Emma Nordlöf & Therese Hallström
Bachelor of Science in Nursing, 180 ECTS, Department of Health Care Sciences. Independent Degree Project, 15 ECTS, VKGT13, 2020
First cycle degree programme not requiring previous university study Supervisor: Anna Klarare
Examiner: Elisabet Mattson
BALINESE NURSES EXPERIENCE WHEN WORKING IN A
HOSPITAL SETTING DURING NATURAL DISASTERS
BALINESISKA SJUKSKÖTERSKORS UPPLEVELSE ATT ARBETA
PÅ SJUKHUS UNDER EN NATURKATASTROF
Abstract
Background: Bali is a country that is constantly affected by new natural disasters and is
located in the area of The Ring of Fire. In Bali, there are four different types of nurses who have different education and different experience. The nurses do not receive any special training in disaster management and do not know what role they should take if a disaster occurs.
Aim: The purpose of this study was to explore Balinese nurses' experiences of working in
hospitals during natural disasters.
Method: A qualitative interview study with semi-structured questions were conducted over
the phone with nurses at a large hospital in Bali. The authors interviewed three nurses from one of Bali´s largest hospitals. The interviewed nurses had different levels of education and experience.
Result: The analyse resulted in that three themes were discovered which were about; Lack of education leads to uncertainty in the nurse's work, Functioning roles and routines are crucial to the nurse’s profession and the nurse’s experience of working in hospital after a natural disaster and its consequences.
Discussion: The discussion highlights Balinese nurses concerns about future natural
disasters and deficiencies in role distribution and routines at the hospital. During the interviews it became clear that the lack of education was the biggest problem among the nurses. The result was discussed based on Katie Erickson's caritas theory.
Sammanfattning
Bakgrund: Bali är ett land som ständigt drabbas av nya naturkatastrofer och ligger i området
The Ring of Fire. På Bali finns det fyra olika typer av sjuksköterskor som har olika
utbildningar och olika mycket erfarenhet. Sjuksköterskorna får ingen speciell utbildning inom katastrofhantering och vet inte vilken roll de ska inta om en katastrof inträffar.
Syfte: Syftet med denna studie var att utforska balinesiska sjuksköterskors upplevelser av att
jobba på sjukhus under naturkatastrofer.
Metod: En kvalitativ intervjustudie med semistrukturerade frågorsom utfördes över telefon med sjuksköterskor på ett stort sjukhus på Bali. Författarna intervjuade tre sjuksköterskor från ett av Balis största sjukhus. De intervjuade sjuksköterskorna hade olika utbildningsnivåer samt erfarenhet av yrket.
Resultat: Utifrån analysen uppdagades tre teman som handlade om; Brist på utbildning, roller och rutiner samt konsekvenser i sjukvården efter en naturkatastrof.
Diskussion: Diskussionen belyser balinesiska sjuksköterskor oro för framtida
naturkatastrofer och brister i rollfördelning och rutiner på sjukhuset. Under intervjun framgick det att bristen på utbildning var det största problemet hos sjuksköterskorna.
Resultatet kommer diskuteras utifrån Katie Eriksons caritas teori.
Innehållsförteckning
INTRODUCTION 1 BACKGROUND 1 PROBLEM STATEMENT 6 AIM/RESEARCH QUESTIONS 6 THEORETICAL FRAMEWORK 6 METHOD 8RESEARCH ETHICHAL CONSIDERATIONS 10
RESULT 11
DISCUSSION 15
CLINICAL IMPLICATIONS 19
PROPOSALS FOR CONTINUED RESEARCH 19
CONCLUSION 20
REFERENCES 21
APPENDIX 1. 24
INTRODUCTION
Indonesia is one of several countries located in an area that is very exposed to different types of natural disasters. Climate change is one of the biggest factors that has caused Indonesia to constantly suffer more and more natural disasters and this means that the nurse's work needs to be developed at the same rate. An increasing number of natural disasters will result in more and more innocent people being hit. How will the nurse's emergency competence be able to develop to the same extent as more and more natural disasters happen and the need for resources?
BACKGROUND
IndonesiaIndonesia is one of the countries in the world that is repeatedly hit hard by various types of natural disasters. According to WHO, Indonesia is in the area of The ring of Fire (World Health Organization [WHO], 2020). This area is approximately 4,000 miles long and extends from Southern Chile to New Zealand and looks like a horseshoe. Indonesia with its 13000 islands has a population of about 267 million inhabitants (National Encyclopedia [NE], 2020). The country has the world's largest Muslim population and is the world's fourth most
populous country. In recent decades there has been a slow improvement in the country with the following factors such as low income, education and cultural differences (Thabrany, 2008).
Natural disasters
All countries in this area are severely and often affected by both volcanic eruptions and other types of natural disasters. By 2030, the world should have achieved common goals, and one of these goals is to solve the climate crisis (United Nations Development Programme, 2020). Climate change poses a threat to the entire population of the world. The risks of global warming lead to serious changes for ecosystems, human security, water supply and increased risk of natural disasters (United Nations Development Programme, 2020).
Indonesia is at risk for many different types of natural disasters ranging from earthquakes to volcanic eruptions (WHO, 2020). All types of disasters in a country cause imbalances and difficulties for the services that are usually seen as obvious. It can be such as clean water, communication, transport and healthcare. Due to the constant climate change in the world, this increases both the number and intensity of the natural disasters. In countries where people
are disadvantaged financially, there is no clear structure on how people should be warned, evacuated and protected from the natural disaster.
When a volcano becomes active and erupts, it is ash, lava, dangerous gases and rocks that pose a danger to the population. This causes people to die and lose their homes. With a volcanic eruption and the dangerous gases such as sulfur dioxide emitted, this contributes to global warming. It is not only the sulfur dioxide that has a dangerous effect on humans. Volcanic eruptions contribute to many more health risks, among other things; eye and skin irritations from acid rain, acute and chronic respiratory illnesses from falling ashes, infectious diseases and burns and traumatic injuries. The last volcanic eruption in Bali was 2017 when the volcano Mount Agung erupted (WHO, 2020). Nearly 120,000 were evacuated from their homes and the highest alert level was announced by the authorities. Swedish citizens found it difficult to get home to Sweden because Bali's international airport was forced to close due to the volcanic eruption.
Earthquakes are a phenomenon that strike without warning and very suddenly. It is a shaking of the ground that can be violent and can lead to landslides, tsunamis and cracks in the ground. Almost 750.000 deaths worldwide were caused by earthquakes between 1998-2017. Depending on the magnitude of the earthquake, there are still immediate and secondary health effects. The immediate health effects are deaths and damage from buildings that collapse. Secondary health effects are infections and ulcers that cannot be treated, risk of infectious disease, increased psychosocial needs. Even during earthquakes, health work becomes vulnerable as health care facilities may be damaged and medical supplies may have been lost (WHO, 2020). In the summer of 2018, Lombok, an island near Bali, was hit by two major earthquakes that caused virtually all tourists to be evacuated from the Gili Islands. About 80 people died (Utrikesdepartementet, 2020).
Tsunamis are massive waves caused by a volcanic eruption, earthquake or underwater avalanche. The 2004 tsunami caused the vast majority of deaths between 1998-2017. Crucial infrastructure, education and a system that allows early warning of people are crucial to saving people and protecting their property from future tsunamis. Other common injuries following natural disasters are open wounds and crushing damage from floating debris. Infectious diseases are also a risk due to tsunamis. This is due to congestion, insufficient water and sanitation. Even after the tsunami, people's mental health effects are negatively affected by lost property, family and agriculture (WHO, 2020). In 2018, Indonesia was most recently hit by a tsunami that triggered waves at a height of about three meters. 2100 deaths
were confirmed and 330,000 people were put in an unsafe existence (Australian Council For International Development, 2018).
World Health Organization
WHO (2020) is constantly working to prepare and allocate resources in the event of natural disasters. Resources include; To build crisis management systems for various health risks, ensure that healthcare facilities have the opportunity to withstand new dangers as well, that they can still be functional despite the disaster that has occurred because it is when it is needed most and ensure that healthcare staff have appropriate training and restoring primary care, building mobile health teams, monitoring potential epidemics through early warning, financial assistance to support health care.
Indonesian health care
Indonesia's health care, like so many other countries in the world, includes both public and private health care (Regional Office of Southeast Asia & World Health Organization. 2017). It is the state that finances the hospitals and primary health care clinics located in the country and the private sector is funded by private companies as well as Islamist or Christian
organizations (Setyowati, 2015). In Indonesia, there is also the possibility for the patient to choose a hospital based on their own religion called Religion Profiled Hospital (Milton da Silva, 2009). The Government of Indonesia is constantly working towards a better health care system that will then lead to a healthier population. In general, Indonesia has a significantly lower quality of healthcare than, for example, Sweden. On the island of Bali, located in Indonesia, the quality of healthcare is of the same quality as in the rest of the country (Milton da Silva, 2009). On the eastern side of Bali, there is predominantly malaria, but there are also dengue fever and TBC on the island as well as rabies. Making surgical procedures in the country is something that experts advise against (Utrikesdepartementet [UD [2020], 2020). Crises in Indonesia, such as various types of natural disasters or other accidents, have been seen to have an impact on the mental health of residents. Indonesia is under constant stress as they are in a vulnerable area both geographically and economically. These factors could lead to extreme mental illness. Indonesia does not prioritize mental health care and it means that it is not detected in time and treatment therefore cannot occur. Indonesian clinics have different priorities; newborn and child health programs, nutrition, health promotion, basic hygiene and environmental programs, immunology and infectious diseases, treatment of diseases. None of
its priorities include any form of mental health care (Setiyawati, Blashki, Wraith, Colucci & Minas, 2014).
Religion
Hinduism is a major part of the religious beliefs practiced in Bali (Weightman, 1997). It was Indian traders who brought Hinduism to Bali. There of Balinese Hinduism is closely related to Indian Hinduism. Hinduism is more of a spiritual lifestyle than a dogmatic religion. The traditions that exist within Hinduism are constantly evolving and changing over time. Hinduism contains traditions, rituals and arts as well as unique events and festivals that associate with their gods and ancestors. In Bali there are over 20,000 temples. Each temple characterizes and is associated with a geographical area. The basic principle of Hindu treatment is to understand the balance between the so-called hot and cold inside the body. Ayurveda, is called Hindu folk medicine. Within this folk medicine there are various natural elements such as water, fire, atmosphere, wind and earth. Fire and wind are the most
significant and are comparable to mucus, bile and breath. Imbalance in these elements leads to illness. Ayurvedic treatment includes activating and suppressing body fluids through drugs, diet, massage or magic. To maintain good body hygiene must be running as stagnant water is regarded as unclean. Blood transfusions are allowed but must occur within the same caste, organ donation and transplantation are largely not allowed. Abortion is prohibited. Wikan (1989) writes that the people of Bali who practice Hinduism make daily sacrificial gifts, such as leftovers and flowers to protect their families or prevent themselves from being injured or ill. In Hinduism, they treat each other with love and respect. This can be linked to Katie Eriksson's caritas theory (2015)
Indonesian nursing education
Setyowati (2015) describes that there are different types of nurses in Bali. The difference between the different types of nurses is that the education looks different but that the form of employment is the same for everyone regardless of degree. This is because there is no special register for Balinese nurses and, in turn, makes it impossible to know what degree of
education the nurse has and all falls under the same title. Setyowati (2015) believes that there are major problems with the Indonesian nurse's profession and education. Almost 60% of Bali's nurses are trained SPK nurses and thus "only" possess knowledge at the upper
1% of the nurses have a Master degree. The Indonesian government is working hard to raise the standard of the nursing education that already exists and has long since changed some schools among the courses offered. This is to make post-secondary education more attractive so that more prospective nurses choose a higher education. Martono, Satino, Nursalam, Efendi & Bushy (2019) mention in their article that Balinese nurses say that they have no further training in disaster management. They also mention that they do not know what role in their professional category they should play when a disaster occurs.
Prior to the 2004 tsunami, there were no specific guidelines for nurse preparedness and knowledge in disaster management (Prasetiyawan, Viora, Maramis & Keliat, 2006). What was put in place, however, were extra resources for nurses to receive training in mental health. These resources include a two-week course in Jakarta for nurses together with other professionals from various tsunami districts.
SPK nurse
A nurse with this education could be compared to Swedish nursing assistant program. It is a high school-based education where staff lack theoretical knowledge but have extensive experience.
D3 Nurse
This training is comparable to the Swedish nurse program. It is a three-year course which includes very practical training. They are knowledgeable, experienced and have good knowledge of the measures to be taken in different health-related situations.
Bachelor nurse
The education is divided into two different groups, A- & B programs. The A program is a five-year program where four of the years are theoretical and one is practical. The theoretical part is concentrated on teaching critical thinking, interventions and investigations.
The B program is a continuing education of already skilled D3 nurses, but who want further theory to be able to become more qualified nurses.
Master's degree
Nurses within this group work primarily as a teacher or sit on the hospital management. They have a bachelor's degree basically but now have a master's degree.
International Nursing Council
ICN's code of ethics is a tool for nurses all over the world to be able to create a common approach that is not dependent on different national laws (International Council of Nurses [swenurse], 2012). The codes are divided into four different main areas. These are the codes that are appropriate for this particular area, natural disasters. The nurse's responsibility is primarily focused on the care of people. The nurse has a shared responsibility with the community to promote and initiate efforts that take into account the public's health and social needs. In order for the nurse to maintain her professional competence, personal responsibility and continuous learning are required. When it comes to own commitments and delegation of responsibility, it is the nurse's responsibility to assess others and their own competence. The nurse applies customized measures to guide and support staff to gain an understanding of a higher level of higher awareness.
PROBLEM STATEMENT
Natural disasters are more common nowadays and have a huge impact on people of all ages. Following a natural disaster, there are many consequences such as physical trauma, mental illness and lost financial access. The availability of caring for people, such as hospital space and right knowledge, after a natural disaster is crucial to being able to save lives and deal with the great situation that has occurred. The purpose of having a good foundation in disaster management and emergency care is to quickly know what the nurse should do and when. It is important to elucidate this topic in order to see development and teach other countries how this can be handled as the climate's major changes cause many parts of the world to be affected by natural disasters. This study can help other nurses to get an overview of what disaster care and how it is experienced in Bali.
AIM
The purpose of this study is to explore Balinese nurses’ experiences when working in a hospital during natural disasters.
THEORETICAL FRAMEWORK
Eriksson (2015) describes how caritas love is a big part of caring for suffering people. In the relationship between patient and nurse, compassion and generosity are needed to achieve the
well-being of both individuals. According to Eriksson (1979), faith, hope and love are what the nurse should strive for and the most optimal for her profession. Basically, her theory is based on the fact that the nurse should relieve suffering, see the whole of the person and let them develop and grow. Passio and Dolor are two different types of suffering where Passio is the mental disorder and Dolor is the somatic and inner pain. Eriksson (2015) argues that professional care must be based on natural care. The most distinctive feature of natural care is that the individual human should take responsibility for his or her own actions with relatives and friends in order to create well-being confidence and satisfaction. Professional care will never be identical to optimal natural care. This is because the relationship between patient and professional care can never be completely natural. In this relationship there will always be a stereotypical pattern. Eriksson (1994) describes that suffering is a significant part of human life and that her theory has a spiritual meaning. She believes that if we can find the meaning of our lives, we should also be able to find meaning in our suffering. Suffering is neither good nor evil, but a constant struggle between the good, the bad and the healthy. Eriksson
emphasizes that in health care there are three different types of suffering; a life sufferer, a disease sufferer and a health sufferer.
Life suffering is something that has an impact on the patient's situation and life. This suffering affects the patient's perception of reality and existence. Eriksson (1994) sheds light on the fact that the suffering of a patient's life can be a threat to its existence. In relation to treatment and illness the disease suffering occurs. This suffering can feel like pain in bodily suffering but can also feel like both spiritual and mental suffering. Punishment, violation, exercise of power or condemnation can cause the patient's dignity to be downgraded and the suffering of the care arises. This may be a consequence of neglected care (Eriksson, 1994). In order to care for patients during disasters, the nurse must understand all the different parts of the theory in order for the care to be optimal. This basic idea is used as a backbone in the nursing work and as a guide to clarify how the nurse's work should go. The theory also emphasizes that the physical body is at least as important as the psychic (Eriksson, 1994). Eriksson's theory is suitable for this study since Hinduism is such a big part of Balinese lifestyle and can be reflected in the nurse's work in Bali. Both Hinduism and Eriksson's theory place great
importance on dealing with love and showing respect. The authors will use Eriksson´s caritas theory as a backbone when conducting the interviews.
METHOD
DesignThe study uses a qualitative design method with semi-structured interview questions in order to be able to study nurses' experiences (Kvale & Brinkmann, 2009). Qualitative research involves the analysis of interviews with a few participants who provide open answers. This method provides a holistic view and understanding of the nurse's experience of working during a natural disaster. The study included individual interviews with selected nurses. This method was chosen in order to have the opportunity to go outside the prescribed interview template if needed.
Participants
The authors criteria were that the participants in the interview had to be nurses who had previously worked in a hospital during a natural disaster. The authors wanted the participants to have different levels of education in order to get a broader view. Another requirement was that the nurses were able to speak and understand English in order to avoid misunderstanding during the interview. The authors had no age or gender requirements. After presenting the study, three nurses wanted to participate in the interview and share their experiences. Due to extreme circumstances with a global pandemic, data collection was halted earlier than initially planned for.
Preparations
An important factor for conducting an interview study is to have knowledge of the country's culture and religion in order to be able to design interview questions (Bengtsson, 2016). The authors read relevant literature, articles and previous studies before embarking on the study to gain a broader knowledge. The literature that the authors found was limited and difficult to compare. There have not been much studies done on the subject before. The majority of the articles read were about how Indonesian nurses worked and what their education looked like. This gave the authors an initial understanding of what it looked like in the country. In order to conduct interviews, it was required that the authors read about interviewing techniques and trained beforehand in order to be able to hold an professional interview (Schatzman and Strauss, 1973). An initial draft of the interview guide was created with the understanding to let participants talk without being interrupted (Polit & Beck, 2008).
Data collection
One month before departure to Bali, an information letter was sent. A letter containing information about the study and the interview questions that were to be asked. The letter was emailed to different hospitals in Bali. Unfortunately, this approach did not produce any response at all. When the authors arrived in Bali they decided to try contacting the same hospitals again but now through their WhatsApp number instead. A short presentation of the authors and the study was sent and within an hour, the authors had received answers from several hospitals. The authors were referred to higher management and eventually got in touch with a responsible nurse at one of the hospitals. Due to COVID-19 pandemic, it was decided that telephone interviews would be the only possible way to get interviews. The responsible nurse selected participants according to the authors wishes. After that the authors got contact information to each participant, they could schedule time for an interview. The selected participants were between 20-55 years old and had between 1-23 years of experience in the profession. All participants were women and worked at one of Bali's largest hospitals. Two of the nurses who participated had a higher nursing education and were D3 nurses, the third was SPK nurse. The interview guide contained extensive questions in order to create a more open dialogue. The questions were mainly about how they had experienced working in a hospital during a natural disaster. The interview started with the authors telling about the purpose of the study. After that, the authors made it clear to the participants that it was perfectly okay to end the interview at any time and also that it was okay to refrain from answering questions they did not wanted to answer. A consent form was emailed to all participants some time before the interview was conducted. When the interviews were conducted, the authors divided between each other who would ask the questions and who would take notes. This was done so that there would be no misunderstanding from any part and that the participant would feel more secure. One asked the questions and the other sat listening and would take notes. This was exchanged between the authors prior to each interview. The interviews were between 20-30 minutes long. After the interview, the authors analyzed and compared notes with each other to obtain what was most relevant to the study.
Data analysis
A qualitative content analysis was used to analyse differences and similarities in the written and verbal data collected (Flick, 2018). This method is used to more easily focus on what is relevant to the study. The process resulted in three themes being discovered and relevant to the purpose of the study. All interviews were conducted over the phone and both authors were
present. The authors' first step in the process was to get an overall picture and understanding of the material collected and each interview was listened to several times by both authors to be compared. The next step was to sort out what was irrelevant to the study and things that had nothing to do with the authors' themes. Once the authors had gone through both the recorded and written data, the results began to take shape and quotes from each participant were included to gain a better understanding and feel of the interviews.
RESEARCH ETHICAL CONSIDERATIONS
Kjellström (2017) describes how important it is to understand research ethics when
conducting a scientific work. According to international guidelines, those participating in the study should not be exposed or harmed improperly. It is important to keep in mind that the individual's identity is protected and that the study is conducted under confidentiality. There are two ways to share privacy; One is that the information that is shared is stored in a way that is secure and that no unauthorized person can access. The second part is about how the
participants' identities and responses should not be linked to a specific participant and thus reveal the identity. Kjellström (2017) also describes how an interview method can be very personal and more intimate than if, for example, a survey was to be conducted.
The authors made it clear to the participants that participation in the study was completely voluntary and that they could cancel the interview at any time. If the participant perceived any of the questions as offensive or inappropriate, they did not need to answer. Any quotes from the participants will not be able to be linked to a specific participant. The authors also told us before the interview started that everything would be done according to confidentiality and the participants' identity will not be revealed. After all interviews were done, these were transcribed and then locked in a password-protected safe. Upon completion of the study, all collected material will be deleted.
Before the author went to Bali to collect material for the study, a project plan was written. The project plan was a first idea for the study and were about how the study was designed and what information there already was out there on the subject. The project plan were then approved by an ethical committee at Ersta Sköndal Bräcke University, 2017-01-17 and given a Dr:number, 1910-A.
RESULT
The results will be presented in three thematic groupings; lack of education leads to uncertainty in the nurse's work, functioning roles and routines are crucial to the nurse's profession, the nurse's experience of working in hospital after a natural disaster and its consequences. The nurse's experience will be clarified with quotes and the categories will be presented individually.
Lack of education leads to uncertainty in the nurse's work
All nurses that participate in the interview had different levels of education, they mentioned that they thought it would be good to have some kind of crisis management in the education and that some parts of the education were missing. The nurses understood the seriousness of the natural disasters and that it is a phenomenon that is happening more and more frequently. A nurse described:
“/.../ During my education, we did not study anything at all about how to work during crisis
situations which does not feel good at all…” P2
All the nurses stated that the nursing education contains many good parts and includes relevant courses that have helped them in real life and shaped them into the nurses they are today. The nurses think that the education has provided comprehensive knowledge for working in a hospital during “normal” circumstances. What the education, however, lacks according to the nurses is courses and practical knowledge in crisis management, trauma care and emergency care. The nurses told the authors that in the event of a disaster, it is necessary that all nurses are available and can help and then have the necessary knowledge.
The nurses clearly stated that they felt afraid of an eventually upcoming natural disaster and that they did not know how to cope with their work. The participants also said that they have tried to discuss this with other colleagues, but they say that it is something that they are responsible for themselves. A nurse described:
“/.../ I have asked my manager for more education but still have not received any answer…” P1
All interviewed nurses described a hopelessness as it is not easy to learn on their own how to work during unpredictable events and that they did not feel that they received enough support
from their manager. The nurses told that they did not know where to obtain information on crisis management. Several of the nurses expressed that they did not have access to the Internet and therefore could not seek out relevant information. The nurses also told us that lack of time was a big factor as they work many hours per day and in their free time they want to spend time with family and friends. The nurses expressed that practical training would be required together with colleagues to make the work more efficient during a possible natural disaster as theoretical knowledge is not sufficient. They believe that if the nurse has not been involved in a natural disaster in the past, theoretical knowledge will not suffice, therefore they must also be able to apply their practical knowledge.
All interviewed nurses pointed out that nursing education should be improved. The education does not change at the same rate as it would be needed given how drastically society and environment are changing. The nurses are aware that natural disasters will occur more frequently in line with global warming and its consequences.
Functioning roles and routines are crucial to the nurse's profession
The nurses mentioned that managers and management did not provide on-site training on natural disasters or other unpredictable events, resulting in confusion about their roles and routines in the hospital. They also mentioned that it is the responsible nurse in place who will set up routines and schedule for the day but that this rarely happens. The nurses describe that during a natural disaster, there is usually no responsible nurse in place as the working group often split during a disaster and they are placed where they are needed most. This results in no one having the main responsibility and being able to delegate the work between them and thus make the work more efficient. The nurses also express that they experience uncertainty in their work and in their role as a nurse when something like this happens.
All the nurses participating in the interview mentioned that the different programs that nurses in Indonesia have to choose from create ambiguities regarding division of labor and
responsibilities. A nurse described:
“/.../ To me it feels unfair when I've been studying for three years and are employed under the
same conditions as other nurses with less education…”P3
The nurses that were interviewed expressed that this not only creates difficulties regarding the roles they have in the hospital but also creates conflicts on a personal level. The nurses
work that someone with higher skills should actually be responsible for. The nurses told that, for example, the nurse who has passed the shortest education and thus possesses the lowest competence may also be given authority to hand out medicines that should really be done by someone with higher skills and knowledge. The nurses said that it felt like D3 nurses had struggled harder to get where they are today and that SPK have had it easier but is still employed at the same level.
The nurses that participated in the interview told the authors that the hospital they worked in is one of the first hospitals that patients come to when a natural disaster occurs and that they are quickly put under high pressure. A nurse described:
“/.../ If a natural disaster occur, I feel unsure about what to do because there are no clear routines at the hospital…” P3
The nurses interviewed went on to say that due to uncertainties about the distribution of work, no one knew how they are expected to act if a natural disaster occured. The nurses describe that they feel helpless as they often feel that they cannot live up to what is expected of them in a disaster situation. The nurses told the authors that when they have worked in previous natural disasters, the biggest problem has been that no one knows or sees how patients should be prioritized. The nurses went on to say that in previous natural disasters, it has been most often that patients have been treated according to the order they have arrived at the hospital and not prioritized according to the injury they have or the need they have when they come in. The nurses describe that despite obvious problems in previous natural disasters, they still have not been able to go through the routines that exist at the hospital or been assigned a specific role to be taken in the event of a natural disaster. The nurses wish that clearer routines exist for how the work during natural disasters would be conducted to get a more efficient work. The nurses felt that despite the fact that in their working group, conflicts can arise for various reasons, there is still good cooperation and cohesion. They express that they care for each other and wish everyone well. A nurse described:
“/.../ I think we work well in teams, the problem is that we don’t know who will do what in different emergency situations…” P2
The interviewed nurses express that they from time to time may feel a degree of injustice towards other nurses. This is often based on the fact that all nurses do the same work despite
the different length of training they have completed. The nurses explain that even though there are injustices surrounding the roles at the hospital, they take great care of the good cohesion they have in the group and that they do not want that to change.
The nurse's experience of working in hospital after a natural disaster and its consequences
The nurses say that there are no specific departments for trauma care or emergency care in their hospital. The nurses explain that this is due to the lack of resources and finance. All nurses expressed the wish that there should be departments that, in the event of a natural disaster, can be adapted to the patients' different needs in order to facilitate the work of prioritizing patients. The nurses told that after the tsunami in 2004, Indonesian health care was the focus point of a huge media crowd as many tourists were affected. This led to a negative picture of the healthcare provided in the country and great blame and guilt was placed on the hospital management. All the nurses interviewed explained that despite this happening in 2004, healthcare still looks the same today. The nurses express that this causes a feeling of concern for upcoming natural disasters. The nurses want the information for tourists and the population regarding natural disasters to be more clear and easily accessible to
provide increased knowledge and awareness of how individuals should act in the event of a natural disaster, which would reduce the pressure on the hospitals when possibly fewer would be harmed. The nurses explain that there is no specific department or staff that can take care of patients with mental illness after a natural disaster. A nurse described:
“/.../ We send home patients who say they are mentally ill…”P2
The nurses told the authors they do not know how to deal with patients that are suffering from mental illness after natural disasters. In most cases patients will simply be sent home as there are insufficient procedures on how to take care of this patient group. The nurses know that there are other hospitals outside Bali that have psychologists in place which means better help can be given there. However this is not offered at the nurses' hospitals. The nurses say that they feel great empathy for the patients who need help with their mental illness after a natural disaster and therefore it is painful for them as nurses that they cannot help the patients. All nurses described that during more severe natural disasters, buildings and other industrial sites are destroyed, making their work more difficult. A nurse described:
“/.../ The hospital I worked at got major injuries after the tsunami and I couldn't work there for months…” P1
The interviewed nurses told how the tsunami in 2004 destroyed their workplace. Parts of the hospital they worked in collapsed causing materials and necessities to be destroyed in connection with this. The nurses also told that affected people were cared for in tents or put in corridors in other buildings. This meant that the care became much worse than if they had been cared for in a functioning hospital.
DISCUSSION
METHODOLOGICAL CONSIDERATIONS
Before leaving Sweden, the authors tried to get in touch with the largest hospitals in Bali by sending an inquiry via mail, this did not produce any results. Once in the country, the authors found whats-app numbers on the hospital's website and made another attempt to get in touch that way and received answers immediately. The responsible nurse that the authors got in touch with at the hospital was very helpful and thought the work was relevant and good. The nurse asked some of her colleagues if they would be interested to participate and this resulted in a smaller group being willing to participate in the study. According to the authors' wishes, the nurses would prefer to have a lot of experience and have been involved and worked as a nurse during an ongoing natural disaster. The purpose of this study was to get an idea of how nurses in Bali work in hospitals during natural disasters. The work was presented by sending attachments regarding the study and a completed interview guide.
In a qualitative study, one does not primarily choose to conduct telephone interviews (Chapple, 1999). When a telephone interview is used to collect data, it is easy for visual signals to disappear which can lead to data loss or distortion which in turn can damage the data quality. Important components that are lost in a telephone interview are loss of nonverbal data such as facial expressions and body language, loss of contextual data such as appearance and age and it is easy for the collected data to be distorted and misinterpreted when authors and participants cannot see each other. Phone interviews can nevertheless give the participants a sense of security as more sensitive information can emerge and gives more anonymity and integrity to the participant. Other benefits can be short interview time and the interviews can give more detailed answers and the authors can write more comments during the interview
which does not prevent the participant from reducing social expectations (Bilal Farooq, 2018). Bryman & Bell (2011) highlight that the environment is an important factor for conducting interviews as well as a prerequisite for participants to feel safe. The authors felt that this was difficult as they could not control the participants' environment through a telephone interview. In order to formulate the questions for the interview, it was important to understand both the culture and the people (Schatzman & Strauss, 1973). To respect and understand the
participants' reality, the questions must be asked in a certain way in order to get more honest answers. The interviews were conducted according to a semi-structured method (Kvale & Brinkmann, 2009). The authors chose this method to be able to ask more open questions and to go outside the interview guide if needed. This was to get as much relevant information as possible. Because of the prevailing situation in the world, the interview data was collected via telephone (Bilal Farooq, 2018). The authors found various articles to be able to strengthen their interviewing techniques since there are several problems that can arise in telephone interviews. The authors tried to stay as close to the questions as possible to get answers to what was asked. The authors chose to go outside the interview guide sometimes when other relevant things came up. There were several factors that made the interviews difficult to conduct. One factor was the language as some had limited English which resulted in them having difficulty expressing themselves (Squires, 2008). In retrospect, the authors think it would have been wise to have an interpreter, but due to lack of time and Covid-19, this was not possible and it was also difficult to get an interpreter over a telephone call. Because the language was an obstacle, the authors noticed that it was difficult for the participants to come up with the right words to describe the course of events. For some questions, it was difficult for the participants to stick to the topic. They often slipped away from the main question and talked about something else that was not relevant to the issue. Some answers that were given felt more genuine than others and it was difficult for the authors to understand how genuine the answers were because the authors could not see the participants' facial expressions or body language during the interview. For a clearer study and a better result, the authors felt that interviews with several nurses had been required and they would need to be conducted with video calls. With more interviews, the authors could have compared different answers to a greater extent and been able to draw more conclusions in the result (Bilal Farooq, 2015).
RESULT DISCUSSION
function roles and routines are crucial to the nurses profession and the nurses experience of working in hospitals after a natural disaster and its consequences.
The majority of the interviews were conducted regarding the participants' views on the different levels of education that exist and also what the education results in after it is completed.
In a study written by (Setoyowati, 2015), he describes how the three different courses in Balinese nurse education create confusion in the work of both the nurse and management. He notes that it is the state that has decided that all nurses, despite different levels of education, should be employed and work under the same title. During the interview, several nurses argued about the lack of education. The authors felt that the different levels of education clearly create confusion in the nurse's work, which contributes to vulnerability in their
professional role as a nurse. All the interviewed nurses clearly stated that they wanted to see a change in the different levels of education so that their confidence would be able to strengthen in their role as a nurse. This could be done if the education had the chance to be developed and improved so that its not causing any suffering for the nurses.
Another study, written by (Martono, Satino, Nursalam, Efendi, & Bushy. 2019) they presented a survey conducted in which 1342 Indonesian nurses participated. This study showed that most of the nurses interviewed felt that they were not prepared for a upcoming disaster and did not understand their role during any emergency preparedness. The nurses interviewed in this study expressed a fear of upcoming natural disasters and concerns about whether they would really be prepared for it and for what role they would then assume. These nurses said that they had no knowledge of crisis management and did not know how to deal with an upcoming disaster. Nurses have expressed that communication is a crucial factor in being able to perform their job in the best possible way (Karagozoglu, Yildirim, Ozden & Çınar 2015). Similar to the result in this study they believe that without interaction and clear delegations, anger and frustration between the nurses and the quality of work will deteriorate and lead to patient safety being compromised. In the long term, this leads to many nurses choosing to end their employment at the hospitals. In Davis (2014) study, she highlights the importance of different roles and clear delegations in health care. She believes that it is one of the utmost importance that different levels of education also provide different types of roles and employment based on competence level. This is necessary to reduce any confusion in specific crisis situations. She also emphasizes that the various work areas that are in a hospital need to be constantly improved in order to maintain the safety of the workplace.
The ICN Code of Ethics (2012) for nurses describes that guidelines in care must be followed in order not to risk or jeopardize the patient's safety.
Another large part of the interviews consisted of how the mental health after a disaster affects both the patient and the nurse. The participants also highlighted that psychiatric aftercare is not a matter of course and that there are no guidelines for the nurse to relate to. A large part of the buildings in Bali, like hospitals and rescue centers, are not adapted or built to withstand a form of natural disaster and are therefore not safe for patients or nurses
(Swedenabroad, 2020). Prior to the 2004 tsunami, nurses had no systematic training on psychosocial support or mental health in crisis situations (Prasetiyawan, Viora, Maramis, & Keliat.. 2006). Following such a devastating natural disaster as the 2004 tsunami, there was considered to be a tremendous need for psychiatric care for both affected and loved ones. This resulted in the start of a collaboration in Jakarta to organize an intensive training program for two weeks. The model used was the "professional nursing practice model" (MPKP). MPKP is an already tried and tested model that has previously been used in mental hospitals around Indonesia. Pandu Setiawan & Viora (2009) also point out that this intensive two-week training was only temporary and is not still arranged for nurses today. The training was discontinued due to the lack of resources. Prasetiyawan, Viora, Maramis & Keliat, (2006) write in their study that after the 2004 tsunami, mental health courses were set. This
knowledge became important and in demand as the people affected by the tsunami began to develop mental ill health in greater breadth after losing large sections of family, friends and financial assets. Here it was important for the nurses to be able to meet and care for these people based on their mental body rather than the physical one that had been the focus before. If a natural disaster similar to the 2004 tsunami should occur again, it is important to be prepared as a nurse and there must be preparedness to be able to respond to mental health and promote health. The result shows that the lack of guidelines and procedures is a fact and for now the country is not sufficiently prepared.
Eriksson (2001) describes that an important factor in care is understanding the patient's suffering and the different phases of the suffering. Basically, the human body, spirit and soul are a unified entity (Wiklund Gustin & Lindwall, 2017). Eriksson (2001) believes that the nurse should nurture with love, understanding and be there for others. Eriksson (2001) illustrates that the human is religious and spiritual and should be cared for in all different stages of suffering. This is reflected in the Hindu faith and thereby in the Balinese health care. This can be interpreted as the nurses having their religion with them in the caring for people and thus caring with love and solicitude regardless of the situation.
CLINICAL IMPLICATIONS
The results of this study highlight that the education needs to include a more in-depth part in disaster management to give the nurses more knowledge. This could result in the nurse becoming more confident in her role and that it would lead to better routines in hospitals if a disaster should occur. The nurses would also need more practical training and especially those who have never been in a previous disaster. In the result, the topic addresses current aftercare and how the nurse would need further education in mental health and how to care for people after a disaster. If more education is offered to the nurses, this would benefit society as the routines would give patients the help they needed and be able to prioritize properly. It would make it easier for Indonesian nurses if they got to be employed in their workplace under different titles based on their education levels and thus avoid confusion regarding responsibilities.
PROPOSALS FOR CONTINUED RESEARCH
Based on the results of this study, it confirms that further research on several parts is needed. In order for the nurses in Bali to obtain the best conditions for coping with a natural disaster, it is necessary that more research that recognizes and problematizes the nursing education and its content conducted in Indonesia today. Further research on practical training for nurses could be done by allowing already trained nurses to be interviewed or answer a questionnaire. This could result in what the nursing education in the country would need to be supplemented with, in order for the nurses to feel safer in their role and better prepared to deal with a
possible natural disaster. Further research that highlights the aftercare of those who have been victims of a natural disaster would also be necessary. To prevent people from choosing to end their lives due to mental illness related to the trauma they have been through, they would need to be intercepted by the care provider for further visits so that they are not forgotten if care is needed. Research like this could be proposed in the same way as mentioned earlier and
hopefully could lead to the nurses being given proper guidelines on how to manage the care of patients with mental illness after a trauma.
CONCLUSION
The results of this study highlights how the Balinese nurses lack important and appropriate knowledge to be able to carry out their work to the extreme in a natural disaster. The result indicated that Indonesian nurse education today does not meet the requirements that are actually imposed on a nurse in the event of a natural disaster, which in turn leads to great uncertainty in their way of working. According to the nurses interviewed, clear roles and routines in the hospitals were very important for the work in a natural disaster to be as effective as possible. All of the nurses interviewed in this study also expressed a wish that there should be guidelines on how to care for the patients and close relatives who, after a trauma, suffer from mental illness.
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APPENDIX 1. (Fill in title)
Interview guide
- Would you please tell us about your hospital’s routines or programs in the event of a natural disaster?
- Could you share an example of working in the hospital during a natural disaster? (follow up: what happened, what did you do, how did it go?)
- How have you been affected both mentally and emotionally after taking care of victims from natural disasters? (follow up: are there anyone nurses can talk to after traumatic events, how would you describe your mental health today after what you have been through?)
BALINESE NURSES EXPERIENCE OF WORKING IN HOSPITAL DURING NATURAL DISASTERS.
We are two students from the nursing program in Stockholm, Sweden. We have received a scholarship to study nursing in an international context. Our hope is to better understand nurses’ experience of working in a hospital during a natural disaster I Bali.
The purpose of this study is to explore Balinese nurses’ experiences when working in a hospital during natural disasters. You are invited to participate in this study because you are a nurse working in an area that often is affected by natural disasters. This study is part of a Bachelor of Nursing degree (independent project 15 ECTS). If you agree to participate in this study, you will be interviewed regarding your experience of working in a hospital during a natural disaster. The purpose of the interview is to explore nurses knowledge and experiences, witch means that there are nor right or wrong answers. Inclusion criteria for the study are being a nurse and having worked in a hospital during a natural disaster. It is our hope that the interviews are more like a conversation than an interrogation. With your permission, the interviews will be audio-recorded, transcribed verbatim and analyzed by content analysis. All data will be stored on a password-protected computer and will be deleted after the work has been submitted. No unauthorized person will have access to the collected data.
Data collected in this study will be confidential. No individual identities will be used in any reports or publications resulting from the study. The interview to be conducted will contain 10-15 open question. The questions focus on how the nurses themselves experience working in hospitals during a natural disaster. There will also be information from the CINAHL, PubMed and PsycINFO databases. The keywords used are nurse, hospital, Indonesia, natural disasters. Data will be kept in locked files at all times. Only persons involved in the study will have access to the files.
Your decision whether or not to participate in this study is voluntary. If you choose to participate, later you can withdraw your consent and discontinue participation at any time without explanation.
approved the study 2017-01-17, 1910-A. If you have any questions about the study, please contact Emma Nordlöf or Therese Hallström by telephone or email. You can also contact the supervisor, Anna Klarare, PhD, with any questions related to this study.
EMMA NORDLÖF, STUDENT THERESE HALLSTRÖM, STUDENT Bachelor student Phone number: 0046707686601 E-mail: emma.nordlof@esbhstudent.se Bachelor student Phone number: 0046731578885 E-mail: therese.hallstrom@esbhstudent.se
ANNA KLARARE, SUPERVISOR PhD
Phone number: +4676 636 5088 E-mail: anna.klarare@esh.se
