College of Nursing

National Taipei University of Nursing and Health Sciences

Master Thesis

The Exploration of Indonesian Nurses Perceived of Quality

Nursing Work Environment: A Case of Sardjito Hospital
In Yogyakarta, Indonesia

Aric Vranada

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

June 2016

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

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

1.2

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

1.3

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

1.4

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

1.5

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

1.6

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

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

2.1

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

2.2

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

2.3

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

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

3.1

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

3.2

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

3.3

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

3.4

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

3.5

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

3.6

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

3.7

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

3.8

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

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

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

15

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

13

CHAPTER I
INTRODUCTION

1.1 Background and Research Motivation

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

high nurse-patient ratio which is reported to be 1:1000. The nurse-patient ratio is

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

2
Aaviksoo, 2009). Lake (2002) explained that conceptualized such a work environment
as one that empowers nurses with increased opportunities for autonomy, accountability,
and control over the work environment.
Researchers of magnet hospitals have identified the following factors in a
positive nursing environment: leadership attributes of nursing administrators (e.g.,
vision and responsiveness), professional attributes of the staff nurses (e.g., nurse
autonomy and control, ability to establish and maintain therapeutic nursepatient
relationships, and collaborative nursephysician relationships), and an environment
that supports professional practice (Lundmark, 2008).
Many factors affecting the job satisfaction of nurses have been linked to
elements in the professional practice environment. Existing studies consistently
emphasize autonomy, interpersonal communication and collaboration, professional
practice, administrative and management practice, opportunity for advancement and
promotion, working conditions, and the physical environment as attributes of job
satisfaction (Choi, Bakken, Larson, Du, & Stone, 2004). Characteristics of nurses work
settings (i.e., type of shift and shift length) also have been examined in relation to job
satisfaction and levels of job stress (Jennings, 2008).
Indonesia, with its population of over 220 million, has health problems similar
to those of other developing countries. Indonesia has experienced in nursing shortage
almost in most both public and private hospitals, and its impact on patient safety and
also quality of care (Dikti, 2013). The Ministry of Health of Indonesia launched data
that average of nursing vacancy rate shown less than 10% in 2013 (Depkes, 2014).
Whereas the hospitals need for nurses is still lacking in Indonesia. The average of
Indonesian nurses in caring for patients is 1:10 ratio (Yusuf, 2012). That such of
shortage is related with the quality of nursing work environment which doesnt meet of
nurses expectation. Bauman (2007) explained that quality workplace is equal to quality
of patient care, and it is indicated by strong relationship among quality of work
environment, nursing shortages, quality of care, and mortality rate. The link between
negative working conditions and employee stress is well known. Work stress and
burnout are also associated with negative work attitudes and performance. In healthcare
settings, these conditions threaten the quality of patient care and patient safety.
According to the survey results of the Indonesian Nurse Association ( PPNI ) in
2006 approximately 50.9% of nurses working in four provinces in Indonesia
experiencing job stress, frequent dizziness, fatigue, less of rest time because the

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

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

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

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

7
CHAPTER II
LITERATURE REVIEW

2.1 Nursing Work Environment

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

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

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

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

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

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

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

14
2.3 Conceptual Framework
Safe practice
environment
Staff Quality

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

Work load, salary &

welfare
Professional
Specialization and
Cooperation
Work Simplification
Informatization
Technology
Professional Cultivation
and Development

Support and Caring

Figure 1. The Quality of Nurses Work Environment

15

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

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

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

Items
16
8
8
6
5
5
9
11
68

Before applying the questionnaire to respondents, researcher will apply

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

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

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

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

21
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APPENDICES

1.

Research Study Time Table Plan

Activity

Find the research topic

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

Jan
15

Feb
15

Mar
15

Apr
15

May
15

June
15

July
15

Aug
15

Sept
15

Oct
15

Nov Dec
15
15

Jan
16

Feb
16

Mar
16

Apr
16

May
16

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2.

Draft Letter of Permission Statement

PERMISSION LETTER FOR REQUESTING AN EXISTING

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

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