ix

RINGKASAN

PENGEMBANGAN MODEL KESELAMATAN PASIEN BERBASIS CARING SEBAGAI UPAYA MENURUNKAN ADVERSE EVENT DI RUMAH SAKIT

UMUM DAERAH (RSUD) KABUPATEN LOMBOK BARAT DAN LOMBOK TIMUR PROVINSI NTB

Keselamatan pasien merupakan salah satu komponen utama dari kualitas pelayanan

rumah sakit tetapi secara umum belum memenuhi standar. Kondisi tersebut

ditunjukkan oleh data bahwa 54,48% rumah sakit di Indonesia dan 58,49 rumah sakit

di Provinsi Nusa Tenggara Barat belum memenuhi standar akreditasi dan standar

keselamatan pasien (Kemenkes RI, 2012). Banyak kasus adverse event (AE) yang terjadi di rumah sakit tetapi belum dilaporkan. Menurut WHO (2004), jumlah pasien

yang mengalami AE di beberapa rumah sakit di dunia adalah 3,2% - 16,6%. Demikian

juga Department of Health and Human Services (Office of Inspector General)melaporkan bahwa klien yang mengalami adverse events dan temporary harm events sebesar 13,5% (Daniel, 2010). Hasil survei kepuasan pasien terhadap pelayanan

keperawatan di Rumah Sakit Umum Provinsi Nusa Tenggara Barat dan di beberapa

Rumah Sakit Umum Daerah di Lombok pada tahun 2010 adalah 65% (RSUP NTB,

2011), lebih rendah dari standar minimal kepuasan pasien yaitu 80% (Kemenkes,

2010). Kepuasan pasien tersebut berkaitan dengan aspek sikap dan perilaku serta

kepatuhan terhadap standar prosedur operasional dan aspek tersebut berkaitan erat

dengan keselamatan pasien. Kondisi itu hampir sama dengan yang disampaikan oleh

Agency for Healthcare Research and Quality (AHRQ) pada tahun 2011 bahwa hampir 50% keluhan (complaints) dari klien berkaitan dengan komunikasi, sikap dan perilaku, kurangnya rasa kasih (lack of compassion) serta sikap kurang peduli (uncaring).Tujuan penelitian ini adalah menyusun model keselamatan pasien berbasis caring dalam keperawatan sebagai upaya mengurangi adverse event di Rumah Sakit Umum Daerah Kabupaten Lombok Timur dan Rumah Sakit Umum Daerah Kabupaten

Lombok Barat. Konsep model tersebut mengacu kepada Swanson’s Caring Theory dan International Patient Safety Goals dari JCI. Swanson’s Caring terdiri atas 1)maintaining belief; 2) knowing; 3) being with; 4) doing for; 5) enabling (Caroline, 2011). International patient safety goals atau Sasaran Keselamatan Pasien (SKP) dari Joint Commossion International (JCI, 2011) merupakan variabel keselamatan pasien terdiri atas: 1) ketepatan dalam identifikasi pasien; 2) komunikasi yang efektif; 3)

terjaminnya tepat lokasi, tepat prosedur dan tepat pasien dalam tindakan

operasi/tindakan invasif; 4) keamanan obat high alert; 5) pengurangan risiko infeksi nosokomial; 6) pengurangan risiko pasien jatuh.

Metode penelitian ini dirancang menjadi dua tahap yaitu tahap pertama eksplanasi

(explanatory research) untuk menjelaskan hubungan kausal antara variabel karakteristik perawat dengan perilaku caring dan sasaran keselamatan pasien berdasarkan jawaban responden. Isu strategis yang dihasilkan dari tahap explanatory research ini dibahas dalam focus group discussion (FGD) dengan melibatkan pakar untuk menyusun Model Keselamatan Pasien Berbasis Caring. Tahap kedua adalah eksperimen dalam bentuk pelatihan untuk penerapan model keselamatan pasien

berbasis caring dalam asuhan keperawatan di ruang rawat inap dan menganalisis pengaruhnya terhadap penurunan adverse event (AE) .yang terdiri atas medication error, flebitis, dekubitus, infeksi daerah operasi dan risiko pasien jatuh sebagai indikator keselamatan pasien.

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kan bahwa klien yang mmenengggalami adaadvevverse events dan tempora13,5% (Daniel, 202020201010101 ).).).). HaHaHasisisilll sus rvrvrvrveieie kekekepupupuasasasa an pasien terha

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ning bebebeb lilililiefefefef;;; 2)2)2)2 knknknnowowowwininining;g;g;g 3)3)3)) bebebeeininini g g g g wiwiwiwithththh; ; ; ; 4)4)4)4) dodododoiningg gg fofofof r;r;r;r 5)5)5)5) enanternatioioioonanananalll papapapatititienenent sasas fefefef tytyty g g goaoaalslslsl atatauauauu S S SSasaa arararan K KKeseseseselelelamamamamatan Paommossion InInInInteteternrnrnaataa iooonananaallll (J(J(JCCCCIII, 20202 1111) ) ) ) mememem rurururupapapakakakakan n nn vavavavarriabel kesetas: 1) ketepatatatat n nn dadadadalalalaam mm m iddddennntititifififikakakaasiii p p p asasasasieieien;n;nn; 2 222))) komunikasi y

nya tepat lokasi, teteteepapapattt prprprp osososedededuruurdddd dadadann tepat pasien d

x

Populasi dalam penelitian ini adalah seluruh perawat dan pasien di semua unit rawat

inap di Rumah Sakit Umum Daerah (RSUD) A di Kabupaten Lombok Barat dan

RSUD B di Kabupaten Lombok Timur Propinsi Nusa Tenggara Barat (NTB). Unit

rawat inap di RSUD A dan RSUD B berjumlah 16 unit. Kapasitas unit rawat inap

yang tersedia adalah 342 tempat tidur. Tenaga perawat yang ada berjumlah 281 orang

(Profil RSUD A dan RSUD B, 2013). Sampel adalah unit rawat inap yang memenuhi

kriteria inklusi yaitu menerapkan manajemen asuhan keperawatan profesional dan

merawat pasien dengan tindakan pembedahan/operasi. Besar sampel yang diperoleh

dari RS A dan RS B pada tahap eksperimen berdasarkan ketentuan di atas adalah 8

orang kepala ruangan, 48 orang perawat pelaksana, sedangkan besar sampel pada

tahap eksplanasi sebanyak 82. Variabel penelitian ini terdiri atas variabel indpenden

dan variabel dependen beserta sub variabel yaitu Karakteristik Perawat, Caring, Safety Caring Model, Sasaran Keselamatan Pasien dan Adverse EventInstrumen pengumpulan data terdiri atas kuesioner dan lembar check list yakni kuesioner caring dimension inventory (CDI), pedoman wawancara caring professional scale (CPS), carative factors untuk meneliti pengetahuan perawat, kuesioner International Patient Safety Goals, lembar observasi (check list) Norton Scale untuk Dekubitus (Decubitus Ulcer Rate), Vip Score (Visual Infusion Phlebitis Score) untuk Phlebitis, Southampton Scoring System untuk Infeksi Daerah Operasi (IDO), Morse Fall Scale dan Humpty Dumpty Scale untuk risiko jatuh, dan NCC MERP indeks for Categorizing Medication Error. Analisis data secara deskriptif untuk memperoleh gambaran mengenai karakteristik

responden dan distribusi karakteristik perawat yaitu pengetahuan (X1), sikap (X2) dan

pengalaman (X3) serta distribusi pelaksanaan caring (Y1) dan Y2 yaitu sasaran keselamatan pasien (SKP). Metode analisis partial least square (PLS) yaitu analisis persamaan struktural berbasis varian yang secara simultan dapat melakukan pengujian

model pengukuran sekaligus pengujian model struktural yang dilakukan

menggunakan software SmartPLS.Hasil dan kesimpulan penelitian. Nilai outer loading dan AVE > 0.5, nilai composite reliability 0. > 6 dan T statistik > 1,96 menunjukkan bahwa uji hipotesis adalah valid dan signifikans. Nilai uji R2 adalah 0.490, maka dapat disimpulkan bahwa Model Keselamatan Pasien Berbasis Caring telah memenuhi persyaratan sebagai sebuah model yang baik.

Temuan baru yang dihasilkan adalah Model Keselamatan Pasien Berbasis Caring yang dinamakan Model Safety Caring Model (SCM). Komponen dari caring yang melandasi keselamatan pasien dalam pelaksanaan asuhan keperawatan dan

pelaksanaan caring yang berorientasi serta memiliki indikator keselamatan pasien secara terukur dalam menurunkan AE membedakan SCM dengan model lain.

Kontribusi SCM terhadap keilmuan yakni menambah dan melengkapi Bidang Ilmu

Keperawatan, Manajemen Rumah Sakit (Clinical Management) dan Teori Manajemen Mutu .Direkomendasikan untuk menggunakan Model Keselamatan Pasien Berbasis Caring sebagai salah upaya meningkatkan mutu pelayanan RS dan perlu penelitian lebih

lanjut mengenai keselamatan pasien ditinjau dari clinical pathway keperawatan. Untuk Institusi Pendidikan Keperawatan perlu menambah muatan kurikulum tentang

caring dan keselamatan pasien maupun keselamatan kerja bagi perawat

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DISERTASI PENGEMBANGAN MODEL... MENAP

er caring dimension iinvvnventory (C(CCDI), pedoman wawonal scale (CPSS)))), ccccarararatata ivivve ee fafafaactccc ororororssss unununtututuk kk mem neliti pengeter Internatioonananaalll PaPaPaPatiitienenenntt SaSaSafefefetytyyy G GGGoaoao llsl , ,, lelelel mbmbmbbararar o oo obsbsbservasi (chentuk Dekuuuubibibib tututuus s s (((DeDeDeD cucuc bibibib tuututus ss s UlUlUlUlcececec rrr RaRaRaRatetetete(((( ),),), ViViVip pp ScScScS orororore ee e (V(V(V(Visual Infuntuk PhPhPhhlelelel bibibitiss,s SSSouououuthththamamammptptptptonononon S S SScocococoriririringngngn S SSysysystetetetemmm unununtuukkk k InInInfeksi Morsee ee FaFaFaFalllllll SSScacacac lelelee dadadadannnn HuHuHuHumpmpmpmptytyty D D DDumumumptptptp y y y y ScScSccalalalale e e unununntututut k k kk riririisisisis kokk jndekekekss ss fofofof rr r CaCaCaC tetetetegogogogoririririzizizizingngngg MMMededededicicici atatatatioioioion Errorororor.r.r.r. datatata aa seseseecacacac rrar d ddeseseseskrkrkrkripii titiiif ff unununtututuuk kk mememem mpmpmpmperererololololeheheheh g g ggamamama babababaraaann n memememengnngn enee

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matan PaPaPaPasisisis enenene B BBerrrrbababaasisisiis ss s CaCaaCariririringnggng tetetetelalalaahhh h mememem memememenunununuhihhh peere sysysysyarararratan ang baik.kk

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namakan Moded ll l SaSaSaSafefefef tytytyty CaCaCaaririiringngngg MoMoMoM dededed l ll (S(S(S( CMCMCMCM)))). Komponen dasi keselamatan pasisisienenen d d dalalamamam p p pelelelakkakaksanaan asuhan kep

xi

SUMMARY

MODEL OF PATIENT SAFETY BASED ON CARING AS EFFORTS TO REDUCE ADVERSE EVENT IN DISTRICT GENERAL HOSPITAL OF WEST AND EAST LOMBOK, WEST NUSA TENGGARA PROVINCE

Patient safety is one of the main components of the quality of hospital services but

generally not meet the standards because 54.48% of all hospitals in Indonesia and

58.49 hospitals in the province of West Nusa Tenggara (NTB) has not met the

accreditation standards and patient safety standards (MoH RI, 2012)

Many problems of adverse event (AE) or unexpected events but not yet reported.

WHO (2004) noted that based on the results of the study, 3.2% - 16.6% of patients

experienced AE in hospitals. The same is delivered by the Department of Health and

Human Services (Office of Inspector General) that a client who experienced adverse

events and temporary harm events by 13.5% (Daniel, 2010). The patient satisfaction

survey department of NTB and in some hospitals in Lombok in 2010, patient

satisfaction with hospital services, especially nursing services was only 65% (RSUP

NTB, 2011), lower than the minimum standard of patient satisfaction was 80%

(Ministry of Health, 2010) , The problem of low rates of patient satisfaction is related

to aspects of the attitudes and behavior as well as adherence to standard operating

procedures and the conditions closely related to aspects of patient safety. It was in line

with the Agency for Healthcare Research and Quality (AHRQ) that deliver research

results in 2011 that almost 50% of complaints from clients related to communication,

attitudes and behavior, lack of compassion and uncaring.

The purpose of this study was to develop a model-based patient safety caring in

nursing as an effort to reduce adverse event (AE) at Hospital B in East Lombok

district and hospital A in West Lombok, West Nusa Tenggara Province. The concept

of the model refers to Swanson's Caring Theory and International Patient Safety Goals

(IPSG) from JCI. Swanson's Caring consists of five (5) components, namely 1).

maintaining belief; 2) knowing; 3) being with; 4) doing for; 5) enabling (Caroline,

2011). International patient safety goals (IPSG) from Joint Commossion International

(JCI, 2011) was a hospital patient safety variables consist of: 1) accuracy in the

identification of patients; 2) effective communication; 3) the right-location, right-

procedure, right-patient surgery; 4) high drug safety alerts; 5) reduction in the risk of

nosocomial infection; 6) reduction in the risk of patient falls

Methods this study was designed in two phases: the first explanation (esplanatory

research) to explain the causal relationship between the variable characteristics caring

nurses with the implementation of the targeted patient safety based on respondents'

answers. Strategic issues resulting from phase explanatory research is discussed in the

focus group discussion (FGD) with the involvement of experts to draw up Model-

Based Patient Safety Caring. The second stage was an experiment in the form of

implementation of the new model in nursing care in the inpatient unit and analyze the

effects on reduction in adverse event (AE) which was composed of medication errors,

phlebitis, pressure sores, infections operating area and the risk of patient falls as

indicators of patient safety.

The population in this study was all nurses and patients in all inpatient units at

Regional General Hospital (Hospital) in West Lombok A and Hospital B in East

Lombok, West Nusa Tenggara. Inpatient units in hospitals A and Hospital B

amounted to 16 units. Inpatient unit capacity available is 342 beds. There were nurses

who totaled 281 people (Profile of Hospital A and Hospital B, 2013). Samples were

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DISERTASI PENGEMBANGAN MODEL... MENAP

nd temporary harm eveentntss bbby 13.5%55% ( ((Daniel, 2010). The pat

department of NNNTBTBTBTB a a andndnd ii in nn sosososomeemee h h hososospipipip tatatalslsls i n Lombok in

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011) wawawaasss aaaa hohohoh sppppitititalalalal papapapatititiienenenntt t sasasaafefefef tytytyty vavavaririririabababablelelelesss cocooonsisisist t t ofofofof:: ffffff 1) a

ation offf papapapatititienenene tststs; ;; 222) ))) efefefe fefefeectctctivivive ee cococ mmmmmmunununu icccaata ioioionn;; ; 3333) ) ) thththt e right-

re, right-paatititit enenenent tt suuuurgggerereryyyy; ;; 444) ) ) hihhhighghggh drdrrdrugugugug ssssafafafafetetete yy alalalalererrertststss;; 555) reductio

mial infection; 666)) ) rererer dududuductctctctioioioi nn n in thththhe riririi kskk o o offff papapapatitititienenenent t tt fafafalls

s this study was desisigngngng ededed iiiinnn twtwtwooo phphphasasesese :: the first explanati

xii

inpatient units that meet the inclusion criteria that apply professional nursing care

management and care of patients with surgery / operation. Sample size obtained from

hospital A and hospital B in the experimental stage were 8 peoples of head room, 48

nurses and sample size in the explanatory stage were 82. Variables of this study

consisted of indpenden variables and the dependent variable and its sub variables

were Characteristics of Nurse, Caring, Safety Caring Model, Patient Safety Goals and

Adverse Event

Data collection instruments consisted of a questionnaire and checklist sheets namely

questionnaire of caring dimension inventory (CDI), interview caring professional

scale (CPS), carative factors to examine the knowledge of nurses, questionnaires

International Patient Safety Goals, the observation sheet (check list) Norton Scale for

pressure sores (Decubitus Ulcer Rate), Vip Score (Visual Infusion phlebitis Score) for

phlebitis, Southampton Scoring System for Infectious Regional Operations, Morse

Fall Scale and Humpty Dumpty Scale for fall risk, and NCC MERP index for

categorizing Medication Error.

Descriptive analysis of the data to get a picture of the characteristics of respondents

and distribution characteristics of nurses that is knowledge (X1), attitude (X2) and

experience (X3) and the distribution of caring implementation (Y1) and Y2 is patient

safety goals. The method of analysis partial least square (PLS) is a variant based

analysis of structural equations that can simultaneously test the measurement model

once the structural model testing performed using software SmartPLS.

Results and conclusions of the study. Value of outer loading and AVE > 0.5,

composite reliability values > 0.6 and T statistics > 1.96 indicates that the test of

hypothesis was valid and significance. Value of goodness-of-fit R2 test was 0.490, it

can be concluded that Safety Caring Model (SCM) has met the goodness-of-fit

The new findings generated was caring based patient safety safety model, called

Safety Caring Model (SCM). Components of caring that underlying for patient safety

in the implementation of nursing care and caring implementation oriented and has a

measurable indicator of patient safety to reduce AE was distinguish SCM with other

models.

Recommended for use Safety Caring Model as an effort to improve the quality of

hospital services and the need for further research on the safety of patients in terms of

clinical nursing pathway. For Nursing Education Institutions need to increase the

curriculum of caring and patient safety as well as safety for nurses

ADLN-PERPUSTAKAAN UNIVERSITAS AIRLANGGA

DISERTASI PENGEMBANGAN MODEL... MENAP

zing Medication Error.

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xiii

ABSTRAK

Latar belakang. Keselamatan pasien merupakan komponen utama dari kualitas pelayanan rumah sakit tetapi secara umum belum memenuhi standar karena 54,48%

rumah sakit di Indonesia dan 58,49 rumah sakit di Provinsi Nusa Tenggara Barat

(NTB) belum memenuhi standar akreditasi dan standar keselamatan pasien

(Kemenkes RI, 2012) sehingga banyak masalah adverse event (AE) tetapi belum dilaporkan seperti yang disampaikan WHO (2004) bahwa 3,2% - 16,6% pasien di

rumah sakit mengalami AE. Kepuasan pasien terhadap layanan layanan keperawatan

di rumah sakit hanya 65% (RSUP NTB, 2011), lebih rendah dari standar minimal

(80% ) dan hal itu berkaitan erat dengan aspek keselamatan pasien serta sekitar 50%

keluhan klien berkaitan dengan komunikasi, sikap dan perilaku uncaring.Tujuan penelitian ini adalah menyusun model keselamatan pasien berbasis caringdan menguji pengaruhnya terhadap penurunan adverse event.Metode penelitian yang digunakan adalah eksplanasi (esplanatory research) untuk menjelaskan hubungan kausal antar variabel dan eksperimen berupa penerapan Model

Keselamatan Berbasis Caring di ruang rawat inap dan menganalisis pengaruhnya terhadap penurunan adverse event (AE) .Populasi dalam penelitian ini adalah seluruh perawat dan pasien di semua unit rawat inap di Rumah Sakit A Kabupaten Lombok

Barat dan RS B di Kabupaten Lombok Timur sebanyak 16 unit, 342 tempat tidur,

281 orang perawat. Besar sampel untuk tahap eksplanasi adalah 82 dan untuk tahap

eksperimen 56. Analisis deskriptif dilakukan untuk memperoleh gambaran mengenai

karakteristik responden dan distribusi frekwensi variabel. Metode analisis partial least square (PLS) untuk pengujian model pengukuran dan pengujian model struktural. Hasil penelitian dan kesimpulan. Nilai outer loading dan AVE >0.5, nilai composite reliability >0. 6 dan T statistik > 1,96 menunjukkan bahwa uji hipotesis adalah valid dan signifikans. Nilai uji goodness-of-fit R2 = 0.490, maka dapat disimpulkan bahwa Model Keselamatan Pasien Berbasis Caring telah memenuhi goodness-of-fitDirekomendasikan untuk meningkatkan keselamatan pasien menggunakan Model Keselamatan Pasien Berbasis Caring dan kepada institusi pendidikan perlu manambah muatan kurikulum tentang caring dan patient safety. Penelitian ini perlu dilanjutkan dengan ruang lingkup yang lebih luas.

Kata kunci: Perawat, Caring, Model keselamatan pasien, Adverse event

ADLN-PERPUSTAKAAN UNIVERSITAS AIRLANGGA

DISERTASI PENGEMBANGAN MODEL... MENAP

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nci: Perawat, Caring,t MoMoMoM dedededell l kkkeseseselelelamamama atata ananan pasien, Adverse evekkkk

xiv

ABSTRACT

Background. There were many adverse events in hospitals globally (3.2% - 16.6%), patient satisfaction with nursing care at the General Hospital of West Nusa Tenggara

and the District General Hospital in Lombok is still low (65%) and about 50% of

patients complaints related to communication, attitude and uncaring behavior. The

issues are closely related to patient safety. This study aimed to develop a Model ofPatient Safety Based on Caring and was tested its effect for reducing adverse events in

District General Hospital of East and West Lombok.

The design of this study in first stage was explanatory research with descriptive and partial least square (PLS) analysis to formulate model of Patient Safety, while in

second stage was used experimental method with risk reduction analysis to test its

effect to reduce the adverse events. The population was nurses and patients in all

inpatient units and sample size for first stage was 82 nurses and for the experimental

phase of 60 nurses and 41 patients was drawn by simple random sampling. Data were

collected by questionnaire and observation.

Results of descriptive research, all elements of caring more dominant (35% - 50%) categorized sufficient and less, except the elements knowing more (51.2%) were

categorized good. Knowledge about caring majority (78%) considered good, while the

attitude and experience 64% and 48% were categorized sufficient. All elements of

patient safety more than 50% were categorized sufficient except the elements

reduction in infection. PLS analysis, generating outer loading value and AVE value

> 0.5, composite reliability value > 0. 6 and t- statistics > 1.96 indicates that thehypothesis test is valid and significance. R

2value of caring was 0411 and Patient

Safety was 0.490, the value of Q2

was 0.700 indicated the model had proven to

qualify goodness. From the risk reduction analysis had proven that adverse events

decreased significance (35% - 45%).

Conclution and recomendation. It is concluded that Model of Patient Safety Based on Caring is a good model for reducing adverse event. It is recommended to

implement this model on broader scope and services quality improvement more

focused on patient safety. Educational institutions is recomended to increase caring

and paient safety in curriculum safety to produce a double effect on the health sector.

Keywords: Nurse, Caring, Model of Patient Safety, Adverse event

ADLN-PERPUSTAKAAN UNIVERSITAS AIRLANGGA

DISERTASI PENGEMBANGAN MODEL... MENAP

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