions that are consid-ered and responsive to their client’s needs.

PCC has become an established approach to the deliv-ery of health care, and a growing number of organizationsare starting to adopt a PCC model of care.8,9 In the UK,Australia, Europe and the USA, there has been substantialdevelopment of the PCC model of care. In the USA PCC

Correspondence: Wan Nishfa Dewi, School of Nursing and Midwifery,University of South Australia, GPO Box 2471, Adelaide, SA 5001,Australia. Email: [email protected]

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International Journal of Nursing Practice 2013; ••: ••–••

doi:10.1111/ijn.12213 © 2013 Wiley Publishing Asia Pty Ltd

is considered to be a health-care priority,10 and in the UKPCC has been embedded in many policy initiatives.9

However, PCC is not widely used in the health-caresystems of developing countries. It is likely that PCC iscontrary to some of the current approaches to care deliv-ery in these countries.1,11 It might also be that the philoso-phy that underpins PCC is different from those thatinform health care in some developing countries. In addi-tion, different countries and institutions have differentunderstandings of what PCC means and different ways oftranslating it into care delivery. This article will explorethe nature and characteristics of PCC with a particularfocus on its introduction into developing countries andspecifically to the Indonesian health-care system.

TERMINOLOGYIn the literature, the word person in person-centred care isused interchangeably with patient, client, individual andresident.12 The variation depends on the context in whichcare is provided. In the hospital setting the term patient-centred care is most commonly used, whereas in aged careit is resident-centred care. Different terms are used inter-changeably in the literature to reflect the concept ofPCC. These include client-centred care, individualized care,self-directed care, patient-centred care, relationship-centredcare and family-centred care.1,13–16 However, the intent ofthe care delivery is consistent across all of these terms:that PCC care should be individualized and responsiveto the needs of the client.

DEFINITIONSDefinitions of PCC in the literature differ. McCormackdefines PCC as ‘the formation of a therapeutic narrativebetween professional and patient that is built on mutualtrust, understanding and a sharing of collective knowl-edge’.17 Suhonen, Leino-Kilpi, and Välimäki18 define PCCas being comprehensive care that fulfils patients’ physical,psychological and social needs. Kitwood describes it as astatus that is given to one person by another and involvesrecognition, respect and trust.19

From a slightly different perspective, Nolan et al.20 con-siders it to be relationship-centred care because all partiesinvolved in the care must experience relationships thatpromote a sense of security, belonging, continuity, goalsand achievements.20 One of the first international organi-zations to introduce PCC into the health-care system toimprove care by considering the totality of the experiencethrough the ‘eyes of the patient’ was the Picker Institute.21

The Picker Institute defines PCC as a partnership betweeninformed and respected patients and their families and thehealth-care team to achieve quality health care.22

The nursing literature is consistent in the view thatbeing person-centred requires the formation of a thera-peutic relationship between care professionals andpatients and other significant persons. McCormack andMcCance proposed a definition of person-centred carewithin a nursing context:

Person-centredness is an approach to practice establishedthrough the formation and fostering of therapeutic relation-ships between all care providers, older people and otherssignificant to them in their lives. It is underpinned by valuesof respect for persons, individual right to self-determination,mutual respect and understanding. It is enabled by cultures ofempowerment that foster continuous approaches to practicedevelopment.13

PCC makes the client and his or her family an integralpart of the care team, and as such they collaborate withhealth-care professionals in the decisions that impact onthe care that they receive.

CHARACTERISTICSIt is not just the terminology and definitions that are opento interpretation; the characteristics of this model of careare also viewed differently. There have been manyattempts to characterize the attributes of PCC. Contem-porary views of PCC are based largely on research con-ducted by the Picker Institute.23 This early work identifiedseven characteristics:

• Respect for patient values, preferences and expressedneeds

• Coordination and integration of care

• Information, communication and education

• Physical comfort

• Emotional support relieving fear and anxiety

• Involvement of family and friends

• Transition and continuitySome authors, such as Mead and Bower,24 Radwin25

and Poochikian-Sarkissian et al.,26 have also attempted todescribe the characteristics of PCC. Although there aresome differences in the characteristics reported, threecommon 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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© 2013 Wiley Publishing Asia Pty Ltd

Importantly, these three characteristics emerge as theprinciples of PCC and are in line with the concept thatnursing care is individualized.4,25,27

Patient and family participation and involvement is animportant component of delivering PCC, particularly innursing care.28 In PCC, the traditional view of caring hasbeen substituted with one that actively engages patients intheir own care. Sharing information and shared decision-making in PCC is a dynamic process in providing bettercare. Information, education and counselling are neededin the PCC model of care, as is health-care practitioners’providing trustworthy information that is responsive andtailored to the patients’ individual needs.29

IMPACT ON HEALTH CAREThere are a number of benefits related to the implemen-tation of PCC into health-care practice, includingincreased satisfaction with care, improved independentself-care, better team performance, organizational effec-tiveness and efficiency, and an enhanced quality of healthcare.2,3,7,27,30–32 PCC can also increase consumers’ satisfac-tion with outcomes of health-care delivery.30 A study byStewart et al.2 on the impact of PCC in healthcare showedPCC contributed to improved recovery and a reduction indiagnostic tests and referrals.2 Hook examined the rela-tionship between PCC and quality of care and found thata good partnership between patients and health-care pro-viders supported patients having a greater say about theircare and improved outcomes such as patient independ-ence in self-care and improved health-care utilization.31

Sidani27 and Wolf et al.7 found PCC contributed toincreased self-care ability, improved functional status, sat-isfaction and quality of care received. These authorssuggest that patient satisfaction and quality of care inwards using a PCC model of care rated more highly thanwards that did not use PCC.

Few developing countries have implemented PCC.However, the impact of PCC in countries such as Lebanonand Jordan has been investigated.32,33 PCC improvedpatient satisfaction, efficiency, competence and attitudesin both countries.32,33 Implementing PCC also brought arange of benefits for patients by enhancing their independ-ence18 and improving quality of care.27,34

INTERNATIONAL EXPERIENCESRecent policy developments across developed countrieshave highlighted the importance of a PCC approach within

health-care services.9,35,36 In the UK, USA, Canada, Aus-tralia and some European countries such as the Nether-lands and Denmark, PCC has become an expecteddimension of high-quality care. In 1997, the NationalHealth Services in the UK started to develop a PCC envi-ronment. From that time the implementation of thismodel became an agenda to be delivered and achieved byall health services in the UK.36,37

In the USA, the concept of PCC has become morepopular since the Institute of Medicine in 2001 reinforcedthis concept of care in the new health system for the 21stcentury. This new model of care delivery considers thatgood quality care should be safe, effective, patient-centred, efficient and equitable and considers PCC a fun-damental practice for high-quality care in the USA.38 InCanada and Denmark PCC provides highly accessible carefor patients and families by health professionals.8 BothAustralia and the Netherlands have also implemented aPCC model of care. The Dutch associate PCC withresponsiveness,8 whereas in Australia PCC is grounded inmutually beneficial collaboration among health-careprofessionals, patients and families.39

THE HEALTH-CARE SYSTEMIN INDONESIA

Indonesia is one of the world’s most densely populatedcountries, consisting of 33 provinces and home to manydifferent cultures, religions and racial clusters, resultingin many different views of health. The diversity ofIndonesia’s environment and population poses enor-mous challenges to effective health-service delivery.40,41

The health-care system consists of two sectors: public (orstate) and private. The government funds public hospitalsand Puskesmas, or primary health-care clinics, across Indo-nesia, and private hospitals and clinics are run by privatecompanies and individual organizations.42 The publicsystem has different levels of care, from Class 1 to Class 3.Class 1 patients usually have some health insurance andreceive the maximum resources that a public healthsystem can provide. Class 2 patients receive a lower levelof service but still incur costs. Class 3 covers the poorestpeople, who have free health care but minimal access toresources. This group is covered by the central and localgovernment health-care cards, or jamskesmas and jamkesda.

Currently, most health-care services in Indonesia arebased on a conventional model of care. Conventional careis related to the delivery of care based on routine activitiesand tasks.43 The conventional care implemented in most

Person-centred care in Indonesia 3


of the hospitals is such that the caregivers expect that theirpatients will be compliant—that is, follow their instruc-tions according to Indonesian social norms. Health-careproviders do not normally consult patients, nor do theydeliver care that is based on individual patient prefer-ences. Socially, patients do not expect that their concernswill come first or that they will have a voice in decisionsrelated to their care delivery.

In Indonesia, health-care professionals are highlyrespected and commonly come from the higher class ofsociety. Doctors have a higher status than nurses. Thisdifference in social status can serve as a barrier betweenthe provider and the recipient of health care. Patientshave little opportunity to discuss or consult with medicalpractitioners, who hold a higher social status than them-selves.43 This hierarchy of social status also influencesnursing practice in Indonesia, because nursing has a socialstatus that is lower than that of other health professions.As a consequence, nurses have little independence in howthey deliver nursing care and determine patient needs.43

Introducing PCC into the Indonesian health-care systemcould challenge this traditional approach to care with anew and unfamiliar model that could also challenge healthpractitioners.

PERSON-CENTRED CARE ININDONESIA

There is very little information about the use of PCC inIndonesia. One study on family-centred care (FCC) foundthat implementing FCC in Indonesia encountered diffi-culties related to an insufficient number of healthworkers.44,45 However, there is little further evidencerelated to PCC in the Indonesian healthcare system.While PCC is a new concept to Indonesian nurse practi-tioners and researchers, it is possible to identify barriers toand enablers of PCC.

BARRIERSAlthough there has been an investment in resources toimprove the quality of health-care delivery in Indonesia,some barriers still exist. These include decentraliza-tion, workforce issues, health education and socialstratification.5,8,37,41,45–47 These barriers all influence theimplementation of PCC in the Indonesian health-caresystem.

The general decentralization process implemented in2001 has had many impacts on the health system. Newresponsibilities have been given to local governments,

which are poorly prepared for planning new health poli-cies, and some public health institutions and hospitals nowhave a focus on profit.46 As stated, workforce issues arealso considered an important barrier to the implementa-tion of PCC in Indonesia. Human resources for health havebeen affected by the decentralization policy. Health work-force issues are grounded in long-standing policies aboutcentral planning and deployment, budget limitations andceilings on workforce numbers in Indonesia.41,48 Existingcivil service regulations constrain central and local govern-ments in addressing the problems.40 These workforceissues might serve to limit any further changes to caredelivery because the system is already struggling to cometo terms with the changes related to decentralization.

Although PCC has been introduced through thenursing curriculum, nurses have not been able to influ-ence its introduction into the clinical area because of theirlack of clinical authority. However, the existing nursingand medical workforce have a limited understandingof PCC. A lack of education about PCC in this grouphas been identified as a barrier in the literature.5,49,50

Therefore, this is likely to be an important barrier to theimplementation of PCC in Indonesia.

Social and economic differences between the health-care professionals and patients are also a barrier to PCC.As previously discussed, in Indonesia health-careprofessionals have a higher social status than theirpatients. This difference in social status can serve as abarrier between the health-care professionals and thepatients. Similarly, the social status of nurses within thehealth system in Indonesia is lower than that of otherhealth professionals, especially medical doctors, so thisimpacts on their autonomy in clinical practice. As a con-sequence, these two factors have acted as barriers toPCC implementation.

ENABLERSThere are also enablers that could support the implemen-tation of PCC in Indonesia. Decentralization has also hada positive impact because it has accelerated change in thehealth sector and in the nursing profession. Decentraliza-tion can increase the responsiveness of a system to localconditions by encouraging the growth of decision-makingcapacity and by developing the skills, abilities and moti-vation of local officials who work in the health sector.51

Therefore, local governments can be more flexible indetermining health sector priorities to better meet theneeds of their region.

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The need to have nursing recognized as a profession inIndonesia has prompted the Indonesian National NursesAssociation to request the government to acknowledgetheir identity as a health profession. They are developinga credentialing system which will provide a legislativeframework within which nurses will practice. Efforts arecurrently underway to develop and implement competen-cies to strengthen nursing as a self-regulating, accountableand professional body with a code of ethical conduct anda ‘Nursing Act’.48 Professional nurses play an importantrole in promoting quality of care in health systems.Having more qualified, skilled and scholarly nurses islikely to foster the transformation of nursing in Indonesia,not only in practice but also in education.

DISCUSSIONStudies have demonstrated the many benefits that accom-pany a person-centred approach to health-care delivery.However, there are few studies of PCC in the developingworld and none in Indonesia. To improve the provision ofhealth care and to implement PCC as a new model of carein Indonesia there are challenges still to be addressed.

The challenges for PCC in Indonesia identified in thispaper are the lack of nursing authority, decentralization,workforce issues and social stratification. Nursing has alack of authority and has been unable to influence the useof PCC in the hospital or clinical setting. Although edu-cation of nurses will assist in the change to care deliveryprocesses, more is needed to ensure a sustained imple-mentation of PCC. The workforce issue can be resolvedby refining the deployment of staff and analysing the skillmix to support the implementation of this new model ofcare.52 Consequently, skilled, qualified and scholarlynurses would improve care and help support the imple-mentation of the PCC model in the Indonesian health-caresystem.

CONCLUSIONA person-centred approach to health care can improve thequality of patient care and increase satisfaction and adher-ence to care programs. PCC is now considered by manyto be an important dimension of quality in health care.However, its implementation internationally might beimpeded by a lack of understanding. Implementation ofPCC in the health systems of developed and developingnations might encounter quite different challenges reflect-ing the unique cultural views, health-care practices and

social norms of individual countries. Implementation ofPCC in a developing country such as Indonesia willrequire changes in attitudes and skills to accommodate thediffering view of health that PCC demands.

ACKNOWLEDGEMENTThe first author would like to thank the DirectorateGeneral of Higher Education, Ministry of Education andCulture, Republic of Indonesia, for her PhD scholarship.

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Person-centred care in the Indonesian health-care system