CHAPTER I

PRELIMINARY

A. BACKGROUND
Nursing services are the main service of hospital services. This happens because
nursing services are provided for 24 hours to patients who need them, in contrast to
medical services and other health services that only require a relatively short time in
providing health services to their clients. Thus the nursing services need to be improved
continuously and continuously so that hospital services will increase as well as
improving the quality of nursing services. (Ritizza, 2013).
The quality of nursing services is strongly influenced by the processes, roles
and functions of nursing service management, because nursing management is a special
task that must be carried out by the manager / manager of nursing which includes
planning, organizing, directing and overseeing existing resources, both resources and
source of funds so that it can provide effective and efficient nursing services to clients,
families and the community. (Donny, 2014).
Considering the important role of nursing service management, in this paper the
author will describe nursing care quality management indicators so that they can
illustrate how quality nursing management should be carried out.

B. PURPOSE OF WRITING
1. General Purpose
Students know how to recognize the quality indicators of nursing services in
hospitals
2. Special Purpose
a. Students are able to explain indicators of patient safety.
b. Students are able to explain the patient's self-care indicators.
c. Students are able to explain indicators of patient satisfaction.
d. Students are able to explain patient comfort indicators.
e. Students are able to explain the patient's anxiety indicators.
f. Students are able to explain the indicators of patient knowledge.

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 CHAPTER II

CONTENTS

A. PATIENTS SAFETY
What is meant by patient safety is a process in a hospital that provides safer
patient services. This includes risk assessment, identification, and risk management for
patients, incident reporting and analysis, ability to learn and follow up on incidents, and
implement solutions to reduce and minimize risk arising.
The patient safety standard according to Article 43 paragraph (2) is carried out
through incident reporting, analyzing, and defining problem solving in order to reduce
unexpected events. What is meant by incidents of patient safety are medical errors,
unexpected events ( adverse event), and near miss. To improve the quality of hospital
services, the Minister of Health according to Article 3 paragraph (1) Regulation of the
Minister of Health Number 1691 / Menkes / Per / VIII / 2011 concerning Hospital
Patient Safety, establishes the National Committee for Patient Safety of the Hospital.
independent under the coordination of the directorate general in charge of the hospital,
and responsible to the Minister.
Patient safety standards according to the Minister of Health Regulation Number
1691 / Menkes / Per / VIII / 2011 concerning Hospital Patient Safety, Article 7
paragraph (2) include:
1. Patient's rights
2. Educating patients and families;
3. Patient safety in continuity of service;
4. Use of performance improvement methods to conduct evaluations and programs to
improve patient safety;
5. Leadership role in improving patient safety;
6. Educate staff about patient safety;
7. Communication is the key for staff to achieve patient safety.

Furthermore, Article 8 of the Regulation of the Minister of Health requires that

each hospital strives to fulfill the Patient Safety Goals which include the achievement
of 6 (six) things as follows:

1. Accurate identification of patients;

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2. Increased effective communication;
3. Improved drug safety that needs to be watched out;
4. Exact-location certainty, appropriate procedure, appropriate patient operation;
5. Reducing the risk of infection related to health services, and
6. Reducing the risk of falling patients.

In order to implement the Patient Safety Standards, according to Article 9 of the

Regulation of the Minister of Health above, the Hospital implements the Seven Steps
to Hospital Patient Safety which consist of:

1. Build awareness of the value of patient safety;

2. Leading and supporting staff;
3. Integrate risk management activities;
4. Develop a reporting system;
5. Involve and communicate with patients;
6. Learn and share experiences about patient safety
7. Prevent injuries through the implementation of a patient safety system.

Through the implementation of the seven steps it is expected that patient rights
guaranteed in Article 32 of Law Number 44 of 2009 concerning Hospitals, are fulfilled.
These rights include obtaining quality health services in accordance with professional
standards and operational procedural standards as well as effective and efficient
services so that patients avoid physical and material losses. The association of hospitals
and health professional organizations according to Article 10 of the Regulation of the
Minister of Health concerning Hospital Patient Safety, is obliged to participate in the
preparation of the implementation of the Hospital Patient Safety Program.

Patient safety indicators, as implemented at SGH (Singapore General Hospital,

2006) include:

1. Patients fall due to negligence of nurses, conditions of patient awareness, nurse

workload, bed model, level of injury, and family complaints
2. Patients run away or go home forcibly, due to lack of patient satisfaction, patient
economic level, patient response to nurses, and hospital regulations
3. Clinical incidents include the number of phlebitis patients, the number of patients
with decubitus ulcers, the number of pneumonia patients, the number of tromboli

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 patients, and the number of pulmonary edema patients due to excessive fluid
administration
4. Sharp injury, including multiple infusion puncture marks, lack of nurse skills, and
patient complaints.
5. Medication incident, including five incorrect (type, drug, dose, patient, method,
time).

B. SELF-CARE
• The number of non-fulfillment needs for bathing, dressing, and elimination caused
by self-limitation.
• Number of unmet self needs (shower, toilet at the level of partial and total
dependence).

Percentage of patient self-care needs:

Number of patients who do not meet their needs x 100%

The number of patients treated with a degree of partial and total dependence

C. PATIENT SATISFACTION
Customer satisfaction is the main indicator of the standard of a health facility
and a low measure of customer satisfaction service quality will have an impact on the
number of visits that will affect the provability of health facilities, while employee
attitudes towards customers will also have an impact on customer satisfaction from time
to time. time will increase, as does the demand for quality services provided (Atmojo,
2006).
According to Irawan (2003), satisfaction is a feeling of pleasure or
disappointment from someone who gets the impression of comparing the results of
service performance with expectations. satisfaction or dissatisfaction is the customer's
response as a result and evaluation of performance / action mismatches that are felt as
a result of not fulfilling expectations.
This is also stated by Sugito (2005) which states that the level of satisfaction is
a function of the difference between perceived performance and expectations, if the

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performance is below expectations the customer will be disappointed Basically the
client's expectations are the client's expectations or beliefs that the service receives will
meet his expectations . While the performance results will be perceived by the client.
The conclusions that can be drawn from some of the meanings above are that
there is a common view that customer / client satisfaction is an expression of feeling
satisfied when accepting the reality / service experience fulfilling client expectations.
According to Kotler & Armstrong (in Huriyati, 2005 & Rangkuti, 2006) the
factors that influence satisfaction are related to consumer behavior, namely
a. Cultural Factor
Cultural factors have the most extensive and deep influence on
customer/client behavior. Cultural factors consist of several components, namely
culture, sub-culture and social class. Culture is a determinant of desires and
behaviors that are fundamental in influencing people's desires or satisfaction. Sub-
culture consists of nationality, religion, group, race, and geographical area.
Whereas social class is a relatively homogeneous group that has a hierarchical
arrangement and its members have values, interests and behavior. Social class is
not only determined by one factor but is measured as a combination of work,
income, and other variables.
b. Social Factors
Social factors are divided into small groups, families, roles and status.
People who influence groups / environments are usually people who have
characteristics, skills, knowledge, personality. This person is usually a role model
because his influence is very strong.
c. Personal Factors
Personal factors are a person's decision to receive service and respond to
experience in accordance with the stages of maturity. Client's personal factors are
influenced by age and life cycle, gender, education, occupation, economic status,
lifestyle, and personality / self-concept. Age has chronological and intellectual
dimensions, meaning chronological dimensions because progress is continuous and
will not return while the age of intellectual dimensions develops through education
and training. Age is a sign of a person's development / maturity to decide for
themselves on an action taken. Age can also increase the likelihood of diseases
such as cardio vascular disease with increasing age.
d. Psychological Factors

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 Psychological factors that play a role with satisfaction, namely motivation,
perception, knowledge, beliefs and establishment. Motivation has a close
relationship with needs. There are biological needs such as hunger and thirst, there
are psychological needs, namely recognition, and appreciation. Needs will be a
motive for directing someone to seek satisfaction (Sutojo, 2003).

According to Kotler (200 in Wijono 1999) states that patient satisfaction is

influenced by many factors, among others: approach and behavior of officers, client
feelings especially when first coming, information quality received, treatment
outcomes and care received, agreement procedures, waiting time . Therefore patient
satisfaction is the response of the patient's needs to the features of a quality service
product or service.

Patient satisfaction instruments based on the Five Characteristics (RATER):

No. Characteristics 1 2 3 4
1. Reliability
The nurse is able to handle your
care problems properly and
professionally
The nurse provides information
about available facilities, how to
use them and the rules that apply in
the hospital
The nurse tells clearly about things
that must be obeyed in your care
The nurse clearly tells you about
things that are prohibited in your
care
The time the nurse arrives in the
room when you need it
2. Assurance
The nurse pays attention to the
complaints you feel

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 The nurse can answer questions
about the care actions given to you
c. The nurse always greets and smiles
when meeting you

The nurse is honest in providing

information about your situation
The nurse is thorough and skilled
in carrying out nursing actions to
you
3. Tangibles
The nurse provides information
about the administration that
applies to inpatients at the hospital
Nurses always maintain the
cleanliness and tidiness of the
room you occupy
Nurses maintain cleanliness and
readiness of medical devices used
Nurses maintain the cleanliness
and completeness of bathroom and
toilet facilities
Nurses always maintain neatness
and appearance
4. Empathy
The nurse provides information to
you which treatment actions will
be carried out
Nurses are easily found and
contacted if you need it
Nurses often look and check your
condition such as measuring

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 tension, temperature, pulse,
breathing, and intravenous fluids
Nurses do not look at rank / status
but are based on your condition
when give services
Take care of your attention and
give moral support to your
situation (ask and talk about your
situation)
5. Responsiveness
The nurse is willing to offer
assistance to you when
experiencing difficulties even
without being asked
The nurse immediately treats you
when you arrive at the inpatient
room
Nurses provide special time to help
you walk, urinate, defecate,
change sleeping positions, and
others
The nurse helps you to get
medicine
The nurse helps you to carry out
photo and laboratory services at
this hospital
Information:
1 = very dissatisfied
2 = not satisfied
3 = satisfied
4 = very satisfied

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D. COMFORT
Comfort is defined as the condition experienced by recipients based on comfort
measurements. There are three types of comfort (encouragement, tranquility and
transcendence) and four experience contexts (physical, psychospiritual, social and
environmental). The types of comfort are defined as follows:
• Relief: the recipient's condition requires immediate and specific treatment.
• ease: calm conditions or satisfaction.
• Transcendence: a condition where the individual is able to overcome the problem
(pain).
Four comfort contexts:
• Physical: related to physical sensations.
• Psychospiritual: related to self-awareness, internal self, including appreciation, self-
concept, sexual and life meaning; relating to the greatest commandment or trust.
• Environment: related to the surrounding conditions, conditions, and their effects.
• Social: related to interpersonal, family and social relationships.

Comfort theory includes three types of logical reasons:

1. Induction
Induction occurs after a generalization process occurs from observing
specific objects (Bishop & Hardin, 2006). When nurses learn about the practice of
nursing and nursing as a discipline, nurses become familiar with implicit or explicit
concepts, terms, propositions, and assumptions that support nursing practice.
2. Deduction
Deduction is the process of inferring general principles or premises to more
specific conclusions (Bishop & Hardin, 2006). The deductive stages of the
development of the theory produce a comfort relationship with other concepts to
produce a theory. Opinions from the triatheorists are included in the comfort theory,
therefore Kolcaba looks for the basic forms needed to unite the three basic concepts:
relief, ease, and transcendence. Something that is desired is a general conceptual
framework that is able to explain comfort to be a more easily understood term and
reduce the level of abstraction (Tomey & Alligood, 2010).
3. Retroduction
Retroduction is used to select phenomena that are suitable to be developed
more broadly and then tested again. This type is applied in areas that have only a

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 few theories (Bishop & Hardin, 2006). The expected results of giving nursing
intervention are obtaining patient comfort that can be seen from the perceptions
expressed by the patient.

E. ANXIETY
Anxiety is the first reaction that arises or is felt by patients and their families
when patients have to be treated suddenly or unplanned as soon as they start
hospitalization. Anxiety will continue to accompany patients and their families in every
treatment action against the disease suffered by the patient.
Anxiety is emotion and is an individual subjective experience, has its own
strength and is difficult to be directly observed. Nurses can identify anxiety through
changes in patient behavior.
Anxiety is an emotion without a specific object, the cause is unknown and
preceded by a new experience. Fear of having a clear source and object can be defined.
Fear is an intellectual assessment of a threatening and anxious stimulus is an emotional
response to that assessment.
Anxiety is a condition that indicates a condition that threatens wholeness and
existence and is manifested in the form of behaviors such as helplessness, inadequacy,
fear, and certain phobias.
Anxiety arises when there is a threat of helplessness, loss of control, feeling of
loss of functions and self-esteem, failure of defense, feeling of isolation (Nursalam,
2015).
The Zung Self-Rating Anxiety Scale (SAS / SRAS) is an assessment of anxiety
in adult patients designed by William W. K. Zung, developed based on anxiety
symptoms in Diagostic and Statistical Manual of Mental Disorder (DSM-II). There are
20 questions, where each question is rated 1-4 (1: never, 2: sometimes, 3: part time, 4:
almost every time). There are 15 questions in the direction of increasing anxiety and 5
questions towards decreasing anxiety (Zung Self-Rating Anxiety Scale). The anxiety
rating scale is illustrated in the table below:

No Statement Never Sometimes Often Always

1. I feel more nervous 1 2 3 4
and anxious than usual

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2. I feel scared for no 1 2 3 4
reason at all
3. I am easily angry or 1 2 3 4
feel panic
4. I felt like I was falling 1 2 3 4
apart and would be
shattered
5. I feel that everything 4 3 2 1
is fine and nothing bad
will happen
6. My arms and legs 1 2 3 4
trembled
7. I was troubled by 1 2 3 4
headache and back
pain
8. I feel weak and easily 1 2 3 4
tired
9. I feel calm and can sit 4 3 2 1
still easily
10. I felt my heart 1 2 3 4
pounding
11. I felt dizzy around 1 2 3 4
12. I had fainted or felt 1 2 3 4
like that
13. I can breathe easily 4 3 2 1
14. I felt my fingers and 1 2 3 4
toes numb and
tingling
15. I feel disturbed by 1 2 3 4
stomach pain or
indigestion
16 I urinate often 1 2 3 4

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17. My hands are usually 4 3 2 1
dry and warm
18. My face was hot and 1 2 3 4
blushing
19. I easily fall asleep and 4 3 2 1
get a good night's rest
20. I have a bad dream 1 2 3 4

The assessment range is 20-80, with groupings including:

Score of 20-44: normal / not worried
Score of 45-59: mild anxiety
Score of 60-74: moderate anxiety
Score of 75-80: severe anxiety

F. KNOWLEDGE
According to Notoadmodjo (2003: 121) Knowledge is the result of "know", and
this occurs after people have sensed a particular object. So this knowledge is obtained
from sensory activity, namely vision, smell, touch and sense of taste, most knowledge
is obtained through the eyes and ears (Nursalam, 2015).
Knowledge or cognitive is a very important domain in shaping one's actions.
Rogers (1974) research in educational books and health behaviors (Notoatmodjo, 2003
and Nursalam, 2007) revealed that before people adopt new behaviors, sequential
processes occur in that person, namely:
1. Awareness, when someone realizes in the sense of knowing in advance the stimulus
(object).
2. Interst, when someone starts to be interested in stimulus.
3. Evaluation, the good and not the stimulus for him.
4. Trial, when someone has tried a new behavior.
5. Adaptation, when a person has a new attitude that is in accordance with knowledge,
awareness, and attitude towards the stimulus.

However, based on further research, Rogers concluded that behavior change

does not always go through the above stages. If the recipient of a new behavior or

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behavior adoption through a process like this is based on knowledge, awareness and a
positive attitude, then the behavior will be long lasting. Conversely, if the behavior is
not based on knowledge and awareness, that behavior will not last long (Nursalam,
2015).

Knowledge of treating the disease:

Number of patients who lack knowledge x 100%

Number of patients treated for a certain period

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 CHAPTER III

CLOSING

A. CONCLUSION
Nursing service quality indicators are very important for a hospital institution,
because the quality of nursing services is an assessment for the community towards a
hospital. This quality indicator is the image of a hospital. There are several factors that
influence the implementation of the quality indicators of nursing services in the
inpatient room.
Quality Management in Nursing Services is a comprehensive nursing service
that includes bio-psycho-socio-spiritual services provided by professional nurses to
patients (individuals, families and communities) both sick and healthy, where care is
given according to patient needs and service standards. In simple terms, the quality
control process starts from compiling standards - quality standards, then measuring
performance by comparing existing performance with established standards. If it is not
appropriate, a corrective action is taken. If you want to improve performance, you need
to set new standards that are higher and so on.

B. SUGGESTIONS
We as nurses today must begin to improve quality management and be able to
maintain quality quality as well as possible. Especially quality management in nursing
services provided to clients and patients so that they can become professional nurses.

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Penerbitan Ikatan Dokter Indonesia
Gillies, D.A. 1994. Nursing Management, A System Approach. Third Edition. Philadelphia :
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Handoko, T. 1997. Manajemen.Yogyakarta: BPFE
Kozier, Erb & Blais. 1997. Profesional Nursing Practice: Concept & Perspectives. Third
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Kuntoro, Agus. 2010. Buku Ajar Menejemen Keperawatan. Yogyakarta : Nuha
Maequis, Bessie L. 2010. Kepemimpinan dan Manajemen Keperawatan: Teori & Aplikasi,
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