“Know Your Nurses” Project:

An Innovation of Patient Engagement Using Modular System

Dr. A. Heri Iswanto, MARS

Introduction – Nurses are needed not only to help patients in physical recovery,
but also the mental recovery. A patient who cannot afford the requirement to
recover because of their physical limitations may experience stress as a sense of
helplessness. It is the nurse’s duty to reduce the psychological stress by helping
physically and providing psychological assistance, such as showing affection and
nurturing. For this reason, it is important that the patients allow themselves to
accept the presence of a nurse. Similarly, it is also important for the nurse to have
a deep concern on the patient in forms of active listening as well as helping
patients to listen to their feelings and empathy. We designed a program namely
"know your nurses" aiming to improve the relationship of patients and nurses by
using the modular system. We implement this program at Kemang Medical Care
(KMC), a hospital in Jakarta. Our goal is to develop a methodology improving
the quality of patients’ care by create a model of effective communication between
patients and nurses.

Methodology – The program is conducted by providing training to nurses about

communication method to build stronger relationships between nurses and
patients. We teach factors affecting communication, elements of therapeutic
communication, therapeutic communication, communication techniques with
sensitive patients, and recognize obstacles in communication that should not be
done by nurses. In addition, patients are asked to get to know their nurse better
and explain the importance of this case to their services.

Results – The result shows the development of the patient's ability to remember
the name of the nurse/ midwife. We found that at first, only 64.2% of patients who
remembered the name of their nurse/ midwife. A month later, we saw an increase
of 29.9%, so in May 83.4% of patients were able to remember the name of their
nurse/ midwife. The next month, the case increased again by 10.4% so that only
7.9% of patients who remained unable to remember the name of their nurse/
midwife. This meant that there was monthly average improvement as much as
20.2% so we were confident in July nearly all patients has been able to remember
the name of their nurse/ midwife. The proportion of nurses’ ability in considering
the needs of the patient. In April, only 72% of nurses could consider the needs of
the patient. In June, 96% of nurses were able to remember the patient's needs.

Discussion –Efforts to improve the nurse-patient relationship at KMC is carried

out by increasing the visit frequency per shift patients. This research find
management is better, nurses understand more about the condition of the patient,
the patients are more built up, and more optimum nursing care.

Keyword : nurse, midwife, relationship, visit frequency.

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Electronic copy available at: http://ssrn.com/abstract=2743118

1. Introduction

Nurses are needed not only to help patients in physical recovery, but also
the mental recovery. A patient who cannot afford the requirement to recover
because of their physical limitations may experience stress as a sense of
helplessness. It is the nurse’s duty to reduce the psychological stress by helping
physically and providing psychological assistance, such as showing affection and
nurturing. Although this relationship cannot slow or stop the pathology of
patients, this relationship may give a significant effect to the patients’ health.
(Lotzkar, 1996). For this reason, it is important that the patient allow themselves
to accept the presence of a nurse. Similarly, it is also important for the nurse to
have a deep concern on the patient in forms of active listening as well as helping
patients to listen to their feelings and empathy (Lotzkar, 1996). In other words, the
relationship between the nurse and the patient is a relationship which is
determined by both parties (Intening, 2014). It is important to have mutual trust,
mutual reciprocity, and caring each other (Mok and Chiu, 2004). On the nurse’s
side, this means that nurses have to have the qualities and personal skills as the
base of the relationship (Mok and Chiu, 2004).

The relationship between nurses and patients is an interpersonal

relationship, therefore, it can be explained by the theory of interpersonal
relationships. According to the theory of Peplau, nurses and patients go through
four stages in building their relationships, namely; orientation, identification,
exploitation, and resolution phases (Said, 2013). Forchuk then revised the theory
of Peplau by shrinking them into three stages: orientation, work, and termination
(Reed and Shearer, 2006). This theory is accepted by Peplau as a revision of his
theory. The orientation phase is the initial phase in which nurses introduce
themselves to patients and use names when talking with patients and shake hands
to build mutual trust and respect (Said, 2013). After knowing each other, they can
build a plan by considering the educational needs of the patient. Work stage is a
phase focusing on patients’ attempt to obtain and use their knowledge to know
about their disease, available resources, and personal strength; while the nurse
focuses on strengthening the role of the family, counsellors, friends, and teachers

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Electronic copy available at: http://ssrn.com/abstract=2743118

in facilitating the development of patient to achieve their health condition (Reed
and Shearer, 2006). Termination stage is the stage where the patient has been
independently using their own power to develop his health. Nurses and patient
discuss the discharge planning and the needs in the transition time (Reed and
Shearer, 2006).

Even so, problems in the orientation phase will be heavier in the

collectivistic culture like in Indonesia. In the collective culture, names are not
something pretty important; the more important one is the hierarchy. In western
culture, one can address his father's name when talking to his father
interpersonally. However, in Indonesia, it is seen disrespectful. Addressing
someone with “Pak" when dealing with an adult male in Indonesia is right
commonplace, but it would seem excessive if we call "Sir" or "Mister" in western
culture. These cultural differences create problems in initiating relationships
between nurses and patients in Indonesia. It would seem odd for a nurse to call
their patient by names when they interact, and vice versa.

In the collectivist culture, prosperity and harmony is limited to the scope

of the family. Outsiders are not seen as something that is being targeted about
welfare. Therefore, nurses who have individualist mind set will be frustrated when
they realize that it is difficult to build personal sincere relationships with a patient
(Hanssen and Alpers, 2010). On the other hand, nurses are required to be an
individualist. This means, they have to be good to the patient not because as
members of the group, but as a part of humanity. Individualism has wider mutual
behaviour orientation than the collectivist because the identity of the individual is
not determined by the group. As a result, they are free to help anyone
(Universalist) (Schwartz, 1992) and get the satisfaction and enrichment of formed
relationships (Mok and Chiu, 2004). On the other hand, the identity of the
individual in the collective society is bound to their group, as a family or tribe.
Therefore, the mutual behaviour is limited to the group. A study by Okonkwo et al
(2014) confirmed that nurses who live in the collectivism cultural background are
not easily affected by this trend because they have an ethic code of that
encourages them to help each other without judging the group. As a result, the

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study on the collectivism context also find out that recognizing the consumers’
names give a significant effect to the quality of the relationships (Ali, 2011).

The illustration above shows that in the nurses themselves, as far as they
are professional, there is no problem in getting to know the patient and providing
the best service in the context of the nurse-patient relationship. The problem is in
the patient who tend to not to personalize the nurse and only mention about their
profession. Calling by names can lead to a family conflict if the nurse-patient
relationship occurs between the nurse and adult patients with the opposite sex and
have intimate relationship in the group (e.g. dating or married). This may suggest
that the nurse is accepted as an in-group of patients by other group members.
Even so, at least patients should know the name of their nurse. This is important
because they can rely more closely to nurses and get better service by
reciprocation principles and social networking among nurses. In situations where
patients meet with a lot of staffs at the hospital, recognition to patients’
appearance and name can accelerate and ease themselves in getting the services
done by the nurses they need.

In line with this idea, we designed a program namely "know your nurses"
aiming to improve the relationship of patients and nurses by using the modular
system. We implement this program at RSIA Kemang/ Kemang Medical Care
(KMC), a hospital in Jakarta. The hospital wants to improve the closeness in
terms of staffs who are less focus in providing nursing care to patients and uneven
nurses’ competence. Our goal is to develop a methodology improving the quality
of patients’ care by create a model of effective communication between patients
and nurses.

2. Method

The program is conducted by providing training to nurses about

communication method to build stronger relationships between nurses and
patients. We teach factors affecting communication, elements of therapeutic
communication (empathy, trust, honesty, validation, attention, and active

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listening), therapeutic communication techniques (techniques that allow the
patient to determine the rhythm of communication, encourage patients’
spontaneity, respond to verbal, para verbal, and nonverbal cues, encourage feeling
expression, and encourage patients to make changes), communication techniques
with sensitive patients (hearing problems, vision problems, aphasic, unconscious,
confused, and angry), and recognize obstacles in communication that should not
be done by nurses (Brody, 2003). Moreover, we also teach the boundaries in the
nurses-patients relationship that should not be violated because it shows an
excessive relationship that is contrary to professionalism (CARNA, 2011). In
addition, patients are asked to get to know their nurse better and explain the
importance of this case to their services. From the patient’s perspective, we refer
this program as "Know Your Nurses".

After the training, we assess the frequency of communication of the nurse

and the patient. We measure it in three months from April to June 2015. The
changes are recorded and checked in order to see if there is difference between the
initial conditions and the conditions after several months of implementation.

3. Results and Discussion

Table 1 shows the development of the patient's ability to remember the

name of the nurse/ midwife. We found that at first, only 64.2% of patients who
remembered the name of their nurse/ midwife. A month later, we saw an increase
of 29.9%, so in May 83.4% of patients were able to remember the name of their
nurse/ midwife. The next month, the case increased again by 10.4% so that only
7.9% of patients who remained unable to remember the name of their nurse/
midwife. This meant that there was monthly average improvement as much as
20.2% so we were confident in July nearly all patients has been able to remember
the name of their nurse/ midwife. The results below indicated that patients have
realized the importance of recognizing their nurses for their own interests, both
for their care provision and the needs of relationship between humans. This matter
will trigger the formation of the nurse-patient relationship that entered the stage of
orientation, work, and termination (Reed and Shearer, 2006: 460).

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Table 1. Number of Patients Able to Remember Their Nurses/ Midwifes’ Names

Explanation April May June

Patients who were able to remember their 64,2% 83,4% 92,1%
nurse/midwife’s name
Patients who were unable to remember their 35,8% 16,6% 7,9%
nurse/midwife’s name

Figure 1 below shows the proportion of nurses’ ability in considering the

needs of the patient. In April, only 72% of nurses could consider the needs of the
patient. In June, 96% of nurses were able to remember the patient's needs.

Figure 1. The Nurse’s Ability to Remember the Patient’s Needs

April May

June

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 Figure 2 below shows the increasing frequency of nurses visit patients in
one shift. There was also an increase, from six times of visit at the beginning to 11
times of visit in two months.

Figure 2. The Visit Frequency of Nurses in One Shift

Visit  Frequency  

April May June

Table 2 shows an increase trend indicating the nurse-patient relationship.

It appears that all the indicators rose consistently from April to June. The most
consistent indicator was the ability to remember confidently the needs of patients
up to 98.7%. The highest increase seen in visit frequency per shift. In April there
were only 6 visits to patients by nurses in each shift. In June, the nurse almost
doubled the visit frequency. The increasing of the monthly average was 36.1%
with a confidence interval of up to 98.6%. The nurse's ability to remember the
needs of the patient's rose 15.8% per month, as much as 72.3% in April to 96.8%
in June.

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Table 2. Increase Trend Indicating Nurse-Patient Relationship

Indicator April May June Trend r2

Visit Frequency per shift 6 9 11 Increase 98,6%
Can remember patient needs 72,3% 86,9% 96,8% Increase 98,7%
Patients remember nurses/midwife name 64,2% 83,4% 92,1% Increase 95,4%
 
Increase May - Apr Jun - Mar Average
Visit Frequency per shift 50,0% 22,2% 36,1%
Can remember patient needs 20,2% 11,4% 15,8%
Patients remember nurses/midwife name 29,9% 10,4% 20,2%

4. Conclusion

Efforts to improve the nurse-patient relationship at KMC is carried out by

increasing the visit frequency per shift up to 83.3%; the nurses’ ability to
remember the needs of the patient up to 33.9%; and the patients’ ability to
remember the name of their nurse/ midwife up to 43.5% in two months.
Furthermore, we also find that patients management is better, nurses understand
more about the condition of the patient, the patients are more built up, and more
optimum nursing care. We hope that in the future other hospitals can try this
program out to improve their nurse-patient relationship.

4. References

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Brody, M. 2003. The Nurse-Client Relationship. In Nursing Fundamentals:

Caring & Clinical Decision Making. Ed: R Daniels. Cengage Learning

CARNA. 2011. Professional Boundaries of Registered Nurses: Guidelines for

the Nurse-Client Relationship. Alberta: CARNA

Hanssen, I., Alpers, L-M. 2010. Utilitarian and common-sense morality

discussions in intercultural nursing practice. Nurs Ethics 2010 17: 201-
211.

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Intening, V.R. 2014. Nursing Performance of Diploma and Baccalaureate
Graduates in Selected Government Hospitals in Yogyakarta, Indonesia:
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Lotzkar, M. 1996. An Observational Study of the Nurse-Patient Relationship in an

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Okonkwo E.A., Eze A.C., Okoro C.M., Echezona A.J.C. and Azike I.N. 2014.
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