A window of Indonesian nurses: challenges and future

Uswatun Khasanah, Ns., MNS

uunkeho@yahoo.com

School of Nursing, Faculty of Medicine and Health Sciences Syarif Hidayatullah, Islamic State
University Jakarta

Presented at: The 2nd International Nursing Student Forum: “Nursing Challenges in the Global
Society”
Faculty of Nursing, Khon Kaen University Thailand

Introduction

Nursing is one of the most important noble professions dedicated to the service of
mankind. Large segments of Indonesian populations rely on nurses and midwives for health care
in communities, hospitals, and other settings, particularly the rural populations. Since nurses are
the key members of the health care team, they must be prepared in order to ensure quality health
care. Nursing education is the foundation to achieve that goal. Nurse education is meant for
preparing the nurse to care for human beings and also to adapt practice in response to the
challenges ahead.
Indonesia is an archipelago with thousands of islands (around 17,508 islands), has
hundreds of local languages, ethnicities, and cultures which would greatly affect the health
services to the community. Indonesia has population around 230 million people, it is the world's
fourth most populous country, and has the world's largest population of Muslims. All this of
course will greatly affect how nursing in Indonesia should be developed in educational settings,
services, and regulations related to nursing, which might be different from other countries.
Here, I am going to provide a snapshot of nursing in Indonesia and also challenges. I
expect it will be useful for this international nursing student forum to strengthen the closeness of
nursing student around the world by knowing the nursing conditions in each country.

A short history of East-Indies nurse in the Dutch period

This segment aims at providing a general picture of nursing in Indonesia. Most books
about nursing claim that nursing emerged in prerecorded time as a first intuitive response to the
primordial human needs of preserving and maintaining life and evolved from the desire of
keeping people healthy as well as providing comfort, care, reassurance to the ill. It is further
argued that nursing has begun as female activity, thus many of nurses are female (Sciortiano,
1995). This is slightly different from the history of nurses in Indonesia.
The available sources indicate that Western medicine preceded nursing in the penetration
of East Indies (present-day Indonesia). Western therapies increasingly penetrated the
Archipelago with the Verenigde Oost-Indische Compagnie (VOC: Dutch East Indies Company).
The first Western medical specialist who began to practice in The East Indies were the
Company’s Surgeons. A more systematic practice of Western medicine on land began with

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establishment in 1621 of the fortress of Batavia as Dutch trade centre in Indies. The construction
of the fortress made medical treatment for the wounded and the sick possible on the site, thus
leading to the fist hospital establishment around 1626.
The hospital ‘nurses majority they were treated the company’s European employees and
the wounded European soldiers, and also acted as guardian, a male activity. Besides carrying out
a few menial domestic activities, they had to control the patients, prevent them from escaping,
fighting or abusing the personnel, and to look after those patient ‘who were insane or whose
spirit was wandering on account of fever”. Thus the hospital “nursing” personnel was chosen
from the local male population, more over it that time was difficult to find local women willing
to work in mostly male hospital.
Extensive missionary work in the East Indies began in the early 19 th century with the
arrival of Dr. Schreurer in 1893 in Yogyakarta, and it was the first time in the Archipelago
nursing personnel were trained informally to take care of the sick. The institutionalized nursing
courses were begun around 1910 in Semarang and Batavia and the informal courses were
converted into specific training programs and became the responsibility of the heads of large
governmental and private hospital. In the beginning, only male candidate with primary education
were admitted to the courses. Female nursing education had a difficult start some years later.
This delay, testifying to male dominance in Indonesian nursing, was causes by a complex of
factors. There were not enough female candidates who could read and write, since female
education had started on a large scale only after 1908. Furthermore it was not considered
appropriate for middle-class girls to work outside their homes and for marriageable girls it was
considered culturally improper to live outside their parents’ home.
At first the only formally qualified personnel were the Dutch nurses who at the turn
century have discovered the Archipelago in search new jobs and career opportunities. They were
employed in the civil hospital as head nurse. The Dutch nurses already familiar with nursing
training in the Netherland often complained about the ignorance of the local staff. To resolve this
situation the nursing training was introduced.
By the end of the Dutch colonial period there were 3 nurse education levels. The lower
level was school for mantri-juru rawat (practical nurse) and the higher level were diploma A1
(general nursing) or diploma B1 (mental health) and women with 2-years midwifery program
were awarded diploma C.
In the year 1962, years after independent day, 3 years diploma in nursing were opened to
educate the nurses candidate and just in the year 1985 Indonesia has bachelor of Nursing at
Indonesia University Jakarta. Just recently in the year 1999 the master program for nursing was
started. In the year 2008 doctoral degree in nursing is started in Indonesia.

Indonesia nurses in the world of work

Nurse as well as in other countries is a major health worker in health services, thus also in
Indonesia. Total number of human resource in Indonesia in 2003 was 450,427 (53% of them or
exceed of 250,000 persons were nurses) in providing health services to approximately 215
million people in Indonesia (table 1). In Indonesia in the year 2010 needs approximately
1,097,119 health workers with approximately 583,000 nurses. With the total production of nurse
approximately 20,000 nurses/year (in range of 18,000 to 22,000 nurses per year), the expected of

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nurses can be produced within the period 0f 2000-2010 (7 years) will be approximately 140,000
nurses or by the year of 2010, there will be roughly 390,000 nurses in Indonesia. This figure is
actually behind the projected need of 583,000 nurses in 2010.

Table 1. Human Resources in Health in Indonesia

No Category of Availability Availability Availability Availability Availability Projection
NRH in 1983 in 1988 in 1993 in 1997 in 2005 Availability
in 2010
1 Medical 1.155 2.815 4.859 6.776 9.695 12.370
doctor:
specialist
2 Medical 15.122 17.662 20.600 28.568 45.015 56.773
doctor:
Practitioner
3 Dentist 1.292 3.821 5.321 6.672 11.069 14.031
4 Pharmacist - 1.777 3.027 7.646 12.815 17.752
5 Nurses 44.651 64.087 94.675 216.52 347.441 419.355
Source: Ministry of Health (2000). Policy of HRH development 2000-2010, Jakarta

However, due to some policy changes and several other factors, it seems that the total
productions of nurse in range of 18,000 to 20,000 nurses are over ‘surplus’ of nurse production.
This ‘excess’ number of nurses due to:
1. Low absorption of government and private health sectors. This low absorption is due to
the GOI low information and budget allocation to placement new nurses in public
hospital, public health center and other public health care facilities. The GOI
(Government of Indonesia) has only able to provide formation and budget allocation for
maximum of 3,000 nurses yearly. While at the private health sectors, the placement of
new nurses has depended on the needs of each private hospital, clinic, and other private
health care facilities. It is predicted that the private health sectors can only absorb
approximately 2,500-3,000 new nurses yearly. Therefore, only 1/3 of the total production
of new nurses in Indonesia can be recruited properly. Placement of remaining 2/3 of the
total nurse production is still uncertain.
2. Decentralization policy carried out at once at the beginning of 2001 has created some
misunderstanding concerning policy and responsibility between national, province, and
district levels in HRH placement. This misunderstanding has causes some rejection of the
local district to the placement of nurses. However, with the revision of decentralization
government regulation with the PP (Government Regulation) 32 2004, this problem
hopefully can be solved in the near future. While low salary, lack of facilitates and
uncertainty of future carrier of nurses are also considered as other importance factors for
unequal distribution of nurses in Indonesia.
3. Concentration of nurses is in the big cities and surrounding areas of Java and other big
islands. Inaccessible geographic conditions and inadequate transportation system to most
areas out of Java, Sumatra, and Bali islands have also created some rejection of nurses to
be placement. Most of hospital, health centers and other health facilities in the eastern
part of Indonesia are located in the small islands or in the remote areas with lack of
transportation system. These problems have been attempted to be solved by additional
compensation to nurses who want to be placement in those areas. However, due to their

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 basic salaries are low and limited budget of the GOI, these traditional compensations are
not big enough to motivate them to be placement in those remote areas.
4. Uncertainty of future career of the nurses is another important factor. Due to budget
limitation, the GOI cannot provide certain fixed future career improvement to all of
nurses. Decentralization also provide some difficulties to nurses to move from remote
district to other accessible district

Based on the above reasons, some “surplus” of the nurses cannot be avoided, however, some
efforts by the GOI has to be taken to solve this problem. The concentration of problem solving is
still some effort for equitable distribution of nurses through out of Indonesia. Alternatively, to
send abroad those ‘surplus’ nurses are one of the best solutions decided by the GOI.
Although the needs for nurses of the destination countries is high enough, but only 25%
of applicants passing the selection course. The passing rate shows quite rising during the last 2
years. The reasons of rising of passing rate: more intensive English preparation for prospective
nurses and intensive nursing training that provided by labor services company or school of
Nursing.
Demand for Indonesian nurses is increasing from Japan and Middle East countries. In the
year 2008 from the 1000 quota demand Indonesian nurses to Japan are only 208 who passed the
selection. For the year 2009, demand for nurses and care workers besides coming from Japan,
there is also a demand from Hong Kong, Australia, New Zealand, the United States, Canada,
Kuwait, Jordan and other countries (National Authority for the Placement and Protection of
Indonesian Overseas Workers, 2008). The demand of Indonesian nurses continues to increase,
because of Indonesian nurses are known as friendly, skilled and obedient in serving patients,
especially for middle east countries are due to similarities between the Indonesian and middle
east culture countries since known as the Muslim country.
There are many Companies that specialize in placement of Indonesian nurse workers
abroad. Some of them are PT Millinium Muda Mandiri and PT AMRI. Several obstacles
Indonesian nurses working abroad are: 1) Language competency. Some countries require the
TOEFL score are 550 or IELTS 6. This is quite high score for the majority nursing students in
Indonesia. Improvement the English competency is a must since in the academic level for the
nursing students. 2) The Indonesia nursing student still not familiar with NCLEX exam. Just the
recent years the NCLEX exam is introduced to the nursing students. However due to the English
limitation, when we try the NCLEX-like test for the nursing student, the score is under
expectation. This is of course to be a good input to nursing education in order to improve many
aspects of the teaching learning process. 3) Parent permission. The parents often refuse when the
child wants to work abroad. 4) Bravery. Some nurse students they still do not brave enough to go
abroad for work.

Nurse education

The national workshops convened by the Consortium of Health Sciences in 1983 strongly
recommended the development of higher nursing education in order to produce qualified nurses
to meet the need for high quality nursing services at all levels of the health care system. These
gave an impetus for advancing nursing education to the higher education system in Indonesia.

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The bachelor degree in nursing in Indonesia began to experience rapid growth in the year 1998.
Bachelor degree in nursing was first opened in the University of Indonesia in the year 1985, and
later in the year 1994 was established at University of Padjajaran, Bandung. Then starting in the
year 1998 many private and state universities offer the bachelor degree in nursing, including the
school of nursing Syarif Hidayatullah Islamic State University that was founded in the year
2005. Now, there are not less than 94 bachelor degrees in nursing in Indonesia and more than
450 3 years-diplomas in nursing.
The number of nursing institutions in Indonesia is quite a lot, however the quality is vary.
Thus, this still leaves a lot of homework that requires working hard from many parties so that the
quality of its graduates can meet the needs of stakeholders. Why do I say a lot of parties involved
in this case, and who are they in the context of nursing education in Indonesia?. In my point of
view there are several parties involved so that we can improve the quality of graduates.
The government has a substantial role in influencing the quality of nursing graduates
through regulations and policies made. In Indonesia there is still many levels in nursing
education. Previously because of the circumstances and conditions still require, the basic level
of nursing education is in high school level called sekolah perawat kesehatan (SPK). Later SPK
has been closed. Later the basic nursing education is 3-years diploma in nursing also called as
vocational nurse. The nurse graduated from bachelor degree in nursing (5-years nursing
program) called as professional nurse. The master program in nursing in Indonesia started around
year 1999 and doctoral degree program in the year 2008. However until now only 2 universities
offer the master program in nursing (Indonesia University and Padjajaran University, Bandung)
and doctoral program in nursing only offered by Indonesian University.
However, the government of Indonesia through the health ministry is now running 4-
years diploma in nursing (advance diploma). Moreover through the ministry of education
legislation has pushed the opening of vocational school (equivalent to high school). This then
opens the opportunity for some parties to set up a nursing school which is equivalent to high
school.
There are a lot of criticisms due to the variation of nursing education that is vocational
and academic. In this case there are opinion differences between PPNI and the government
about the level of nursing education. The PPNI (The Indonesian National Nurses Association-
INNA) expects the ideal of nursing education levels start from3 years diploma in nursing,
bachelor degree, and master degree (Specialist 1) , doctoral degree (specialist 2) and no 4-years
diploma in nursing.
In Indonesia the total of 3-years diploma, 4-years diploma, and bachelor degree are more
than 500 institutions. This is quite lot number comparing with the needs of nurses within
Indonesia. This is a challenge for nursing education in Indonesia to generate nurses with the
national standard. In fact, the quality of nursing education in Indonesia is still very diverse from
well organized program of nursing education to nursing education held potluck.
According to a paper entitled “A methodology for assessing the professional
development needs of nurses and midwives in Indonesia” (Hennessy et al, 2006), a number of
issues compromise the development of high-quality nursing graduates. The issues include:
- There is no statutory regulatory authority for nurses and midwives, and consequently
there are no regulatory standards for education and clinical competence;
- One consequence of the lack of regulatory standards for education and clinical
competence, and the absence of proper job descriptions, is that the level of education and

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 training of many health care professionals does not necessarily match the nature of the
work being undertaken;
- Despite the lack of standards, it is estimated that 60% of nurses and midwives have
inadequate training and preparation for the role, which creates the potential for
substandard care delivery; and
- Many nurses and midwives practice with little or no supervision, which engenders a
situation whereby practitioners, under pressure from the mounting health demands of the
population, may feel obliged to undertake clinical activities that exceed their education or
their competence level

In conclusion, sitting together between governments and professional organizations to

discuss the best solution is expected so that the level of nursing education in Indonesia became
more focused and clear.

A Great home work for Indonesian Nursing Association

For the national level Indonesia has PPNI-Persatuan Perawat Nasional Indonesia
(Indonesian national nurses association). PPNI was established in the year 1974. The Indonesian
National Nurses Association (INNA) is a strong voice for nursing, society and committed to the
provision of quality professional nursing care in the public interest. It is a PPNI vision. PPNI in
this moment has a great homework that is establishment of nursing council for self-regulations
through issuing of the nursing law. However until now the nursing law has not been legalized.
The Indonesian nurses have been standing for so long but until now, the government’s reaction
to respond of the nursing policy which has been setting up a while for very slow.
The government through ministry of health seems difficult to legalize the nursing law by
reason of government’s opinion that the nurse does not need regulation in the law level, but the
ministerial regulation level. This leads the nurse movement in Indonesia for asking the house of
representative that the Indonesian nursing law to be in their agenda because it seems difficult to
expect ministry of health to do that job.
The nursing law is very important for Indonesian nurse because of it is the basis for
establishment of nursing council. The nursing council duties are to draw up the nurse
competency, regulate and run competency exam, register of nurses, to legitimize the standards of
nursing education and also regulate the nursing practice. Hopefully by nursing law establishment
can shaping the nursing quality in order to be equal with nurses from other countries.
Furthermore under the ASEAN Mutual Recognition Arrangement on Nursing Services (MRA on
Nursing), the nursing education should able to produce the skilled nurses in order to be able
compete with nurses from abroad.

AIPNI: The Academic Community Concern

There are now Association of Indonesia nursing education center (AINEC/AIPNI).

AIPNI established at 2001 and focus on bachelor degree in nursing education. The member of
AIPNI is now not less than 94 school of nursing. AIPNI is the association which aims to improve
educational quality in nursing education.
AIPNI has developed some guidelines, such nursing curriculum, and also offers training
course related nursing education such as curriculum development training, soft skill training,

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study guide development training, teaching methodology training, and now turn to develop the
nursing clerkship system models as well as the teaching methodology in the clerkship program. I
am confident with the involvement of AIPNI nursing education will move forward significantly.

Conclusion: Need a strong leadership

I am not seeing anything that has been mentioned above as a problem; however this is more as a
challenge for the Indonesia nurses. It is the future of nursing as a profession - not its past - that
makes me confident about the young women and men undertaking their nursing education
today. Nursing will play an even greater role in delivering a better, sooner, more convenient
health care service. Carrier as overseas nurses is challenging. The only that we need is a good
system in nursing so that the nursing education can produce competent nurses that able to
compete with nurses around the world. In Indonesia case, strong leaderships are needed in any
aspect of nursing: education, political, as well as services in order to be able to organize nursing
better. And I am sure that we can.

References

Di Brown. (2009). Nursing care innovations to improve quality. Paper presented at: Nursing
education Expo. Jakarta.
Sciortino, Rosalia. (1995). Care-takers of cure. Gadjah Mada University Press: Yogyakarta.
Suwandana. A, Muharso, Achadi. A, & Arystami, K. (2009) Human resources on health for
foreign countries: A case of nurse surplus in Indonesia.
National Authority for the Placement and Protection of Indonesian Overseas Workers. (2008).
BNP2TKI : Opening Jobs in Japan. Retrieved from:
http://www.bnp2tki.go.id/content/view/238/231/.
Siswanto. (2006). Reform of nursing in Indonesia. Indonesia national nurses association.
WHO. (2000). Nursing and midwivery education in the 21st centurt. Report of intercountry
counseltation, Bangkok, Thailand.