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--- Barriers in Treating Patients with Acute Coronary Syndrome in Indonesia Primary Health Care: a Phenomenological Study
Kumboyono Kumboyono1; Dini Prastyo Wijayanti2; Titin Andri Wihastuti3; Septi Dewi Rachmawati4 Yulia Candra Lestari5
2,5Student in Master Program of Emergency Nursing, Medical Faculty, Universitas Brawjaya
1,3,4 Lecturer in Master Program of Nursing, Medical Faculty, Universitas Brawjaya
*Corresponding author: Kumboyono Kumboyono School Nursing, Medical Faculty, Brawijaya University, Indonesia
Tel: +6281805004106; Fax: +62 0341 564755
e-mail: abu_hilmi.fk@ub.ac.id / publikasikoe@gmail.com ABSTRACT
Introduction: Acute Coronary Syndrome (ACS) is the leading cause of mortality in the world. Primary prevention strategy focuses on reducing the risk of disease spread. At the same time, curative strategy aims at reducing the risk of disability and mortality. Initial therapy should be considering early stabilization and immediate advanced care to reduce the risk of complication. Therefore, it is important to improve guideline, the medical referral system, and family consent procedure to save patients with ACS.
Aim: This research aimed at exploring the barriers faced by nurses in treating patients with ACS in PHC.
Method: This research employed a qualitative research method using descriptive phenomenology. This study involving 16 subjects of nurses working in PHC with in-depth interview. The data analysis procedure proposed by Clark and Brown 2013 Result: Three main themes were pointed out by 16 participants; 1)Update Guidelines, 2) Inefficient referral process to other health centers, 3) Consent making process by the
family
Discussion: Barriers in performing health care for patients with ACS in the emergency unit of PHC needs updating guideline to be enhanced by engaging the advancement of technology and communication using electronic medical record system, family
education, and fulfillment of better medical facilities to make the process more efficient.
At the same time, also improves the management service for patients with ACS and making it possible for PHC to provide reliable health care as the first health care provider for the society.
Keywords: Nursing Barriers, Health Care Referral, Acute Coronary Syndrome (ACS), Emergency Nursing, Primary Health Care.
Introduction
Acute Coronary Syndrome (ACS) refers to a condition or complication of diseases which cause unstable condition caused by burst of blood vessels, causing sudden occlusion in the coronary artery [1]. According to the data released by the WHO (2008), acute
coronary syndrome is the world’s top killer and causes death twice as much as cancer [2]. Record shows that around 7.200.000 people (12.2%) have died of ACS.The chance in rescuing patients with cardiac arrest declines around 7-10% every minute [3].
Based on the data released by the European Society of Cardiology (ESC) on the guideline,initial stabilization procedure within the first 72 hours for patients who have low risk of complication [4]. Primary Health Care (PHC) attempts at providing responsive, comprehensive, effective and efficient that decreases the expenses of inpatient care and reduces the health gap in the society in order to let anyone have the access to reach excellent health service at affordable price. PHC in Indonesia is a first-level health service in peripheral areas development in health services. There are fullfill of 20 million with rate 70% -90% in the population with health problems.
This problem should be taken as a challenge for PHC hospital to improve its service and facilities [5]. A study conducted in New Zealand shows that generally nurses always try to apply nursing principles while they are performing their jobs [6]. The role of PHC nurses in Indonesia performs health promotion, screening and treatment of general emergency diseases. PHC service In treating emergency patients, referral procedure should be highly concerned, regarding to the fact that the distance to more advanced hospitals is quite far, and ineffective communication procedure as well as the lack of facilities might appear as the barriers during the process. At the same time, primary treatment that focuses on decreasing the risk and reduce of ACS. Whilst, curative strategy should also be given to decrease the risk of disability and death.
Patients who felt the symptoms of cardiac diseases need deep investigation and immediate treatment, chest pain not always caused by ACS [7]. Barriers in this process needed to be determined regarding to the fact that families of the patients might be
lacking of knowledge to take immediate consent, nurses might also lack of experience and skills, as well as limited resources, accessibility issues and inefficient referral
procedure [8]. Some indicators are used to evaluate the quality of emergency treatment including nurses’ emergency nursing experience, medical facilities and trainings given to deal with emergency patients [9].
A study conducted in Sri Lanka also shows that poor communication [10]. The result of this study is expected to give insights in solving the problems and improving the referral system across health care providers as well as advancing the facilities in PHC.
Material& Method
Research Design A qualitative approach using a descriptive phenomenology design was employed in this study. The result of this study describes nurses’ view about their
nursing experiences related to certain concept or phenomena.
Setting
This research took place in Primary Health Care Turen, Malang Regency, East Java, Indonesia. Population and samples For this study were selected by snowball sampling.
Criteria of selection were that participant 16 nurse at PHC who owned 3-15 years nursing experience and minimal had 1 year experience treatment patients with ACS. 16 nurses possessed diploma degree on nursing and bachelor of nursing. All of the
participants joined several professional trainings such as BCLAS, BTLS, PPGD and K3.
Data Collection
Instrument In-depth interviews were done to collect data in which voice recorder was used to help the researchers in recording the complete data. The semi-structured in-depth interviews were conducted based on critical decision method using a set of open-ended questions, allowing the participants to give in-depth and broad explanation about their views. Procedure This research was conducted for 4 months from September to December 2017. Researchers acted as the key instrument in this study. After being given the explanation, the participants were asked to sign a consent for. Researchers scheduled the exact time and place for the interview.
Data Analysis
The data obtained from the interview were transcribed to be later analyzed using the thematic method proposed by Clark and Brown (2013)[11]. The thematic data analysis consisted of these steps: (1) transcribing; (2) identifying the data; (3) coding; (4)
grouping the key words into sub-theme categories; (5) arranging the themes; (6) writing the report of data analysis which contained nurses’ explanation about their experience that could not be analyzed using software.
Ethics
Ethical clearance procedure was administered and legalized by the board of ethics of the Medical Faculty, Brawijaya University number 216/EC/KEPK/06/2017.
Finding
The participants (nurses) selected for this research were 20 – 35 aged and had been working in the ED for 3 to 15 years. In the term of education background, it was obtained that participants almost were DIII-nursing graduates while the other 4 had Bachelor's degree in Nursing. Participants have training certifications of BCLAS, BTLS, PPGD and K3.. According to the results of the qualitative data analysis, there are three themes obtained based on the objective of the research.
Theme 1: Update Guidelines The sub theme is update of ACS management SOP The update is done by updating, replacing, adding, or subtracting. With the updated
guidelines, nurses have a sense of calm in performing the action. I have ever known the guideline, but yaa, you know, sometimes patients in EDs have different
characteristics.Whether the ED is crowded (full of patients) cannot be ascertained, we will try to take care of him accordingly with the guideline... (P9) In my opinion, the SOP should be upgraded in accordance with the scientific development and adjusted to the policy.
The existing SOP may be replaced, added, or subtracted (P11,P16) Theme 2: Inefficient referral process to other health centers The sub theme are The communication network among health care providers, Barriers in transferring the patients to more advanced hospitals. the need for equipment availability, and Additional duties. We desperately looked for referral hospital but it took quite a while. Patient’s condition dropped.
Unfortunately, 30 minutes was not enough to save the patient.(P6) We always called the referred hospitals, usually we contacted the regional hospitals but sometimes it was not easy to reach them. So we had to bring the patients to RSSA (Saiful Anwar Hospital) which is quite distant (P1, P3).
When the EKG record indicates IMA case, we directly refer the patient to a more
advanced hospital. But the referral process can only be granted by ACS group. Thus, we always have to consult the case to cardiologists before it is granted. Usually, we
contacted the cardiologists via telephone. Sometimes they did not grant the requests and we could not do anything. (P7) ...no oxygen saturation tester available. So, nurses collected their own money to buy it in order to save the patients with heart disease indication (P5, P14) We already propose for the equipment which has been months and years, but there is no response ....(P10,P15) Actually, I tend to respond it as a part of the delegation or responsibility that we have to commit. But, it cannot be denied that such duties will increase our workload...
(P13) Theme 3: Consent making process by the family The sub theme are Family rejected tranffering patient and Family rejected medical treatment Sometimes, conflicts occurred.
Families insisted on staying here even if the patients agreed to be transferred to regional hospitals. Families wanted to stay in nearby hospitals.(P12, P2) Families might not understand the condition of the patients. They stuck to their own assumption to tranfer advanced hospital. They underestimated the patients’ condition. (P4) There were families who rejected the heart resuscitation procedure because they felt terrible to the patients.
They might have watched the procedure on television and they assumed most of the procedure failed (P8). Discussion Transition in Epidemiology has changed the paradigm that believed non-contagious diseases could not be the major cause of mortality. Nurses in PHC hold the responsibility to give pre-hospital emergency health treatment which requires them to have adequate human resources and excellent coordination and
communication among the personnels [10]. Patients lives are the top priority of the SOP, allowing the nurses to change treatments in order to minimize any live-threatening risks [12].
The results of the interviews showed some barriers , first: guideline ineffective, the lack of medical tools or devices, delegation tasks or additional make nurse work overload, such as taking transporter actions and handling administrative. According Deaton (2016) that study found the nurses who have some barriers yet still showed a high level of responsibility for patients by maintaining their care quality despite those emerging barriers[16]. Therefore, the nurse practice guidelines renewal is important to be done to improve the quality and service. SOP development is an effective tool to improve the quality of service and documentation completion, so also avoid heavy workload[13].
Referral to other health care facilities requires a strategic, pragmatic, even, and
coordinative system to provide a continuum health care from the first health facility to a more advanced health facility. This theme describes that crucial issue is related to the lack of knowledge, skills, resources and accessibility that also affect the efficiency of the referral process [8]. There has to be a good integration in the communication system between PHC and regional hospitals to make the process faster. However, some nurses stated that sometimes negative responses due to disagreement from ACS consultant group in the regional hospitals.
Studies show that as many as 67% of the population reported poor accesibilty to reach advanced health services in rural areas compared to urban areas [14,15]. Vast
advancement of technology makes it possible to create innovations in medical
treatment system. Excellent integration of advanced information, communication and technology allows betterment in information system which guarantees information continuity, quality service, medical treatment, and better access for people who live in outskirt areas.
The innovations can be made in the form of electronic medical record system and telemedicine [16]. Beside that lack of facilities like equipment at PHC, nurses often had to make their own donation which reflects their sincerity to their patients to buy some
equipment needed because limited and it would take quite. Oxygen saturation tool is an important tool to measure the oxygen level in patients’ blood and shows the risk of heart attack. This deficiency is associated with budget constraints which will have an impact on service quality [17].
According to the interview, they agree that family as decision making. Families are the closest relatives of patients. Any treatment given to the patients should be agreed by the family at first by signing the inform consent.This procedure also reflects the legal ethical even in emergency situation, such as informed consent like two-way
communication between patient and one or more health practitioners which patients should be given the rights benefits and risks treatment [18]. Any medical treatment should not be given when in a sensitive and difficult condition either or not to take life-saving treatment such as cardiopulmonary resuscitation (CPR) even if this treatment might save patients’ lives [19].
New Zealand has a complete set of patients’ basic rights which involves the participation of the patients, patients’ family and medical practitioners in deciding the medical
treatment. Meanwhile, in some Asian countries, there is a cultural-bond phenomena in which the family hold the strongest authority. Nursing ethics require the nurses to reach this balanced decision by solving the problems related to family consent [20].
Conclusion In this study, nurses who participated in this study have explained the problems. Three major problems appear as the barriers during the treatment.
These problems can be solved by implementing an advanced integration of technology in the communication system such as using electronic medical record system and guidline of nurse need updating, educating patients’ family and the management of health care service, especially for patients with ACS. SOURCE OF FUNDING The funding sources of this research are from the researcher's own personal funds Limitation This research explains the Barriers found by nurses of PHC in peripheral areas of Indonesia.
The result of this study cannot be simply generalized for other areas.
Implications for further research
Implication for future researchers to design guidelines for PHC services by implementing network-based referral system and using electronic medical record system to provide better emergency nursing in PHC services.
Ackowledgement
The greatest gratitude is expressed to the Medical Faculty of Universitas Brawijaya that has funded this research.
Conflict of interest
No conflict of interest involved in this research.
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