Design of primary care team method development in improving the quality of nursing care at Jayapura Regional General Hospital, Papua: An action research study

The phenomenon of Problems in the Application of Primary Nurse Methods in Implementing Nursing Care Methods at Jayapura Hospital according to the results of research, interviews, and implementation of FGDs lies in the lack of understanding, level of education, level of communication, and placement of structures that are not in accordance with the standard operating procedures of the Type B Education Hospital which has the Vision of Jayapura Hospital as a national referral hospital in Eastern Indonesia so that the application of methods must be in accordance with the Type of Hospital and the Vision, Mission of the hospital beside the application of a method must be equipped with Modules, Guidelines, Policies, and continuous focus group discussions so that the application can improve the quality of patient safety and satisfaction. From the results of the FGD, the researchers got ideas to implement the pure primary nurse method supported by primary nurse implementation guidelines, modules, guidelines and at the same time mapping nurses in re-credentialing who would become heads of rooms, primary nurses as driving forces and associate nurses as implementing nurses according to clinical nurse placement (PK-I, PK-II, PK-III, and PK-IV).


Introduction
In the era of globalization, hospitals need to continuously improve service quality and patient safety on an ongoing basis where a hospital service is said to be of quality if the patient is satisfied so the development of Nursing Care Service Methods must be improved in accordance with Nursing Care Standards and Hospital Accreditation Standards.The primary nurse team method is a professional nurse service that can improve the quality of a hospital.The Primary and Associate Nurse Implementation Method has been implemented at Jayapura Regional General Hospital but has not been maximized.RSUD Jayapura applies the Primary Nurse Modification Team Method and Associate because RSUD Jayapura is one of the SKPDs under the Papua Provincial Government so the placement of staff is still influenced by the existing Government System and indirectly affects the placement of the service method system at RSUD Jayapura.
The role of duties and functions of a primary nurse meets the needs of patients in total during hospitalization, conduct assessments and plan nursing care in a comprehensive manner, communicate and coordinate in making nursing care for patients from admission to discharge plans, and provides nursing care to patients according to plans and coordinates with other health teams.According to Dr. Ratna Sitorus [1] Primary nursing methods are characterized by accountability, autonomy, authority, advocacy, staffing, and the 5C of contiguity, communication, collaboration, coordination, and commitment.Primary nurses not only have the authority to make referrals to social workers, schedule clinical appointments, and conduct home visits but also act as field managers responsible for supervising teams of associate nurses (two or three teams) and are responsible to the head of the room.
The limited human resources available and the level of DIII Nursing Education at RSUD Jayapura affect the application of the Primary Nurse Modification Team Method at RSUD Jayapura, which is still too far from what is expected besides that between the workload and the human resources available there are many imbalances that result in less than optimal nurse performance in handling clients or patients.In addition to the lack of nurses, the application of the method is still not optimal because there are not many nurses who have a high level of nursing education.The process of assessment, nursing diagnosis, planning, implementation, and evaluation does not run continuously due to the lack of competence of the head of the room and the primary nurse so that the function of monitoring the implementation or performance of nursing.From the phenomena that occur, the researcher is interested in examining "Team Method Design in Improving the Quality of Nursing Care (Action Research Study)".

Research Design
Qualitative design is used to answer research problems.The characteristic of the qualitative method is to conduct investigative research that is carried out systematically to describe, explain, predict, and control the phenomena observed in the research Implementation of Team Methods in Improving the Quality of Nursing Care (Action Research Study) researchers use inductive and deductive methods to find out the implementation of methods that have been used in Jayapura Hospital.

Research Location
The research was conducted at Jayapura Regional General Hospital, Papua Province, especially in the female internal medicine inpatient room, male internal medicine room, female surgical room, male surgical room, orthopedic room, pulmonary care room, and pediatric room.

Participant
In this study, participants who will be involved include the Head of the Room, Primary Nurses, Associate Nurses, and Hospital Management.Participants in this study were a team of nurses who implemented the team method in improving the quality of nursing care at Jayapura Regional Hospital, including the head nurse, primary nurse, associate nurse, head of nursing quality development, and deputy director of medical services and nursing services.
Taking participants in this study used the purposive sampling method, which is one of the non-random sampling techniques where the researcher determines sampling by determining specific characteristics that are in accordance with the research objectives so that it is expected to answer research problems.Participants were selected based on information that supports a study obtained from previous interviews.

Data Collection
Researchers use tools in this study in the form of notes and voice recorders on mobile phones and teleconference Zoom to help smooth data collection and before conducting research the cellphone will be tested for functionality and feasibility.Notes will be used to see the expression or non-verbal communication of participants, all notes related to this research will be kept confidential.The researcher also developed a focus group discussion (FGD) guide as the main tool that will guide the FGD process.
There are several stages in this approach, the first stage begins with the implementation of FGDs with the aim of identifying and knowing the extent to which the Implementation of the Team Method in Improving the Quality of Professional Nursing Care After completing the FGD, the researcher then contracts time to validate the results of the FGD and provide opportunities for participants to ask questions.The results of the FGDs were then analyzed and obtained a theme that had made keywords and categories of each theme.

Results and discussion
The research was conducted at Jayapura Regional General Hospital (RSUD Jayapura).The data collection method was carried out using FGD techniques attended by 8 participants with the following characteristics: Analysis of table 1 shows the demographic data of the participants in this study, namely nurses who work in the male internal medicine ward, male surgery, female surgery, female internal medicine, orthopedic room, children's room, super VIP room, pulmonary care room, from the head of the room to the primary nurse and executive nurse.Educational background S1 as many as 7 people, the remaining 1 participant S2 education, the youngest is 41 years and the oldest 53 years.Then the length of work of nurses is at least 14 years and the longest is 22 years.

Theme analysis outcome
The results of research conducted on participants through the FGD method.Participants were given a total of 10 questions as a theme in the FGD process, then participants were given a statement of consent to become a subject and made a contract regarding the place and time of the discussion.The results of the FGD process have been analyzed in accordance with Collaizi's analysis [2] and several findings were obtained based on the answers of the participants involved in the FGD implementation.The discussion was conducted in a circular sitting position and then the researcher repeated it to several participants until the results were saturated, validating the results of the group discussion.The results of the FGD process were systematically organized and immediately consulted with supervisors and resource persons regarding the results of the design of the Primary Care Team Method.The data obtained in the FGD process by the researcher was then organized in the form of direct sentences and made transcripts of the results of the statements and determined keywords and categories from the statements of 8 participants P1 to P8.The results of these findings obtained themes that have been made about the design of the development of primary care team methods, based on questions and statements from participants and the determination of keywords and categories.As a result of thematic analysis, the following three themes were obtained:

Lack of Understanding of the Duties and Functions of the Head of the Room, Primary Nurses, and Associate Nurses
The results of the focus group discussion showed that the lack of understanding was caused by several aspects, both in terms of human resources and education level.3 out of 8 participants, obtained statements that they did not understand the duties and functions of the head of the room, did not know, did not know, did not understand their duties and functions, or were somewhat complicated with the work team.The findings of the study were that conceptually, all participants (8 participants) could convey what was meant by the definition of the primary nurse team method in the Professional Nursing Care Model (MAKP).There was a big concept about the lack of understanding of the duties and functions of the head of the room, primary nurses, and associate nurses.Jayapura Regional Hospital is guided to implement a professional nursing care method that contains professional nurses.So that the implementation of a national referral hospital in eastern Indonesia with the most complete, best, renowned, and developed health services, but there are many things that need to be addressed, especially the availability of professional staff where RSUD Jayapura still has 324 vocational nurses who need to be upgraded to professional nurses.
This is what makes the lack of understanding, nurses know but do not understand and then do not know the procedure, associate nurses do not understand the main tasks and functions and the head of the room is not so efficient in dividing the main tasks and functions.In accordance with the explanation above, an effort is needed to improve the ability of nurses in the implementation of the team model professional nursing care method.The optimal implementation of the MAKP team model will result in good nurse performance.This must be supported by the leadership ability of the head of the room, knowledge, and motivation of nurses to develop professional nursing care and not consider work as a routine.The role of leadership in an organization is very important.Integrating leadership in nursing care methods will improve the quality of nursing services [3].Increasing nurses' knowledge is done by holding training seminars conducted in-house training and ex-house training.This is in accordance with the results of research conducted by Kristin et al [4] that training will improve skills, knowledge, and trust between service providers or nurses and service recipients.
Figure 1 Analysis results of the first theme

Verbal and Non-Verbal Communication has not been working optimally
The research findings in the form of theme 2, obtained the results that the target of Verbal and Non-Verbal communication to nurses in the primary team is something that has an impact in supporting work.The following FGD results of participants' statements related to effective communication in a team are needed especially in the application of the primary nurse team method if communication is not good then the team will not be efficient in working.This second theme is supported by the formulation of a category, namely vocational nurses are more dominant, the placement of primary nurses and associates is less efficient, work demands are greater than the number of human resources (HR), primary nurses are only on morning shifts, the censorship that affects the education level of individuals/patients.
RSUD Jayapura as a type B hospital must meet HR standards according to Government Regulation No. 95, 2019 regarding the teaching hospital, which is educated professional nurses, but human resources at Jayapura Hospital still have 324 vocational nurses, thus affecting effective communication in the application of professional nursing care methods.In addition, this level of education affects the nursing structure both in the application of primary nurse methods as a driver in improving service quality and patient satisfaction.Effective communication is the exchange of information, ideas, and feelings that produce changes in attitudes so that a good relationship is established between the messenger (communicator) and the recipient of the message (communicant), measuring the effectiveness of a communication process can be seen from the achievement of the goal of the message sender.This effective communication can be built in the application of the primary nurse method where the primary nurse is the driving force in carrying out professional nursing care and the associate nurse as the implementing nurse who receives the message or communicant.So that patient satisfaction can be guaranteed from admission to discharge.effective communication so that the continuity of the nursing plan is guaranteed.This can be achieved if the performance of nurses in the implementation of professional nursing care is carried out in accordance with existing standards.Nurse performance is an action taken by a nurse in an organization in accordance with their respective authorities and responsibilities, where good performance can provide satisfaction to service users and also improve the quality of nursing services [5].
Inpatient room nurses must improve in providing nursing care to patients by increasing teamwork and implementing team-model nursing care according to standards so that patient satisfaction is met.In addition, nurses must be open in informing every care given to patients.Patient satisfaction can be achieved if there is open communication from service providers, both doctors and nurses, about the services provided to patients [6].
Figure 2 Results of the second theme analysis

Level of education that is not in line with the hospital type classification
Statements from 4 of the 8 participants formed the third theme supported by a category, namely: There is still a hospital evaluation of the level of education of nurses at Jayapura General Hospital.As a teaching hospital, RSUD Jayapura must meet the requirements and standards of a teaching hospital that has the function of service, education, and research in the fields of medicine, dentistry, and other health, this requires the availability of nursing human resources, which on average are nurse educated so that the nursing care method that can be applied is the primary nurse method in MAKP.
To replace the primary nurse modification nurse method which is still dominated by vocational nurses.Researchers encourage the management of the Jayapura Regional Hospital to be able to increase the level of education of vocational nurses to become professional nurses in accordance with the type of hospital B education.
In accordance with the explanation above, an effort is needed to improve the ability of nurses in the implementation of the professional nursing care method of the team model.The optimal implementation of the MAKP team model will result in good nurse performance.This must be supported by the leadership ability of the head of the room, knowledge, and motivation of nurses to develop professional nursing care and not consider work as a routine.The role of leadership in an organization is very important.Integrating leadership in nursing care methods will improve the quality of nursing services [3].Rahayu et al [7] stated that knowledge has an influence on the implementation of the MAKP primary team model.

Figure 3
Analysis results of the third theme

Conclusion
The implementation of Primary Nurse Modification Method in Jayapura Regional Hospital has been implemented evenly in the inpatient room but not maximally because there is no documentation (primary nurse modification method module) so it becomes an obstacle in the implementation in the field besides the placement structure in the inpatient room there is still a diploma III nursing nurse who occupies the position of head of the room and primary nurse.Therefore, RSUD Jayapura must have a professional nursing care method because it is a type of teaching hospital with a big vision.

Disclosure of conflict of interest
We have no conflicts of interest to disclose.

Statement of informed consent
Informed consent was obtained from all individual participants included in the study.

Table 1
Demographic Data of Participants