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College of Nursing National Taipei University of Nursing and Health Sciences Master Thesis



The Exploration of Indonesian Nurses’ Perceived of Quality Nursing Work Environment: A Case of Sardjito Hospital In Yogyakarta, Indonesia



Aric Vranada



Advisor: Chiou-Fen Lin, Ph.D., RN



June 2016



CONTENTS CHAPTER I INTRODUCTION ................................................................................ 1 1.1



Background and Research Motivation ............................................................ 1



1.2



Research Objectives ........................................................................................ 4



1.3



Research Question ........................................................................................... 4



1.4



Research Hypothesis ....................................................................................... 4



1.5



Operational Definition..................................................................................... 5



1.6



Research Contributions ................................................................................... 6



CHAPTER II LITERATURE REVIEW ................................................................... 7 2.1



Nursing Work Environment ............................................................................ 7



2.2



Measurement Related to Nursing Work Environment .................................... 9



2.3



Conceptual Framework ................................................................................. 14



CHAPTER III RESEARCH METHOD .................................................................. 15 3.1



Study Design ................................................................................................. 15



3.2



Setting............................................................................................................ 15



3.3



Population and Sample .................................................................................. 15



3.4



Research Instruments .................................................................................... 16



3.5



Data Collection .............................................................................................. 18



3.6



Data Analysis ................................................................................................ 18



3.7



Ethical Consideration .................................................................................... 19



3.8



Research Process ........................................................................................... 19



REFERENCES ........................................................................................................... 21



LIST OF TABLES Table. 1 8-Dimentions Indicator of Quality Nurse’ Work Environment….……….......



15



LIST OF FIGURES Figure 1. The Quality of Nurses’ Work Environment…………………………............



13



1



CHAPTER I INTRODUCTION



1.1 Background and Research Motivation Nurse are health workers in hospitals that provide nursing care to patients for 24 hours. Workload of nurses was high due to insufficient numbers of nurses will have an impact on the decrease in work productivity that may affect nurses care for patients. Nurses play an important role in patient care in hospital organizations. Their ability to provide excellent patient care is influenced by the health of the work environment, defined as the extent to which they can engage in professional practices identified as essential to quality patient outcomes (de Brouwer, Kaljouw, Kramer, Schmalenberg, & van Achterberg, 2014) Several countries face difficulties in attracting and retaining nursing shortage (Zhu et al, 2013). In Uganda in 2008 it was observed that there was an imbalance between the number of nurses trained and those who register to practice. It was speculated that nurses have migrated to other countries, have joined other fields, or sit at home due to the poor work conditions. Nurses also complain that their work is very stressful citing the very



high nurse-patient ratio which is reported to be 1:1000. The nurse-patient ratio is reported to be above the 1:2 or 1:5 recommended by the World Health Organization for fatal complications and common illnesses respectively (Natukunda, 2008). In Dagahi study that 74.5 percent of nurses were dissatisfied with the quality of their work life in Iran. From Khaghanizadeh study have indicated that 81% of nurses have an average level of quality of work life. On the other hand, one of the most important sources that create stress in every body’s life is his/her job (Mohammadi et al., 2011). Brooks and Anderson (2004), stated that nursing workload was too heavy, and that there was not enough time to do the job well. Respondents had little energy left after work, were unable to balance their work and family lives and stated that rotating schedules negatively affected their lives. A possible answer to the upcoming shortage is the creation of a productive and healthy work environment for nurses because relationships and work processes of work environments affect nurse job satisfaction, productivity, quality of patient care and turnover rates (Aiken et al., 2011). A positive nursing work environment enables nurses to demonstrate professional practice (Hinno, Partanen, VehvilÄInen-Julkunen, &



2 Aaviksoo, 2009). Lake (2002) explained that conceptualized such a work environment as one that empowers nurses with increased opportunities for autonomy, accountability, and control over the work environment. Researchers of magnet hospitals have identified the following factors in a positive nursing environment: leadership attributes of nursing administrators (e.g., vision and responsiveness), professional attributes of the staff nurses (e.g., nurse autonomy and control, ability to establish and maintain therapeutic nurse–patient relationships, and collaborative nurse–physician relationships), and an environment that supports professional practice (Lundmark, 2008). Many factors affecting the job satisfaction of nurses have been linked to elements in the professional practice environment. Existing studies consistently emphasize autonomy, interpersonal communication and collaboration, professional practice, administrative and management practice, opportunity for advancement and promotion, working conditions, and the physical environment as attributes of job satisfaction (Choi, Bakken, Larson, Du, & Stone, 2004). Characteristics of nurses’ work settings (i.e., type of shift and shift length) also have been examined in relation to job satisfaction and levels of job stress (Jennings, 2008). Indonesia, with its population of over 220 million, has health problems similar to those of other developing countries. Indonesia has experienced in nursing shortage almost in most both public and private hospitals, and its impact on patient safety and also quality of care (Dikti, 2013). The Ministry of Health of Indonesia launched data that average of nursing vacancy rate shown less than 10% in 2013 (Depkes, 2014). Whereas the hospital’s need for nurses is still lacking in Indonesia. The average of Indonesian nurses in caring for patients is 1:10 ratio (Yusuf, 2012). That such of shortage is related with the quality of nursing work environment which doesn’t meet of nurses’ expectation. Bauman (2007) explained that quality workplace is equal to quality of patient care, and it is indicated by strong relationship among quality of work environment, nursing shortages, quality of care, and mortality rate. The link between negative working conditions and employee stress is well known. Work stress and burnout are also associated with negative work attitudes and performance. In healthcare settings, these conditions threaten the quality of patient care and patient safety. According to the survey results of the Indonesian Nurse Association ( PPNI ) in 2006 approximately 50.9% of nurses working in four provinces in Indonesia experiencing job stress, frequent dizziness, fatigue, less of rest time because the



3 workload is too high and time-consuming, low salaries without adequate incentives. Sheward (2007) mentioned that nurses working overtime continuously or work without adequate support tend to not get in a lot of work and poor health conditions. There are no many researches examine about quality level of nurses’ work environment in Indonesia. Almost researchers in Indonesia doing investigation related to nurses’ work life. According to Randa (2010), from total 30 inpatient nurses who worked at dr. M. Djamil Hospital, Padang 20% stated that the compensation received less balanced, 63.3% stated security is still not guaranteed to work, 83.3% stated facilities obtained less complete, 66.6% stated that environmental safety less secure employment, 50% of nurses reported having low participation in employment, 76.6% did not get a chance in development career, 66.6% of nurses expressed solving problems in the job less maximum, 30% of nurses expressed in the job less effective communication. In order to provide safe and quality of care, need development of professional strategies and also promote the quality of nursing work environment. In response to nursing shortage issues in Indonesia, measurement using quality of nursing work environment (QNWE) could be a good breakthrough of resolving Indonesian nurses’ unemployment, low nursing retention, and overall satisfaction (Lin, Lai, Lu, & Huang, 2014). Nursing work environments are the key issue while ensuring that quality care is provided also the importance of understanding nurses’ perceptions about their work (Almost et al., 2013). Sardjito Hospital is the type A hospital which a referral hospital in Yogyakarta and South Central Java area. One of its missions is to give complete services, quality and affordable for community, towards a featured hospital in Southeast Asia (Ulfa, 2015). Sarjito hospital has 23 Medical Functional Unit, 29 installation with 750 amount number of beds, divided into VVIP, VIP, the main class, class I, class II, and class III. Sardjito hospital has 874 nurses and total of them shared in all departments of the hospital (Sardjito Hospital, 2015). Ulfa (2015) stated as a referral hospital in Yogyakarta and southern part of Central Java, Sarjito hospital had experienced receiving many patients with a variety of cases. The amount number of patients who entered Sardjito hospital for JanuarySeptember 2014 as many as 24.127 patients. With that amount number of patients, nurses of Sardjito hospital are also required to have competence in conducting caring (Joint Commission International, 2011). Handini (2012) explained if the number of



4 patients who come to exceed the normal capacity of nurses to work, it can lead to excessive workload, physical fatigue, mental and emotional and led to the occurrence of burnout in nurses. From those reasons above, researcher interested in exploring of Indonesian nurses’ perceived of quality nursing work environment in Sardjito Hospital of Yogyakarta. 1.2 Research Objectives The purpose of this study is to explore the quality of Indonesian nurses’ work environment level. The objectives are as the following: 1. To explore Indonesian nurses’ perceived quality level of work environment 2. To analyze relationship between Indonesian nurses’ demographics and their perceived quality levels of work environment. 1.3 Research Question Regarding of research purpose, there are two research questions in this study, those two research questions are: 1. What are Indonesian nurses’ perceived quality levels work environment where they are working in hospital as 8 dimensions of quality nursing work environment (QNWE)? Those 8 dimensions are: (a) safe practice environment, (b) staff quality, (c) workload, salary, and welfare, (d) specialization and cooperation, (e) work simplification, (f) information, (g) professional cultivation and development, (h) support and care, and total satisfaction on current nursing work environment. 2. What are the relationship between Indonesian nurses’ demographics and their perceived quality levels work environment where they are working as a QNWE in all those 8 dimensions? 1.4 Research Hypothesis Based on background stated above, the researcher defined hypothesis as the following: 1. There is high perceived quality levels of Indonesian nurses’ quality work environment at Sardjito Hospital of Yogyakarta 2. There is positive relationship between Indonesian nurses’ demographics data and their perceived quality levels work environment at Sardjito Hospital in Yogyakarta



5 1.5 Operational Definition The definition of each predictor is as follows: 1. Quality of Nursing Work Environment Quality of Nursing Work Environment (QNWE) is a tool that be used to measuring the quality level of nurses’ work environment. QNWE has 8 domains as follows: a. Safe practice environment A nursing practice environment free of biological, physical, chemical, psychosocial, and ergonomic hazards b. Staff quality Quality means nurses’ educational experiences, work experiences, and other obtainable practice qualifications c. Workload, salary and welfare Salary defined as the institution pays staff regularly to compensate their hard work. Welfare defined as nursing unit or department has sufficient nursing staff and assistants based on their service provided. Received rewards or services as part of institution employees, which is not directly related to personal performance, often time they are non-monetary rewards d. Professional specialization and cooperation Defined as multidisciplinary team members respect each other and how they work together e. Work simplification The institution continually simplifies nursing work procedures f. Informatics The institution uses informatics to increase efficacy, accuracy, and expediency g. Personal cultivation and development The institution cultivates excellence in nursing staff by allowing them to develop professional nursing roles and project a professional nursing image h. Support and caring The administrator’s management style offers support and care for nursing staff to optimize their performance 2. Nurse A person who has received the appropriate education and training in the discipline of nursing in providing nursing care in the hospital to individual, family,



6 and community. Nurse also a person educated and licensed in the practice of nursing. (American Nurses Association). 1.6 Research Contributions The contributions of this study are as the following: 1. This paper makes positive contributions as theoretical sciences about quality of nursing work environment to the literature and academic development. 2. This study adds to the relatively small amount of nursing research that examines quality of nursing work environment related to quality of care, and encourage of researchers to develop it as new evidence based in nursing area. 3. The results of this study help provide a better understanding and considering the importance of quality nursing work environment in practice area. 4. This study provide better feedback of administration procedure in hospital to develop quality of nursing work environment and also human resources.



7 CHAPTER II LITERATURE REVIEW



2.1 Nursing Work Environment Environment literally means surrounding and everything that affect an organism during its lifetime is collectively known as its environment. In another words “Environment is sum total of water, air and land interrelationships among themselves and also with the human being, other living organisms and property”. It includes all the physical, biological and cultural elements surrounding and their interactions. Physical elements are space, landforms, water bodies, climate soil, rocks and mineral. Biological elements such as plants, animals, microorganism and men constitute the biosphere. And cultural elements such as economic, social and political elements are essentially manmade features (Singh, 2009). As one of the elements of environment, nurses are biological element who an indispensable part of healthcare systems. Nurses also have environment aspect surrounding among them, it is defined as nursing work environment. The Nursing Work Environment (NWE) is defined as the context within which nurses provide their services, and includes infrastructural, management and social components. The nurses’ work environment is a multidimensional phenomenon, which includes many elements that enable nurses to practice with a sense of contribution and professional satisfaction. According to Estabrooks et al. (2002), the professional practice environment of nurses must possess characteristics that allows them to provide the quality of care aspired by the profession. The nursing literature emphasizes work environment characteristics of autonomy and empowerment for decision making, communication and collaboration with interdisciplinary coworkers, working conditions, recognition, support of and recognition by supervisors, supportive administrative practices and physical characteristics of the environment as qualities contributing to nursing job satisfaction, retention and turnover (Kohn et al. 2000, McNeese-Smith & Crook 2003, Strachota et al. 2003, Best & Thurston 2004, Lynn & Redman 2005, Lu et al. 2005). In 2002, Aiken et al. found a relationship between nurse staffing and patient death and nurses’ burnout and job dissatisfaction. While it may not be surprising that the nurses’ work environment is related to patient safety (Aiken et al. 2002, Houser 2003, Page 2004), these studies also emphasize the opportunity to have a positive impact on patient safety



8 while improving working conditions for nurses and quality nursing practice environment. A quality nursing practice environment is defined as a practice environment that has the organizational and human support allocations necessary for safe, competent and ethical nursing care. Research shows that the quality of the practice environment directly impacts the quality of care that registered nurses (RNs) and other health professionals can provide and has an effect on patient safety. In addition, research has linked job satisfaction, productivity, recruitment and retention with the quality of registered nurses’ practice environments (NANB, 2011). Mondal (2015) stated that there are amount factors related to quality of nursing care, as following: work load and burnout dimensions playing mediating roles, manager supports, levels of human and material resources for providing care, opportunity of job training, praise and encouragement, and shortage of nurses. There is different way about factors that influencing the quality of nurse work environment, such as: clinically competent nurses, adequate staffing, good nurse–physician relationships, autonomous nursing practice, nurse manager support, control over nursing practice, support for education, a culture that values concern for patients (Kieft, de Brouwer, Francke, & Delnoij, 2014). Multiple national and international studies and a Canadian collaborative committee composed of ten partners including: the Canadian Council on Health Services Accreditation (CCHSA), Academy of Canadian Executive Nurses (ACEN), Association of Canadian Academic Healthcare Organizations (ACAHO), Canadian College of Health Service Executives (CCHSE), Canadian Federation of Nurses Unions (CFNU), Canadian Healthcare Association (CHA), Canadian Health Services Research Foundation (CHSRF), Canadian Medical Association (CMA), Canadian Nurses Association (CNA) and the National Quality Institute (NQI) have identified five key attributes that must be in place to ensure a quality practice environment and include: 1. Workload Management: There are sufficient RNs to provide safe, competent and ethical care. 2. Nursing Leadership: There are competent and well-prepared nurse leaders at all levels in the organization. 3. Control over Practice: RNs have responsibility, authority and accountability for nursing practice. 4. Professional Development: The organization supports and encourages a lifelong learning philosophy and promotes a learning environment.



9 5. Organizational Support: The organization’s mission, values, policies and practices support and value RNs and the delivery of safe and appropriate nursing care. 2.2 Measurement Related to Nursing Work Environment According to assessment tools of nursing work environment that has been used in Magnet Hospital to measure the quality of nurses’ work environment, there are various instruments (Gu & Zhang, 2014), as following: 1. Nursing Work Index (NWI) Based on qualitative interviews with nursing staff in magnet hospitals, Kramer and Hafner developed the Nursing Work Index (NWI) in 1989 to facilitate the evaluation of nurse satisfaction and perception of quality of care. A total of 65 items were identified, reflecting the organizational traits of a hospital. The subscales of the NWI encompasses management style, leadership, organizational structure, clinical practice, and professional development. The items included are subject to three nursecentered conditions: “This is important to my job satisfaction”; “This is important to my being able to give quality patient care”; and “This factor is present in my current job situation”. The NWI uses a 4-point Likert scale; responses range from strongly agree (4 points) to strongly disagree (1 point), where higher scores indicate more significant traits of magnet hospitals. The content validity of the scale was not tested by statistical methods, but was recognized by three out of four experts on research of magnet hospitals. However, over the past 20 years, some items in the NWI have become outdated, and the tool itself resembles a list of factors in the nursing work environment that affected nurse satisfaction and quality of care in the 1980s. 2. Revised NWI (NWI-R) Aiken and Patrician developed the revised NWI (NWI-R) based on the NWI. Through proof-of-concept study emphasizing the correlation of items and their potential to reflect the traits of a healthy working environment, the new scale ultimately contained 57 items after relatively less correlated items in the original scale were excluded. Aiken and colleagues used the NWI-R for the first time in 1994 in a controlled study of 39 magnet hospitals and 195 non-magnet hospitals, and found lower patient mortality and significantly higher NWI-R scores in magnet hospitals than in non-magnet hospitals. Based on this scale, follow-up studies attempted to develop subscales to evaluate related content in the nursing work environment, and the total



10 Cronbach's α coefficient of the NWI-R is 0.96; the coefficient for each subscale ranges from 0.75 to 0.79. In recent years, researchers in various countries have conducted localized research using the NWI-R. In Australia, Joyce and Crookes constructed the Australian version of the NWI through cultural adaptation, adjusting the language, content, and presentation of the original scale. In France, Bonneterre and colleagues extended the NWI-R and developed the NWI–Extended Organization (NWI-EO) by verifying its reliability and validity through a survey of 4085 nurses from 214 hospitals. The scale included three dimensions (team cohesion, work organization, support from management personnel) and 19 items. However, items in the NWI-R are still outdated, which was their drawback. Moreover, this tool is insufficiently related to the magnet work environment, such as the new item “team nursing as the nursing delivery system”, which cannot effectively distinguish between a magnet and non-magnet work environment. In addition, the NWI-R is no longer applicable for evaluating nurse satisfaction or the perception of quality care, which are traits of magnet hospital organization. 3. Practice Environment Scale of the NWI (PES–NWI) As the NWI contains 65 items, it requires too much time to complete a questionnaire survey. Lake screened out 48 items associated with the nursing practice environment from the NWI and constructed the Practice Environment Scale of the NWI (PES–NWI). Through covariance matrix and factor analysis identified five subscales (nurse participation in hospital affairs, nursing foundations for quality of care, staffing and resource adequacy, nurse manager ability, leadership, support of nurses and collegial nurse–physician relationships) and 31 items. The first two dimensions reflect the overall hospital nursing practice environment, the remaining three reflect the nursing practice environment in individual units. The Cronbach's α coefficient of the PES–NWI is 0.82; the coefficient for each subscale ranges from 0.71 to 0.84. Lake indicated that the use of this scale helped to build and maintain an efficient, quality nursing practice environment. Researchers in other countries used the PES–NWI in attempts to identify the relation between the nursing practice environment and clinical nursing satisfaction and patient outcomes. They found that higher PES–NWI scores indicated lower nurse burnout and turnover rates and better patient prognosis. In China, Chen and colleagues undertook a nationwide cross-sectional survey using the PES– NWI to evaluate the nursing work environment in different units. They found that the



11 “collegial nurse–physician relationships” dimension scored the highest among all of the dimensions in all types of units, while the “staffing and resource adequacy” and “nurse participation in hospital affairs” scores were the lowest. Moreover, the nursing work environments of intensive care units were poorer than that of internal and surgical units. Concerning the current domestic situation that the use of PES–NWI are restricted in investigation research, we suggest further study on the correlation between the nursing practice environment and nurse satisfaction and turnover rate and patient outcomes, which would aid in providing a reliable foundation for the long-standing demands for a healthier working environment. 4. Essentials of Magnetism (EOM) instrument The Essentials of Magnetism (EOM) tool emphasizes the traits of a healthy nursing work environment and aids evaluation of the status of magnetism of the environment, forming the basis for administrators to decide whether a hospital is qualified to apply for the Magnet Recognition Program. The tool was invented by Kramer and Schmalenberg in 2004, and its revision, Essentials of Magnetism II (EOMII), was unveiled in 2005. The EOM contains 54 items and eight dimensions (cultural values, nurse manager support, control of nursing practice, clinical autonomy, adequacy of staffing, nurse–physician relationships, nurses' clinical competency, and support for education). The EOM uses a 4-point Likert scale, with responses ranging from strongly agree (1 point) to strongly disagree (4 points), and has good internal consistency. The EOMII has 58 items and eight dimensions, two of which differ from the EOM in terms of items and content (nurses' clinical competency, support for education). Currently, the EOMII has been translated and adapted into a Turkish version, while the Chinese version was developed by Bai and colleagues. It has been suggested that magnet hospitals should use this tool for self-assessment to maintain and continuously improve the nursing work environment, while non-magnet hospitals are advised to use it to draw a clearer picture of the gap between non-magnet and magnet hospitals so as to implement reform programs. It is worth noting that the data collected should include indicators reflecting certain information about individual nurses, nursing groups, units, and hospitals with the aim of thoroughly evaluating the magnet status of hospitals. 5. Perceived Nursing Work Environment (PNWE) instrument The Perceived Nursing Work Environment (PNWE) instrument was completed by the American researchers Choi and colleagues in 2004, and it uses the same scoring



12 method as the NWI. It has 42 items and seven dimensions (professional practice, staffing and resource adequacy, nursing management, nursing process, nurse/physician collaboration, nursing competence, positive scheduling climate). The coefficients of the first six dimensions range from 0.70 to 0.91, while the last has a low coefficient of 0.56, which is probably because this dimension includes only three sub-items. The total Cronbach's α coefficient of the PNWE is 0.95. In 2005, Cimiotti and colleagues used the PNWE to conduct a questionnaire survey of more than 2000 nurses to compare the nursing work environment between three kinds of hospitals (magnet hospitals, hospitals applying for magnet recognition, non-magnet hospitals), and reported that the nurses in magnet hospitals had a more positive perception of their nursing work environment. In China, Chen and colleagues translated and revised the PNWE to perform a preliminary evaluation of the overall condition of the nursing work environment. 6. Revised Individual Workload Perception Scale (IWPS-R) The Revised Individual Workload Perception Scale (IWPS-R) is a revision of the IWPS; both were developed by Cox to evaluate nurse perception of the nursing work environment. The original IWPS had 46 items and used a 5-point Likert scale, with responses ranging from strongly disagree (1 point) to strongly agree (5 points). The Cronbach's α coefficient of the IWPS-R is 0.96 and the coefficient of each subscale ranges from 0.61 to 0.83. In 2006, Cox revised the original scale based on its usage and reduced it to 29 items, but retained the same dimensions in the original scale. The content validity of the scale was evaluated by five experts in nursing administration and the psychometric field with a total Cronbach's α coefficient of 0.92, and the coefficient of each subscale ranged from 0.68 to 0.88. In Taiwan, Lin and colleagues translated and revised the PNWE following a survey involving Taiwanese nurses. Applying principal component factor analysis, they excluded five items whose factor loadings were insufficient and identified 24 items in total. The Cronbach's α coefficient of the scale is 0.88, and coefficients of the subscales range from 0.61 to 0.85. The PNWE is mainly used to evaluate support from administrators, peer-staff, and clinical units, as well as workload and intention to stay. However, compared to other scales, the PNWE is greatly dependent on the subjective perception of nurses, which may result in discrepancy with the actual status of the nursing work environment. 7. Quality Nurses’ Work Environment (QNWE) The Quality Nurses’ Work Environment (QNWE) is an instrument that developed by Taiwan Union of Nurses Association (TUNA) which provided a unique



13 set of subscales (safe practice environment, staff quality, work, salary and welfare, specialization and cooperation, work simplification, informatization, professional cultivation and development, support and care, and total satisfaction on current nursing work environment) designed to assess the quality of nursing work environment. It showed adequate internal consistency reliability, moderate intra-class correlation across subscales, appropriate content validity and strong construct validity. This developed instrument was assigned by Taiwan Department of Health. The QWNE instrument consist of 65 items which is divided into 8 set dimensions. A five-point Likert-like rating system was used for this instrument, which scale 5 represented fully qualified, 4 as mostly qualified, 3 as partially qualified, 2 as less qualified, and 1 as totally unqualified. All dimensions range of content validity index resulted from 0.83 to 1. Internal consistency reliability of Cronbach’s Alpha was used to determined reliability test, and it’s resulted from 0.70 to 0.96 for all 8 dimensions. The QNWE is strongly used to examine the quality of nurses’ work environment relinked to the nurses’ demographic data (Lin, Lu & Huang, 2013)



14 2.3 Conceptual Framework Safe practice environment Staff Quality • • • • • • •



Age Gender Marital Status Education Degree Administrative Position Department Working Experiences as Nurse



Work load, salary & welfare Professional Specialization and Cooperation Work Simplification Informatization Technology Professional Cultivation and Development



Support and Caring



Figure 1. The Quality of Nurses’ Work Environment



15



CHAPTER III RESEARCH METHOD 3.1 Study Design This is a non-experimental study, with a cross-sectional descriptive study approach. A descriptive study is one in which information is collected without changing the environment, and learn about the characteristics of a population at one point in time. The predictors set in the study were age, gender, marital status, level of education, work experience, type of hospital, employment status, and monthly salary. Former studies about quality of nurses’ work environment had very rare in Indonesia. Most of the previous studies discussed about nurses’ motivation and patient’s satisfaction. A variable is the characteristic or attribute of an individual, group, educational system, or the environment that is of interest in a research study (Korb, 2012). This study only has one independent variable such “Perceived of Indonesian Nurses’ of Quality Nursing Work Environment”. 3.2 Setting This study will be conducted in Sardjito Hospital in Yogyakarta, Indonesia in every inpatient wards and emergency department. The data collection will be began in July 2014 and ended in September 2014. 3.3 Population and Sample The total of respondents are nurses who work in Sardjito Hospital of Yogyakarta which 874 total amount of population. All of respondents should met the inclusion and exclusion criteria set by the researcher, which are as the following: Inclusion Criteria: a. Nurses with diplomas, associate and bachelor's degrees or higher who were working in a hospital b. Nurse who has worked at Sarjito hospital at least 6 month c. Nurses who work at inpatient wards and emergency department d. Willing to participate in the study Exclusion criteria: a. Nurses with under diploma degree or below b. Nurse who has worked at Sarjito hospital less than 6 month c. Nurses who work at administration office and outpatient department



16 d. Unwilling to participate in the study or rejected the offer The total sample on site has met the minimum requirement of the sample size. Calculated by G-Power 3.1.2 version software, it showed at least the study has to recruit 164 respondents as the total sample size. In the analysis, .05 alpha error and .80 power were set to establish a good analysis. To avoid the loss of participants, a 10% of attribute rates was established (Faul, Erdfelder, Buchner, & Lang, 2009). The sampling method of this study is by using simple random sampling. Simple random sampling is sampling method that within a particular study population, everyone has an equal chance of inclusion criteria in the sample. It is considered ‘fair’ and therefore allows findings to be generalized to the whole population from which the sample was taken (Somekh & Lewin, 2005). There is 6 steps to draw the sample in this study such as the following: a. Define the population. This step researcher defines 874 amount population of nurses who work at Sarjito hospital of Yogyakarta b. Choose the sample size. By calculating the sample need using G*power computer software, researcher has estimated the number of sample size to be recruited is 164 respondents. c. List of population. Researcher need the total of 874 list population record and narrow it down considering inclusions criteria, then draw it as 164 amount as respondents that needed. d. Assign the number to the units. Researcher need to assign a consecutive number from 1 to N, next to each of the respondents. In this study, this would mean assigning a consecutive number from 1 to 164. e. Find the random numbers. Researcher need a list of random numbers before selecting the sample of 164 respondents from the total list of 874 respondents. These random numbers can either be found using a computer program that generates these numbers. f. Selecting the sample. Finally researcher select which of the 874 respondents will be invited to take part in the research. In this study, this would mean selecting 164 random numbers from the computer program table. 3.4 Research Instruments In this study, the instrument that will be used to measure the quality of nurses’ work environment is Quality Nurses’ Work Environment (QNWE) with TUNA-



17 developed questionnaire and has been modified by Lin, Lu and Huang (2014). The questionnaire contains two parts: the demographic information of nurses and 8dimention of QNWE questionnaire. The questionnaire scoring used a 5-point likert-like rating system where 5 represented fully qualified, 4 as mostly qualified, 3 as partially qualified, 2 as less qualified, and 1 as totally unqualified. Table. 1 8-Dimentions Indicator of Quality Nurse’ Work Environment Indicator Safe Practice Environment Staff Quality Workload, Salary and Welfare Professional, Specialization and Cooperation Work Simplification Information Technology Professional Cultivation and Development Support and Caring Total Items



Items 16 8 8 6 5 5 9 11 68



Before applying the questionnaire to respondents, researcher will apply permission letter to obtain the consent of the original author. The questionnaire was examined based on the expert content validity index (CVI) with all dimensions ranged from 0.83 to 1. The Reliability test for the instrument was examined with an internal consistency reliability of Cronbach’s Alpha ranging from 0.70 to 0.96 for all 8 dimensions. The instruments are written in English and has not been translated to the Indonesian language as the respondents do not speak or read English. So in this case, the instrument need to be translated into Indonesian language. Suleman and Yates (2011) in their translation-back translation study stated that there are three steps to do the translation which are adopted by the researcher in this study. The first step is translating the original instrument to Bahasa Indonesia by translator 1. Translator 2 will be blinded to the original instrument so that this person will be able to translate the one from Bahasa Indonesia to English. Translator 3 will compare both instruments. The second step is reviewing both versions of instruments to see if there are any low grade given by translator 3. There is no low grade comparison so that means the translation good and nothing needed to be changed. The third step is testing the instrument to



18 nurses to see if they understand the instrument. The explanation will be done in the local language as they respondents understand it clearly. Other than that, the instruments are acceptable. After translation progress is done, the Indonesian version of instrument will be examined both of content validity and reliability. The validity of the instrument will be examined by using CVI (content validity index) which concerning of two aspects such as: the clarity of language and relevance of question to the object that reviewed by experts. The reliability of the instrument will be examined by using Cronbach’s Alpha. Cronbach's alpha determines the internal consistency or average correlation of items in a survey instrument to gauge its reliability. The instrument defined as reliable instrument if it is met the minimum value of alpha (α) as 0.7 or above (Wells and Wollack, 2013). 3.5 Data Collection The Institutional Reviewer Board (IRB) letter will approved in July 2014, after sending the proposal research and research permit letter from school. As soon as the IRB letter is granted, the data collection started. One public hospital will be involved in the study. The respondents will be recruited based on the eligible criteria and gotten the explanation about survey regarding the study. The questionnaire will be distributed by researcher. The completed questionnaire collected by the researcher maximum 3 days after the questionnaire was given to the respondent then coded into a computer database. Only the complete filled questionnaire or at least more than a half-filled of the questionnaire will be accepted. Once the analysis has been completed, the result will be shared to the related departments. 3.6 Data Analysis Statistical Package for the Social Science (SPSS) version 20.0 will be utilized to analyze the data. There are two hypotheses set by the researcher. Each hypotheses has its own analysis to answer. 1. There is high perceived quality levels of Indonesian nurses’ quality work environment Descriptive analysis of mean, standard deviation, and percentage are will be used to describe the nurses’ demographic and their perceived levels of quality work environment.



19 2. There is positive relationship between Indonesian nurses’ demographics data and their perceived quality levels work environment. Inferential statistical of analysis of variation (ANOVA) and lineal regressions are will be utilized depicting the relationship between nurses’ demographic and perceive level, with the probability of type I error of 0.05, and the expected effect size is set as 0.95. 3.7 Ethical Consideration Before the study has started, researchers applied for IRB in Indonesia. Once the IRB has been granted, data collection started. Permission letter to the hospital will be sent before the actual data collection began. The researcher guaranteed the privacy of each data of the respondents. Therefore all of the respondents remained anonymous. All data was kept confidential, coded, and analyzed in the researcher’s private computer. All of questionnaires will be destroyed after all data has been analyzed. The final results would be shared to the related institutions and departments. 3.8 Research Process This study consists of three phases of research process such as the following: 1. Preparation a. Deciding research topic b. Formulating research problem 2. Planning a Research Study a. Conceptualizing research design b. Finding and constructing instrument for data collection c. Defining and selecting population and sample d. Writing research proposal e. Presenting research proposal f. Writing research proposal revision 3. Conducting Research Study a. Applying IRB b. Translating the instrument into local language c. Examining validity and reliability of the instrument d. Conducting simple random sampling e. Collecting data



20 f. Processing and displaying data g. Writing research report and result h. Presenting research result i. Writing research revision j. Submitting research thesis



21 REFERENCES



Aiken LH, Clarke SP, Sloane DM, Sochalski J & Silber JH (2002) Hospital nurse staffing and patient mortality, nurse burnout and job dissatisfaction. Journal of the American Medical Association 288, 1987–1993, 2040–2041. Estabrooks C, Tourangeau A, Humphrey C, Hesketh K, Giovannetti P, Thomson D, Wong J, Acorn S, Clarke H & Shamian J (2002) Measuring the hospital practice environment: a Canadian context. Research in Nursing & Health 25, 256–268. Kohn LT, Corrigan JM, Donaldson MS (2000) To err is human: Building a safer health system. National Academies Press, Washington. McNeese-Smith DK & Crook M (2003) Nursing values and a changing nurse workforce: values, age and job stages. Journal of Nursing Administration 33, 260–270. Strachota E, Normandin P, O'Brien N, Clary M & Krukow B (2003) Reasons registered nurses leave or change employment status. Journal of Nursing Administration 33, 111–117 Lynn MR & Redman RW (2005) Faces of the nursing shortage: influences on staff nurses’ intentions to leave their positions or nursing. Journal of Nursing Administration 35, 264–270. Best MF & Thurston NE (2004) Measuring nurse job satisfaction. Journal of Nursing Administration 34, 283–290. Houser J (2003) A model for evaluating the context of nursing care delivery. Journal of Nursing Administration 33, 39–47. Page A (2004) Keeping Patients Safe: Transforming the Work Environment of Nurses. National Academies Press, Washington. Aiken, L. H., Cimiotti, J. P., Sloane, D. M., Smith, H. L., Flynn, L., & Neff, D. F. (2011). The Effects of Nurse Staffing and Nurse Education on Patient Deaths in Hospitals With Different Nurse Work Environments. Medical care, 49(12), 1047-1053. doi: 10.1097/MLR.0b013e3182330b6e Almost, J., Doran, D., Ogilvie, L., Miller, C., Kennedy, S., Timmings, C., . . . BookeyBassett, S. (2013). Exploring work-life issues in provincial corrections settings. J Forensic Nurs, 9(1), 3-13; quiz E11-12. doi: 10.1097/JFN.0b013e31827a56f3 Choi, J., Bakken, S., Larson, E., Du, Y., & Stone, P. W. (2004). Perceived nursing work environment of critical care nurses. Nurs Res, 53(6), 370-378.



22 de Brouwer, B. J., Kaljouw, M. J., Kramer, M., Schmalenberg, C., & van Achterberg, T. (2014). Measuring the nursing work environment: translation and psychometric evaluation of the Essentials of Magnetism. Int Nurs Rev, 61(1), 99-108. doi: 10.1111/inr.12073 Gu, L.-Y., & Zhang, L.-J. (2014). Assessment tools of nursing work environment in magnet hospitals: A review. International Journal of Nursing Sciences, 1(4), 437-440. doi: http://dx.doi.org/10.1016/j.ijnss.2014.10.013 Hinno, S., Partanen, P., VehvilÄInen-Julkunen, K., & Aaviksoo, A. I. N. (2009). Nurses’ perceptions of the organizational attributes of their practice environment in acute care hospitals. Journal of Nursing Management, 17(8), 965-974. doi: 10.1111/j.1365-2834.2009.01008.x Kieft, R. A., de Brouwer, B. B., Francke, A. L., & Delnoij, D. M. (2014). How nurses and their work environment affect patient experiences of the quality of care: a qualitative study. BMC Health Serv Res, 14, 249. doi: 10.1186/1472-6963-14249 Mohammadi, A., Sarhanggi, F., Ebadi, A., Daneshmandi, M., Reiisifar, A., & Amiri, F. (2011). Relationship between psychological problems and quality of work life of Intensive Care Units Nurses. Iranian Journal of Critical Care Nursing (IJCCN), 4(3), 135-140. Randa. (2011). Hubungan Komponen Kualitas Kehidupan Kerja Dengan Kinerja Perawat Pelaksana Di Instalasi Rawat Inap Bedah Dan Non Bedah Rsup. Dr. M. Djamil Padang Tahun 2010. Skripsi Program Studi Ilmu Keperawatan Fakultas Kedokteran Universitas Andalas Padang Ulfa, M. (2015) Hubungan Antara Stres Kerja Dengan Burnout Pada Perawat Di Instalasi Gawat Darurat Rsup Dr Sardjito Yogyakarta. Jurnal Keperawatan Universitas Gajah Mada Faul, F., Erdfelder, E., Buchner, A., & Lang, A. G. (2009). Statistical power analyses using G*Power 3.1: Tests for correlation and regression analyses. Behavior Research Methods, 41, 1149 – 1160. doi:10.3758/BRM.41.4.1149 Suleiman, K., & Yates, B. (2011). Translating the insomnia severity index into Arabic. Image: Journal of Nursing Scholarship, 43, 49-53. doi: 10.1111/j.15475069.2010.01374.x



23 Jennings M.N., (2008). Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Agency for Healthcare Research and Quality. United States Lundmark VA. (2008). Magnet Environments for Professional Nursing Practice, Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US) Somekh B., and Lewin C., (2005). Research Methods in The Social Sciences, London, Thousand Oaks, New Delhi: Sage Publications, Inc. Wells C.C., and Wollack J.A., (2013). An Instructor’s Guide to Understanding Test Reliability. Testing & Evaluation Services. University of Wisconsin Singh Y.K., (2009). Teaching of Environmental Science. APH Publishing Corporation. UK



24



APPENDICES



1.



Research Study Time Table Plan Activity



Find the research topic Chapter 1 Chapter 2 Chapter 3 Proposal Thesis Defense Submission of the proposal IRB Research Data Collection Research Data Analysis Thesis Final Defense Final Thesis submission



Jan 15



Feb 15



Mar 15



Apr 15



May 15



June 15



July 15



Aug 15



Sept 15



Oct 15



Nov Dec 15 15



Jan 16



Feb 16



Mar 16



Apr 16



May 16



25 2.



Draft Letter of Permission Statement



PERMISSION LETTER FOR REQUESTING AN EXISTING RESEARCH INSTRUMENT June, 10th 2015 National Taipei University of Nursing and Health Sciences Ming-te Road, Peitou Distric, Taipei Dear [Original Author’s Name] I am a Master student from National Taipei University of Nursing and Health Sciences writing my thesis tentative titled “The Exploration of Indonesian Nurses’ Perceived of Quality Nursing Work Environment: A Case of Sardjito Hospital In Yogyakarta, Indonesia” under direction of my thesis advisor Dr. Chiou-Fen Lin. I would like your permission to use your survey instrument in my research study. I would like to use and print your survey instrument under the following conditions: a. I will use this survey instrument only for my research study and will not sell or use it with any compensated or curriculum development activities. b. I will translate the survey instrument into Indonesian languange regarding the population sample can only understand Indonesian language c. I will include copyright statement on all copies of the instrument If these are acceptable terms and conditions, please indicate your agreement by sending me back your email.



Sincerenly, Aric Vranada Graduate Institute of Nursing Student National Taipei University of Nursing and Health Science 365 Mingde Road, Beitou District, Taipei 112-19, Taiwan, R.O.C Phone : +886-978 476 494