Nursing Master Program, Medical Faculty, University of Brawijaya, Indonesia
*Corresponding Author’s Email: bangkipli@yahoo.com
ABSTRACT
Introduction: Nurses save life of patient in emergency state condition which involves many aspects such as family of the patient, patient’s friends, and even medical equipment as well as existing facilities. Emergency state service at remote area allow a nurse to acquire many experiences dealing with lived relationship of phenomenologist, which define a meaning of relationship which eases a nurse in doing his task.
Purposes: To explore the meaning of interactional experiences between a nurse with family of the patient, other nurses, other medical workers, society and medical equipment in providing emergency state service at a remote area in Kokonao, Papua.
Method: The method of this research is qualitative with interpretive phenomenology approach and Van Manen data analysis model.
Finding: The themes that emerged based on lived relationship of nurses as phenomenologist at remote area, Kokonao, Papua are three: struggling to understand cultures and language of the natives, understand a situation that insisted to act alternatively, caring for patients who need first aids.
Conclusion: Health service at remote area at Kokonao, Papua done by a nurse needs effort to create strong relationship with patient, family of the patient, society, or with limited facility for the sake of better service.
In providing treatment, a nurse play the role and functions such as giving treatment, being family advocate, preventing disease, educating, counseling, collaborating, ethically deciding and also play the role of researcher (Hidayat, 2012). Nurse at emergency room not only provide care services but also need to maintain good relationship with peers, friends or patients and their families. This becomes a very crucial matter. It also needs knowledge and ethics of a nurse to be able to perform all kinds of treatment quickly and accurately under pressure with critical thinking. So, it requires skillful and competence nurses.
Expert of existential phenomenologist combines the ideals of existentialism with philosophy and methodology of phenomenology to study how an individual lives. These researchers believed the importance of context in developing individual experience, and the individual and his world is said to be closely related one to another. Through living in the world, an individual experience is formed (Valle, King & Halling, 1989; Marable, 2011). Besides that, supporters of existential
phenomenology have four main existential reasons which become source of all human experiences: (a) space/world, (b) body, (c) time, and (d) relationship/other people. Generally, these are the four main existential basics create in each individual’s life (Van Manen, 1990; Marable, 2011). Overall, experts of existential phenomenologist are of the opinion that everyone’s experience is closely related to context and takes form into four main basic existences. Relying on the notion, such as by Merleu-Ponty, those experts see subjectivity of human’s experience. Lived relationship is a way to keep relationship with other people inside of our shared interpersonal space. Since an individual meets other people, he gets closer each other corporally (physically). As an individual meets other people, he can develop conversational relationship to allow them tp pass beyond ourselves (Beck & Polite, 2012).
The method is qualitative method with interpretive phenomenology developed by Heidegger in 1962. The philosophy followed by Heideger is not only a description of human but it emphasizes on understanding and interpretation (Beck & Polite, 2012). The participants of this research are nurses with experience to handle emergency state at remote area, Kokonao, Papua. Technique of selecting the sample is by using purposive sampling after meeting determined inclusive criteria. There are six actively involved participants. Data collection of this research is in-depth interview. This research also uses Van Manen data analysis because this method represents interpretive or hermeneutic phenomenology research design (Beck & Polite, 2012). Ethical test was done in Halu University, Oleo, Kendari, Southern-East Sulawesi.
This research uses Van Manen data analysis because it represents interpretive or hermeneutic phenomenology design. Based on Van Manen (1990) (Beck & Polite, 2012) three methods were detailed with line-by-line approach, selective or highlighting approach, and holistic approach. Systematically the stages are:
The researcher reads verbatim transcript of each participant many times and reads in detail to get closer and more familiar expressions of the participants as well as to understand the expressed meaning.
Researcher tries to draw out the keywords which are considered to have psychological phenomena based on targeted purposes of this research. The keywords gained are then formulated into categories, sub-themes, and themes representing the meanings of the participants’ statement.
Researcher rereads all verbatim texts of each participant to find out themes of the texts. Results of the analysis of experience of six participants related to lived experience regarding the relationship principles toward nursing experience in providing emergency state treatment at the remote area are: trying to understand cultures and native language of the people, feeling to be
insisted to act alternatively, caring toward patients who need aids. All of them are in line with the relationship of lived relationship and purposes of the research.
This theme, according to Indonesian Dictionary, textually means “really comprehend, to properly know”. The word culture in Indonesian Dictionary is “when something becomes habit and is difficult to change”. The word language in Indonesian Dictionary means “sound symbolic system used by members of society to interact”. This theme emerges because all participants in the research are new comers in Kokonao. The participants must habituative to live in such condition where participants need cultural and language understandings of the society because they will live together with the society. Subtheme building up this theme is creating better relationship with the natives. Good relationship with the natives is important thing for the participants during interaction to avoid any misunderstanding which may cause abuses by the society. This process is done by getting closer to the society, using well-understandable language in daily communication or in providing health services.
“one of the ways out is by struggling to get closer to them (society) to create trust among each other and avoid accident to occur again (punching)” (P2)
“the most important is communication to make them accept our intention. We simply let them understand our educative intention”(P1)
The next subtheme is to understand lack of understanding of the habit of the natives. Nurses at the remote area face various characteristics of the natives with all their weaknesses and strength. Trying to understand their weaknesses means nurses want to accept their real condition beyond their expectation. In research context it can be said that this theme portrays society’s lack of knowledge about health which become evident in their shown habits while interacting. Here are the statements of the participants:
“among the hindering factors of our jobs, one of them is their lack of knowledge (the society)” (P2).
“their lack of knowledge about healthcare can be fulfilled with Basic Living Support such as CPR like quick action. We applied CPR to the patient, but they think we will hurt them” (P2)
“Communication with patient’s family is difficult because sometimes we know that the family, specially the natives of Papua, is temperamental. Sometimes they hit and do all kinds of reckless thing” (P1)
This theme appears because emergency state nurses at the remote area encounter classic problems such as poor facilities. Inspite of the adverse conditions some participants expect to do the best service with all limitation. One of the subthemes of this theme is providing demanded therapy effect. Some participants struggle to provide medicine, but the resource of medicine needed by patient are limited there. Here are the statements:
“I did not have paracetamol stock. Thus, we saved some of the patient who should have gotten 1 strip of 10 tablets, but we only gave 5” (P1)
“At that time our Lidocain or how should I call it – an anesthesia drug was not there. So I used ice water and pressed for a moment” (P2)
Keeping the equipment sterile and clean is also an important point in providing emergency state treatment. But, it becomes a problem for nurses at the remote area. Efforts to provide clean medical equipment is the subsequent theme. Nurses try to keep the equipment clean and functional so that they can be used when it is needed. The usage of used hand gloves many times and boiling the equipment becomes common activities to do.
“The hands gloves, which we already used (frowning the forehead) after we wash it, we put it under the sun” (P3)
“We do not have a sterilizing tool so we can only use pot and we boil it to sterilize them” (P6)
Finding equipment around them becomes the next difficult job of the nurses during the emergency state service. The subtheme using findable equipment to provide service is an effort to keep providing optimal service for the patients.
“Going to carpenter to get light wood which can be used for splint” (P1)
“Ya, the patients are taken on the boat. We are on it also and hold (a wooden club as standard) the infusion” (P1)
The development of this attitude towards patients is built by some subthemes, started by prioritizing patient’s safety. To prioritize their safety, the participants are demanded to provide principle of handling emergency state accordingly to the sake of patient’s life. The participants must prioritize to provide emergency state services for the patients.
“Which one is prioritized, which patient is in life threatening condition, which one can still wait a bit longer. So this is how it goes… suddenly there is another patient yelling ‘the family is bleeding out there, please pick him!”(P1)
Putting aside any risk suffered by the patients
“We think from human aspect if we do not handle it then the risk will be on the patient. It may take his life when he is not treated soon” (P5)
Concerning patient’s recovery
“Actually it feels frightening… it is frightening… We actually cannot do this one without doctor. We were worried whether he can recover sooner or not” (P6)
Then it is the effort of the participants to take carry the patients safely, while travelling towards healthcare.
“usually we stabilized the patient first. Then we take him to the town. When the patient has been stabilized, we take him…” (P6)
“We needed to take him because we realized his condition (the patient). We were insisted to go to Timika. We got problems on the way because of receding water but only stopped there. To go passing through this really needs extra effort. But although we did so, it was just the same (we could not continue) because there was no water” (P2)
The next subtheme is about risk taking for the sake of the patients while providing emergency state treatment. This risk is when the participants must perform some medical action for the sake of the patients which is not within their job description.
“whether we like it or not (the medical action), we need to do it rather than letting the patients worsen. We cannot just ignore him that way” (P2)
“Because the condition insisted us to do so (medical action). We must take action. We cannot wait for the doctors” (P3)
“So, for example, if the doctor goes to town. There will be no doctor (at remote place) so whether we like or not we are demanded to act as doctor or act as midwifery and so on” (P1)
“Actually we are afraid. I, personally, are afraid to do doctor’s job because I know it is not my job and authority. But when we know the condition of the patients, whether we like it or dislike it we need to act as a doctor” (P5)
Financial awareness is one of the subthemes which is done by participant to provide medical service.
“We looked for a boat, gasoline, sometimes we owed the gasoline. Then we went there, we asked many (for paying for us), but sometimes we did not get any money to replace …” (P4)
“Suddenly, it was not here, the fuel, the gasoline. So, automatically we needed to go and borrow again at the shop. Sometimes we felt sorry (we collectively gathered money) to take the patient” (P1)
In doing the task as nurses, the participants always put empathy toward the patients by showing their cares on what the patients and society feel.
“Sometimes we are sorry to leave (going to town) some people we already come to know” (P1)
“Actually, we are sorry because we had to struggle to take the patients to Timika, because of natural hindrance (we wait), then we need to seek the boat” (P6)
This subtheme portrays caring for patients in which later the participants maintain the service even at remote places by struggling to give the best service they can do.
“limited equipment but we need to do what we can do. As for example, according to the patient need Lidocain is not available. So whether we like or dislike it, we need to do it
without anesthesia… We needed to do it although the patients will be in pain, we needed to save his life” (P5)
Contextually, efforts to understand cultures and the native language mean that participants need to understand both condition and habits of Kokonao natives. This is difficult because the patient knowledge level is low, and their temperament is unpredictable. So, participants need to simply communicate so as to easily understand the people to succeed in delivering health message while providing service in daily life.
Culture consists of traditional ideas and related values to learn, to share, to transmit one to subsequent generation. Appropriate intervention and treatment to the cultures become the main important component in giving nursing education because the result will be positive for them (Li, 2016). Cultural competence refers to the ability to communicate between cultures and to understand the practices of an individual’s the native culture from outside (Delgado et al., 2013). The statement is in line to what participants did in this research. They struggled to understand local custom and provided understanding about their services by using simple and easy language of communication with the people with low knowledge level. This is done to make the message and service guidance to be understood by the people there.
Delgado et al., (2013) suggested that cultural competence covers an individual’s empathy toward other people, curiosity, basic appreciation for himself and other people along with acknowledgement of all humans’ intrinsic values. They are in line to what participants did by empathically struggling and understanding all limitations of the native with high temperament with respect to response to something. The participants tried to accept the natives’ condition while interacting to provide service by not being easily emotional. It is done to avoid any conflict which may lead to abuse, both physically and mentally. Thus, it becomes different challenge for medical workers at the remote area to provide health service and provide sensitive-cultural treatment because each population has norm and traditional practices guiding its life.
Contextually, this feeling means that participants are put into dilemma where they need to execute medical treatment or only give nursing during emergency state treatment with the limited facilities. This insists that the participant need to execute actions to save the natives by modifying current available sources. One of them is by putting ice cube on the wound to anesthetize the affected area when Lidocain is not available in their working place. This theme is in line with qualitative study by Susilawati (2016). She stated that medical workers at battle field face such adverse condition. So, to save victims they have to modifying treatment actions to manage with the limited sources.
Besides limited equipment and material to perform emergency state actions, the participants also face other difficulties in remote condition of Kokonao. It makes them impossible to provide disposable equipment such as handschoen and bandage. It compels the participants to reuse the equipment after washing and drying. It is in line with the work of Crigger et al (2007) who stated that the disaster condition where nurses work, which is not ideal, they face challenges and
limitations. Such situation still demanded to provide maximum treatment. It leads to alternative provision skill based on needs at the remote place as important matter to be appreciated by many people. It functions as a positive achievement.
Contextually, this attitude means that participants must provide nursing care towards the patients in emergency state treatment to offer better service. This theme shows that participant has behave according to Jean Watson’s caring theory. This behaviour is shown by participants by building themes: prioritizing patients’ safety and voluntarily taking risk for the sake of patients. They also must show empathy towards patients as embodiment of Theory of Human Caring (Watson, 1979; Alligood, 2017). Such a relationship is created by nurses as treatment giver and patients and the receiver with a purpose to improve recovery rate of an individual which is affected by effort of the nurses to protect the patients. Nurses are also responsible to help patients achieving knowledge and help them in their struggle to improve their health as essence of caring relationship between client and nurse. Besides that, Alligood (2017) stated that the point of nursing is caring. So, the health treatment provided by a nurse must consider all the factors of caring toward clients. Such a care will help to preserve the client’s self-esteem as an individual. It means that while giving treatment, a nurse must appreciate clients as a human being with their strengths and weaknesses. Watson also stated that a nurse as medical worker providing service with all the effort to help patients to reach mental tranquility by providing knowledge, and self-control as well as readiness for patients to get fully recovered. Nurses stand upon their strong commitment to protect, to improve, and to recover dignity and facilitate clients’ recovery. Watson also stated that nurses must be able to show their quality as professional workers by providing health services based on knowledge and ethical codes as commitment of caring. It can be said that nurses must face the challenge to provide the best treatment by using knowledge without any doubts in their minds.
Caring process of the participant is shown by providing better services for the sake of patients’ safety during emergency state condition. But the participants also do it sincerely in each service. It is reflected in subtheme empathy to patients and keeping service provision. It is in line to what Watson (Alligood, 2017) said that each individual is unique and shares different responses toward their problems. So, it needs understanding of the nurses who are providers of treatment toward those responses, both the responses that are occurring and will occur in future. Besides that, as interpersonal relationship between nurses and clients, caring must be shown in the form of attention and intervention to maintain the health of the clients and to put positive energy in the relationship.
Lived relationship principle consists of four existential phenomenology of nurses’ experience in providing emergency state service at remote area. The study results portray themes such as trying to understand culture and language of the natives, act alternatively in a situation, caring patients whom need aids, and self-reflection. These themes appear as efforts of nurses in a remote area
while performing their tasks involving, maintaining of good relationship with the native people or to perform well even with limited facilities so that the emergency state services still runs optimally.
The researcher would like to thank all the participants involved, the head of health care center for giving this chance to take sample in the working region, and to all lecturers for guiding and advising this research.
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