STANDING ORDER, KOLABORASI DAN

DELEGASI *)

Disampaikan Kembali Oleh ;

Ns. Dodi Wijaya, M.Kep.
PSIK UNIVERSITAS JEMBER
*) Materi Workshop Peningkatan Peran Perawat Primer Dalam
Meningkatkan Profesionalisme Dan Mendukung Akreditasi
Rumah Sakit Versi 2012, FIK UI, Salemba
 UNDANG-UNDANG REPUBLIK INDONESIA NOMOR 38 TAHUN 2014 TENTANG KEPERAWATAN

Tugas dan Wewenang

Pasal 29
(1) Dalam menyelenggarakan Praktik Keperawatan, Perawat bertugas
sebagai:
a. Pemberi Asuhan Keperawatan;
b. Penyuluh dan Konselor bagi Klien;
c. Pengelola Pelayanan Keperawatan;
d. Peneliti Keperawatan;
e. Pelaksana tugas berdasarkan pelimpahan wewenang; dan/atau
f. Pelaksana tugas dalam keadaan keterbatasan tertentu.
Pasal 32
(1)Pelaksanaan tugas berdasarkan pelimpahan wewenang
sebagaimana dimaksud dalam Pasal 29 ayat (1) huruf e hanya
dapat diberikan secara tertulis oleh tenaga medis kepada
Perawat untuk melakukan sesuatu tindakan medis dan
melakukan evaluasi pelaksanaannya.

(1)Pelimpahan wewenang sebagaimana dimaksud pada ayat (1)

dapat dilakukan secara delegatif atau mandat.
Pasal 32
(1)..
(2)..
(3)Pelimpahan wewenang secara delegatif untuk melakukan
sesuatu tindakan medis diberikan oleh tenaga medis kepada
Perawat dengan disertai pelimpahan tanggung jawab.

(4)Pelimpahan wewenang secara delegatif sebagaimana

dimaksud pada ayat (3) hanya dapat diberikan kepada
Perawat profesi atau Perawat vokasi terlatih yang memiliki
kompetensi yang diperlukan.
(3) Pelimpahan wewenang secara mandat diberikan oleh
tenaga medis kepada Perawat untuk melakukan sesuatu
tindakan medis di bawah pengawasan.

(4) Tanggung jawab atas tindakan medis pada pelimpahan

wewenang mandat sebagaimana dimaksud pada ayat (5)
berada pada pemberi pelimpahan wewenang.
(3)Dalam melaksanakan tugas berdasarkan pelimpahan wewenang
sebagaimana dimaksud pada ayat (1), Perawat berwenang:
a.melakukan tindakan medis yang sesuai dengan
kompetensinya atas pelimpahan wewenang delegatif tenaga
medis;

b. melakukan tindakan medis di bawah pengawasan atas

pelimpahan wewenang mandat; dan

c. memberikan pelayanan kesehatan sesuai dengan program

Pemerintah.
Skema Kerangka Kerja Kompetensi Perawat KERANGKA KERJA KOMPETENSI
PERAWAT INDONESIA

PRAKTIK PROFESIONAL, ETIS, LEGAL, PEKA BUDAYA

AKONTABILITAS PRAKTIK ETIS PEKA BUDAYA

PRAKTIK LEGAL

PEMBERIAN ASUHAN DAN MANAJEMEN

PRINSIP ASUHAN KEPERAWATAN

PERENCANAAN PENGKAJIAN

EVALUASI IMPLEMENTASI

PROMOSI KESEHATAN HUBUNGAN KOMUNIKASI TERAPEUTIK

KEPEMIMPINAN DAN MANAJEMEN

PELAYANAN KESEHATAN INTERPERSONAL DELEGASI DAN SUPERVISI

KESELAMATAN LINGKUNGAN

PENGEMBANGAN KUALITAS PERSONAL & PROFESSIONAL

PP-PPNI_Rita_2015

PENGEMBANGAN PROFESI PENINGKATAN KUALITAS PENDIDIKAN BERKELANJUTAN

PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA NOMOR
14 38/MENKES/2010 TENTANG STANDAR PEIAYANAN KEDOKTERAN

• Standar Prosedur Operasional, selanjutnya disingkat SPO

adalah suatu perangkat instruksi/langkah-langkah yang dibakukan
untuk menyelesaikan proses kerja rutin tertentu, atau langkah yang
benar dan terbaik berdasarkan konsensus bersama dalam
melaksanakan berbagai kegiatan dan fungsi pelayanan yang dibuat
oleh fasilitas pelayanan kesehatan berdasarkan standar profesi.
 PERATURAN MET,ITERI KESEHATAN REPUBLIK INDONESIA NOMOR
14 38/MENKES/2010 TENTANG STANDAR PEIAYANAN KEDOKTERAN

• STANDAR PROSEDUR OPERASIONAL

Pasal 10
(1) Pimpinan fasilitas pelayanan kesehatan wajib memprakarsai penyusunan SPO sesuai dengan jenis dan
strata fasilitas pelayanan kesehatan yang dipimpinnya.
(2) PNPK harus dijadikan acuan pada penyusunan SPO di fasilitas pelayanan kesehatan.
(3) SPO harus dijadikan panduan bagi seluruh tenaga kesehatan di fasititas pelayanan kesehatan dalam
melaksanakan pelayanan kesehatan.
(4) SPO disusun dalam bentuk Panduan Praktik Klinis (clinical practice guidelines) yang dapat dilengkap
dengan alur klinis (clinical pathway), algoritme, protokol, prosedur atau standing order.
Standing order a physician's order that can be exercised by other health
care workers when predetermined conditions have been met.
http://medical-dictionary.thefreedictionary.com/standing+order

Standing medical orders

Orders, rules, regulations or procedures prepared by a physician or approved by a
physician or the medical staff of an institution for patients which have been examined or
evaluated by a physician and which are used as a guide in preparation for and carrying out
medical or surgical procedures or both.
These orders, rules, regulations or procedures are authority and direction for the
performance for certain prescribed acts for patients by authorized persons as
distinguished from specific orders written for a particular patient or delegation pursuant
to a prescriptive authority agreement.
Standing Order Guidelines 2012 . Published in June 2012 by the Ministry of Health, New Zealand
 To issue a standing order a person must be one
of the following:

(a)an individual practitioner in practice

(b)a practitioner who is an employer of a practitioner or a person permitted to supply or
administer a medicine under a standing order
(c)a practitioner who exercises managerial control over a practitioner or a person permitted
to supply or administer a medicine under a standing order
(d)a practitioner who is authorized by a group of practitioners or a group of people
permitted to supply or administer a medicine under a standing order on their behalf.
 Issuer retains overall responsibility to:

• ensure the legislative requirements for the standing order are

met
• ensure that anyone operating under the standing order has the
appropriate training and competency to fulfil the role

• countersign, audit and review the standing order.

 The regulations require that the standing
order includes:
an explanation of why the standing order is required
the circumstances in which the standing order applies – for example, a
paramedic in an emergency or a registered nurse running a specified
school clinic
the class of people able to administer and/or supply under the standing
order – for example, paramedics, registered nurses
the competency requirements of the person administering and/or
supplying a medicine under a standing order.
the treatment of condition/s to which the standing order applies – for example, urinary tract infection,
asthma

the medicines that may be supplied or administered under the standing order

the indications for which the medicine is to be administered and the recommended dose or dose range
for those indications

the number of dose(s) of the medicine for which the standing order is valid

the contraindications and/or exclusions for the medicines, the validated reference charts for dose
calculation (if required) and the monitoring of a medicine (if required)

the method of administration

whether countersigning is required and, if countersigning is required, the timeframe for countersigning

the clinical documentation to be recorded

the period for which the standing order applies

Checklist for use ofstanding orders
Nurses’ reported use of standing orders in primary health care settings
VOLUME 7 • NUMBER 1 • MARCH 2015J OURNAL OF PRIMARY HEALTH CARE
Jill Wilkinson RN, PhD

• RESULTS: The sample were experienced RNs (mean 24 years since

registration) and 53% have a postgraduate qualification. Some nurses’
understanding of a standing order included provision of a prescription to a
patient. Standing orders were used frequently (42% reported use 1 to >5
times/day) for a wide variety of conditions. There is a significant relationship
between undertaking the stated professional development requirements and
confidence in the clinical decisions made (p=0.025). Over half (52%) would
like to use standing orders more often.
 Contoh:
Statemen Policy Standing Order
North California Nursing Board, 2009
Components of Standing Orders should include:
1.Condition or situation in which the standing order will be used
2. Assessment criteria
3. Subjective findings
4. Objective findings
5.Plan of Care including: a. Medical treatment/pharmaceutical regimen if subjective and objective findings as
listed above are present b. Nursing actions c. Follow-up requirements
6. Criteria or circumstances in which the physician is to be called
7. Date written or last reviewed
8. Signature of provider
KOLABORASI
 Model Patient Centered Care
(Interdisciplinary Team Model – Interprofessional Collaboration)

DPJP
Perawat Apoteker
Clinical/Team Leader
• Koordinasi Psikologi Ahl
Pasien, i
• Kolaborasi Klinis
Keluarga Gizi
• Sintesis
• Interpretasi
Fisio Radiogrfr
• Integrasi asuhan  terapis
komprehensif -Analis
Lainnya

1. Pasien adalah pusat pelayanan, Pasien adalah bagian dari Tim

2. Nakes PPA (Profesional Pemberi Asuhan), merupakan Tim Interdisiplin,

diposisikan di sekitar pasien, tugas mandiri, delegatif, kolaboratif,
kompetensi memadai, sama penting / setara pd kontribusi profesinya

3. DPJP : sebagai Clinical Leader, melakukan Koordinasi, Review,

Sintesis, Interpretasi, Integrasi asuhan komprehensif
 Proses Asuhan Pasien
Patient Care

Asesmen Pasien
(Skrining, “Periksa Pasien”)

I 1. Informasi dikumpulkan : Anamnesa, S

Asesmen Ulang
pemeriksaan, pemeriksaan lain / O
Nakes Profesional
Pemberi Asuhan
penunjang, dsb
2. Analisis informasi : dihasilkan
A Diagnosis / PRoblem / Kondisi,  A
identifikasi Kebutuhan Yan Pasien
3. Rencana Pelayanan/Care Plan :
R untuk memenuhi Kebutuhan Yan P
Pasien

27

Implementasi Rencana/
Pemberian Pelayanan
Monitoring
 Standar Akreditasi RS v.2012

Patient Centered Care

Nakes Pemberi Asuhan Pasien

Asuhan Pasien Pasien

Interdiscplinary Team
Kolaborasi Interprofesional
 Standar
Interprofessionality AP, PP

 Kolaborasi Interprofesional
Bila beragam Nakes dari berbagai latar
belakang profesi bekerja bersama
menangani pasien, keluarga,
pengasuh,serta komunitas untuk
memberikan mutu asuhan terbaik

“Tidak lagi cukup bagi para Nakes PAP untuk menjadi sekedar
profesional. Dalam iklim global sekarang, tenaga kesehatan
juga dituntut menjadi interprofesional” (WHO, 2010)

(Framework for Action on Interprofessional Education & Collaborative Practice, WHO, 2010)
 Kompetensi Profesional
Penampilan tingkah laku dari suatu kumpulan terintegrasi dari pengetahuan,
ketrampilan, dan sikap yang menggambarkan ranah karya suatu profesi kesehatan
yang spesifik diterapkan dalam konteks asuhan yang spesifik

Kolaborasi Interprofesional
Bila beragam Nakes dari berbagai latar belakang profesi bekerja bersama menangani
pasien, keluarga, pengasuh,serta komunitas untuk memberikan mutu asuhan terbaik

Kompetensi Interprofesional
Penampilan tingkah laku dalam bentuk suatu kumpulan terintegrasi dari
pengetahuan, ketrampilan dan sikap untuk :
• Bekerja bersama lintas profesi, bersama tenaga kesehatan lain,
• Dan dengan pasien / keluarga / komunitas / populasi
• Guna meningkatkan hasil kesehatan dlm konteks asuhan yg spesifik

KARS Dr.Nico Lumenta (Framework for Action on Interprofessional Education & Collaborative Practice, WHO, 2010)
 The Principles ofCollaborative Relationships :
American Nurse Association, 2012
I. Effective Communication
One of the most basic elements of human interaction is the ability to communicate.
Communication, particularly in high-intensity environments such as health care, is not
merely the transaction of words.Effective communication requires an understanding
of the underlying context of the situation, an appreciation for the tone and emotions
of a conversation, and the accurate information. When implemented consistently, the
principles relating to effective communication can bridge the figurative divide of "you
vs. me", and ensure a reliable and dynamic means of relaying information and
feedback.
 Principles Effective Communication

1.Engage in active listening to fully understand and contemplate what is being

relayed.
2.Know the intent of a message, and what is the purpose and expectations of that
message.
3. Foster an open, safe environment.
4. Whether giving or receiving information, be sure it is accurate.
5.Have people speak to the person they need to speak to, so the right person gets the
right information.
 II. Authentic Relationships
• Professional nurses cultivate caring relationships with their patients, supporting them
in meeting their physical, mental, and spiritual needs related to health.
To bolster the profession and the quality of care patients receive, nurses must
reciprocate that kind of relationship with each other. And, as professionals, nurses
engage in the art and science of caring, and by their very nature, nurses thrive when
they experience caring from their colleagues.The principles relating to authentic
relationships give nurses a guide for developing these types of interactions with one
another, and cultivate the nurse's sense of being cared for that promotes their ability
to do the same for patients.
 Principles Authentic Relationships
1.Be true to yourself – be sure actions match words, and those around you are confident that
what they see is what they get.
2.Empower others to have ideas, to share those ideas, and to participate in projects that
leverage or enact those ideas.
3. Recognize and leverage each others’ strengths.
4. Be honest 100% of the time – with yourself, and with others.
5. Respect others’ personalities, needs, and wants.
6. Ask for what you want, but stay open to negotiating the difference.
7. Assume good intent from others’ words and actions, and assume they are doing their best.
III. Learning Environment and Culture
• A well-developed practice environment supports great nursing care, and gives
nurses the satisfaction of knowing that their work is valuable and meaningful. The
attributes of a learning environment are both objective and subjective; whereas
some aspects are clear and visible, some are just a sensation or feeling.However,
contrary to what it seems, creation of a learning environment is not a top-down
phenomenon. Nurses at all levels contribute to a learning environment by
demonstrating trust, support, and representation.The principles pertaining to
learning environment allow nurses and others to thrive and succeed at their work
because they are not afraid of failure
 Principles Learning Environment and
Culture
1. Inspire innovative and creative thinking.
2. Commit to a cycle of evaluating, improving, and celebrating, and value what
is going well.
3. Create a culture of safety, both physically and psychologically.
4. Share knowledge, and learn from mistakes.
5. Question the status quo – ask ―what if ‖, not ―noway.‖
 Position Statemen
Interprofesional Collaboration
Canadian Nurses Association, 2011
• Client-centred care — Interprofessional client-centred care requires collaboration among clients, nurses and other health
professionals who work together at the individual, organizational and health-care system levels. Health professionals work together
to optimize the health and wellness of clients and involve the client in decision-making. Clients are actively engaged in the
prevention, promotion and management of their health.
• Evidence-informed decision-making for quality care — Evidence-informed decision-making through the use of best practice
guidelines, protocols and resources will support interprofessional collaboration. Health professionals work together to identify and
assess research evidence as a basis for identifying treatment and management of health problems. Health outcomes are continuously
evaluated to track the effectiveness and appropriateness of services.
• Access — Teams of health-care professionals working in collaboration will ensure that patients can access the most appropriate
health-care provider at the right time and in the right place. Supporting continuity of care and continuity of care provider is crucial
to ensuring high-quality, client-centered interprofessional collaborative care.
• Epidemiology — Using assessments of the demographics and health status of clients will ensure the relevance of health services,
including the identification of appropriate health professions. Trends in the health of the population are tracked to assess the
impact of the services offered.
 Position Statemen
Interprofesional Collaboration
Canadian Nurses Association, 2011

• Social justice and equity — The people of Canada are entitled to a health system
that has the capacity to keep people well by linking interprofessional collaborative
care to social justice, equity and determinants of health;supporting health
promotion; and promoting community-based care as well as acute illness care.
• Ethics — Each profession brings its own set of competencies — the results of
education, training and experience — to collaborative health services. Health-care
professionals working in interprofessional collaborative teams learn from each other
in ways that can enhance the effectiveness of their collaborative efforts.
• Communication — Active listening and effective communication skills facilitate
both information sharing and decision-making.
 Professional Communication and Team Collaboration
Michelle O’Daniel, Alan H. Rosenstein , 2012

Components of Successful Teamwork

• Open communication
• Non punitive environment
• Clear direction
• Clear and known roles and tasks for team members
• Communication & Teamwork
• Respectful atmosphere
 Components ofSuccessful Teamwork

• Shared responsibility for team success

• Appropriate balance of member participation for the task at hand
• Acknowledgment and processing of conflict
• Clear specifications regarding authority and accountability
• Clear and known decision making procedures
• Regular and routine communication and information sharing
• Enabling environment, including access to needed resources
• Mechanism to evaluate outcomes
DELEGASI
 What is delegation?
• To commit powers to act as a representative for another (Webster
Dictionary).
• The transfer of responsibility for the performance of a task from one
person to another with the former retaining accountability for the
outcome. (ANA, 1994)
• Transfer to a competent individual the authority to perform a selected
nursing task in a selected situation. (NCSBN, 1995)
 Definitions of Delegation

• National Council of State Boards of Nursing (1995)

• Transferring to a competent individual the authority to perform a selected nursing
task in a selected situation.

• American Nurses Association (1996)

• Transfer of responsibility for the performance of a task from one individual to
another.
 Definition of Delegation

Achieving performance of care outcomes for which you

are accountable and responsible by sharing activities
with other individuals who have the appropriate authority
to accomplish the work (Yoder-Wise, 2008).
 Four Components of Delegation
• care outcomes - patient care is safely provided

• accountable and responsible - both RN and delegatee have an obligation

to care for that patient and ensure the task is completed

• sharing activities – both the RN and delegatee work together to

accomplish care

• appropriate authority – the RN selects the appropriate person to delegate

the task
Activities That May Not Be Delegated:
AACN Delegation Handbook,2nd Edition , 2004
Nursing activities that may not be delegated include:
 Performing an initial patient assessment and subsequent assessments or nursing interventions
that require specialized nursing knowledge, judgment, and/or skill
 Formulating nursing diagnosis
 Identifying nursing care goals and developing the nursing plan of care in conjunction with the
patient and/or family
 Updating the patient’s plan of care
 Providing patient education to patient and/or family
 Evaluating a patient’s progress, or lack thereof, toward achieving desired goals and outcomes
 Discussing patient issues with physician
 Communicating with physicians or implementing orders from physician ƒ
 Documenting the patient’s assessment, response to therapeutic interventions, in the patient’s
plan of care
 Administrating medications
 Providing direct nursing care
Thanks for your attention …