Journal details including published articles and guidelines for authors can be found at:
http://www.iomcworld.com/ijcrimph/
To cite this Article: Hariyati RTS, Sahar J. Perceptions of Nursing Care for Cardiovascular Cases,
Knowledge on the Telehealth and Telecardiology in Indonesia. International Journal of
Collaborative Research on Internal Medicine & Public Health. 2012; 4(2):116-128.
Correspondence concerning this article should be addressed to Rr. Tutik Sri Hariyati; Faculty of Nursing, University
of Indonesia, Indonesia | Email: rrtutik@yahoo.com, tutik@ui.ac.id
ABSTRACT
Background: Nowadays, the life-style displacement promotes the increasing of degenerative
disease, such as cardiovascular disease, which since 1995, has been stated as the main cause of
fatality in Indonesia. Telehealth was defined as the use of the telecommunication technology to
support the health information and increase the health service. Telehealth in developed countries
can improve the behavior of healthy living. Telehealth in Indonesia is expected to increase
healthy lifestyles that can reduce the risk of cardiovascular disease and other degenerative
diseases.
Objectives: This study aimed to explore perceptions of related experience in the nursing care of
cardiovascular cases, experience in the use of telehealth and hopes in telehealth implementation
in Indonesia.
Study Design: This study used a qualitative study with focus group discussions approach.
Participants in this study are 64 nurses. The selection of participants was carried out using
purposive sampling. The data of this research, which were in the form of transcript and field
report from each group discussion of the FGD, was analyzed using the phenomenology method
developed by Collaizi.
Results: The theme of nursing care was divided into 4 sub-themes that were: assessment,
diagnosis, planning, implementation and evaluation. The subtheme of definition and hopes to
telehealth was stated, “As far as I know, the heart hospital has used online system, so that if we
want to do referral, the patient can consultation directly, but t I don’t know about the system.
With Telehealth, nurses could observe the sign and symptoms from patient’s home.
Conclusion: The results of qualitative studies show that telehealth In Indonesia was limited.
Expectations for the development of telehealth/telecardiology is to further facilitate consultation,
communication and education can support the patient or a nurse.
considering the experience of the participant All the research content and ethical clearance
subjectively and uniquely. Descriptive problems had been gone under review and had
phenomenology was chosen in this study to do gained approval by the Indonesian Ministry of
a direct exploration, analysis, and description Research and Technology Foundation. The
toward a certain phenomenon.10 ethical clearance also had been approved by
the ethical committee of Faculty of Nursing
This study was a study to explore the University of Indonesia.
perception of the health provider, especially
the nurse’s perception, toward the nursing care In this study, the beneficence principal was
that had been given to the cardiovascular implemented by publishing the advantages of
clients; the continuity nursing care between this research where it was expected that this
Puskesmas and hospital; and also the study could be used as basic data for
knowledge and the expectation toward the developing the telenursing, which in the end
telenursing. could improve the nursing care service. The
respect for person was related with the rights
to gain the thorough information and the
autonomy from the participant to deliver their
Participant
opinion and experience based on the real
The participants of this research were 64 condition. Before following the FGD, all the
nurses, consisted of 22 males and 42 females. participants had been given explanation about
The participants were the representatives from the research, and all the participants had given
hospital. Puskesmas, and local health their inform consent as a proof of their
department in Jakarta, Bogor, Depok, willingness to become the participant in the
Tangerang, and Bekasi. The participants were FGD.
divided into 6 groups, each groups consisted
of 6 to 12 people.
The selection of the hospital and Puskesmas Data Collecting
was carried out using purposive sampling,
meaning that the participants in this research The method to collect the data used the Focus
were determined by several terms and Group Discussion/ FGD method. A focus
conditions made by the researcher.11 The group is a group interview of approximately
criteria for the chosen hospital were the six to twelve people who shared similar
hospital located in Jabodetabek area which characteristics of common interests. A
implemented cardiography case treatment, and facilitator guided the group based on a
the hospital which had possibility to be predetermined set of topics. The facilitator
exposed with the telehealth innovation. On the creates an environment that encourages
other hand, the selection of Puskesmas was participants to share their perceptions and
based on the reachable visible distance points of view. Focus group are a qualitative
between the Puskesmas and the chosen data collection method, meaning that the data
hospital. The reachable distance was one of is descriptive and cannot be measure
the factor that allowed the continuity care numerically.12
between puskesmas and hospital. In this study, the participants were divided
into 6 groups of FGD where in each group
consisted 8 to 12 participants. The grouping
was based on the location between the hospital
Ethical Issue
and Puskesmas which allowed the referral was to integrate the whole idea into a
process. Each group was led by a facilitator, complete description.
assisted by an observer who observed and
noted the non-verbal responds, and a
technician who facilitated the audio-visual
used during the research process. Each Research Result
participant in every group had the same
The results of the study showed that based on
opportunity to deliver their experience related
the meanings each of the participants
with the nursing care toward the
attributed to: 1) cardiovascular case, 2)
cardiovascular cases, the continuity of care,
nursing care on the cardiovascular case, 3)
and the telenursing innovation.
problem in the continuity process of nursing
Before conducting the real research, an care, 4) the knowledge about the
experimental test toward the key instrument telehealth/telenursing, and 5) the expectation
had been carried out. All the facilitators, toward the telehealth/telenursing.
observers, and technicians had followed the
experimental process and had equated their
perception toward the expected goal of the 1) Cardiovascular Case
research and the questions in which will guide
the facilitator in conducting the FGD. After This theme was the illustration of the
the FGD had been conducted, the focus cardiovascular case which had been handled
discussion notes was then being informed in hospital and Puskesmas. This theme was
toward the participant to clarify whether the divided into subtheme of cardio case and
notes was matched with what was being vascular case.
delivered by each participant.
a) Cardio case: cardiovascular diseases
treated by the hospital and Puskesmas
were varied. The referral hospital
Data Analysis usually handled several cardiovascular
disorders which were more variative
The data of this research, which were in the than the Puskesmas could handle. The
form of transcript and field report from each heart disorders that were mentioned by
group discussion of the FGD, was analyzed the participants were MCI (Myocard
using the phenomenology method developed Cardio Infark or Myocardial Infarction),
by Collaizi.13 The steps in the data analysis congenital heart disease, infection, and
process included transforming the FGD voice dysryhtmia. This kind of cardiovascular
record into verbatim form, after that the diseases was mentioned by the
researcher re-read the narrative script so that participants as: ...if we’re talking about
they could choose the appropriate word and cardiovascular case, we’ve met almost
the key point which were related with the all kind of cases, and if we’re talking
phenomenon which was being researched. The about the frequency, the most common
next process then to formulize, based on the case are the history of infark, failure,
significant key point, and classify into valve disorder in children ........ there is
category and subcategory. The category and also hypertension, CVD (Cardio
subcategory which had correlation will be Vascular Disease) ...., Acute Coronary
classified under the same theme. The next step Syndrome. When being examined in
Puskesmas, it may be not known as
heart disorder, but when being checked The sub-themes of health assessment were
in heart hospital, it was detected as illustrated in the assessment category:
MCI, CHF (Congestive Heart physical, psychological, and supporting. The
Failure)....... physical assessment was illustrated as:
b) Vascular case: this theme emerged from “Physical assessment… measuring the vital
the sub theme and category of vascular signs
disorder and its complication. The
vascular disorder was illustrated by the …assessment related with circulation
participants as: system… consciousness…
“Most hypertension........., .... Essential Measuring the blood pressure, usually along
hypertension..... Oh, hypertension crisis.... with heart rate…
Hypotension crisis.... High cholesterol or
…the heart rate, from their breathing…
post-hypertension like stroke. Yes, DVT...
(Deep Vein Thrombosis)”. …the conjunctiva looks pale, or the patient
has difficulty to breath.
…the signs of the heart disorder, the pain, the
2) Cardiovascular Nursing Care capillary refill…
The theme of nursing care on the
…body height, body weight, abdominal
cardiovascular client was divided into 4 sub-
circumference … with total cholesterol
themes that were: assessment, diagnosis,
level…
planning, implementation and evaluation.
The category of psychological assessment was
a) Assessment sub-theme was including
illustrated as below:
the sub-sub themes of anamnesis, health
examination, and diagnosis. The sub-sub “…mostly the patients were
themes of anamnesis were identified anxious……terrified…”
through the main complaint and clinical
history. The main complaint was The category of supporting assessment was
illustrated by the participants as: illustrated as below:
“… what’s your complaint, since when did “…usually, we conduct the ECG
you feel that, perhaps it’s in family medical examination…
history… assessment, what’s the pain scale,
where the pain is distributed.” …every patient who is more than 40 years old
undergoes the ECG examination.
Medical history and treatment were illustrated
by the participants as below: The ECG devices, x-ray devices have been
available in Puskesmas Kecamatan.
“… previous medical history, the probable
history, and we also need to assess the risk
factor…” b) Sub theme of Nursing Diagnosis
“… particular medicine, was the heart attack The sub theme of nursing diagnosis was
happened during activity or while he identified from the sub-sub themes of
rested…” nursing problem. Furthermore, it was
c) The sub theme of planning was “Started from bed-rest until the patient
explained by the sub-sub themes of could walk.
intervention which identified from two
… the diet appropriate with patient’s
categories, which were the nursing care
condition…
plan and the standard operating
procedure (SOP). The nursing care plan And then, what is it called, diet… the diet we
was described by the participants as: suggested usually low sodium diet.
“… we advised them, that when he released
from hospital, he should seek for the nurses
again, so that we can make him another The category of ADL and wound care was
nursing care plan…” mentioned by:
The SOP was illustrated as: “Started from the daily routine like bathing…
“Medical SOP was existed; so was the For the surgery-cases, it depends on the case
nurse’s.” whether it needs wound care, activity, and
medicine treatment.”
d) The sub theme of implementation was
illustrated in the sub-sub theme of The category of health education was defined
independent intervention, divided into by the statement as below:
several categories: Monitoring/
observation; oxygenation; positioning; “When the patient was about to be released,
fluid balance; mobilization; nutrition/ we give the health education.
diet; activity daily living; wound care; ... explained about their medication, the
soothing; health education; reduction of dosage.
psychological stress; exercise/ activity/
rehabilitation; promotion; and discharge For cardiovascular case, perhaps, whenever
planning. The category of monitoring/ the patient goes, they should bring the
observation and oxygenation was medication in their bag.
illustrated by participants as:
The education related with risk factor”.
“… its nursing care plan, usually we strictly
observed the vital signs… “For the psycho... their mental, we advise the
client not to think the things that could make
… monitor the client’s complain… them stress...
The category of exercise/ physical activity/ And then in hospital, we also have a program
rehabilitation was stated by the participants as: to ask about patient condition after returned
home. So, we called the patient and asked
“Teach how should be a normal breathing... their condition, or asked if there is something
that can be helped, and reminded the patient
What can be done, what should not be done.
for their upcoming check-up”.
...don’t do hard task yet...
...related with their rehabilitation...
3) Hindrance of the caring process and
...further intervention”. continuity of care between hospital
and puskesmas
The health promotion category was defined
as: The hindrances toward the caring process
were identified through the theme of: the
“Counseling of healthy life style... like synergy of care in puskesmas and hospital had
Sanitary and Healthy Behavior... lifestyle and not been working out and the continuity
life pattern...... not smoking......and then the system between hospital and puskesmas.
exercise that can be practice at home”.
a) The synergy system had not worked out
yet
The category of discharge planning was “.... patient that has been released from the
explained as: hospital should have checked themselves in
puskesmas, but the fact is they went straight to
“For the pacemaker case, since the beginning the hospital for the check up...
they had been observed the planning... we
give relevant books to the patients because . Well... it really depends from the society, we
they have to be independent, what should be just received their aspiration.
done because a device was installed inside
them. For example, they should be able to ...patient came from urban are usually just
count their heart rate. come to puskesmas only to ask for reference
letter for the hospital, without going through
We have told them clearly about their illness, the assessment first. Sometimes they just
and motivated them that they could be complain of having arythmia, or chect pain,
recovered. and they asked for reference to the heart
hospital, it looks like a giant hospital.”
Don’t forget for the next check up...
b) The continuity of service system
e) The sub theme of supervision was
identified through evaluation with the “They said that the service in puskesmas is not
evaluation category during the to the point, there is no system which allows
hospitalization and the evaluation post- the patient to consult the specialist... the
hospitalization. The category was service was slow.
illustrated by the statement below:
...currently now, the one from Slipi to Cipto
“Well, maybe evaluation. After we have done Mangunkusumo hospital, the ones from
all the implementation... Menteng are referred to Heart hospital. It
should have been a networking between “... nowadays it has been common by using
hospitals, so that it would be faster. phone and fax
... not using internet, but phone
4) Knowledge and expectation toward ... in puskesmas, just phone
the innovation of telehealth and
telenursing technology ... use the MMS, for fracture patient, we send
the image...
The knowledge and expectation toward the
innovation of telehealth and telenursing ... communication via internet...
technology could be identified through two
... through web site. Usually in question form,
themes which were the theme of knowledge
then the doctor will answer
and expectation.
.... I’ve heard about it... the teleconference
a) Knowledge
model... the operation was abroad. The camera
The theme of knowledge was identified was installed, the training was in our country.”
through 8 sub themes, which were the
The category of telecardiography was stated
subtheme of definition of telehealth; subtheme
as:
of the types of telehealth; the usage of
telehealth; the benefit from telehealth; and the “... it looks like monitor, if there is complaint,
subtheme of nurse’s role on telehealth. it was put on the chest, then being monitored
from the hospital...
The subtheme of definition of telehealth was
identified from the general exposure, the ... if arrhythmia occur, we will give instruction
participants’ statements were as below:
I had been working in Harapan Kita Heart
“As far as I know, the heart hospital has used Hospital, the device is small. There were once
online system, so that if we want to do patient who lived in Bogor with device. Then
referral, the patient can administer directly, we attached the device, and then we just
but then I don’t know about the system... observe in monitor for less than a minute, and
then print the image. Then, we can consult to
... I don’t know about it, but I’ve heard
specialist and then we returned it to the
before.... I’ve heard about telemedicine. We
sender.
didn’t know that it was telehealth
The subtheme of the advantages of this
... the nursing evaluation and intervention
program was identified from the category of
without face to face
coordination, information provider,
... in puskesmas we don’t have the system yet consultation inter-profession, client could
because we only carry out a basic assessment discuss about their problem, and observe the
patient. Those coordinated category was
The subtheme of types of telehealth was informed in the participants’ statement as
identified from the category of phone/fax, below:
MMS, cardiography screening,
internet/website, teleconference, distance “... there’s a good coordination between
health education, and telecardiography. hospital system and basic health service.
... the information provider, using internet, ... the continuity of education...... support in
phone, etc facilities...
... we can consult it to another health The expectation related with the
professional...” implementation of telehealth was identified
from several sub categories, including:
... even the doctor could consult the sub-sub
specialist. Connectivity, practical for the society and
fast-service
... if I were the client... well... I can discuss
about my problem... “... there’s connectivity between puskesmas
and hospital...
... so the patient does not need to go to heart
hospital. ... there’s networking between hospital. So
that it can be faster...
... if they need medication, we can let them
know first. ... patient could get a fast-service, and also
avoid risk...
... the result had been read by the doctor, what
are the instructions, we can tell them that ... they don’t need to go far, for example if it
can be treated at home...
... their child was in fever, then we were
called... we listened to them... then we advise ... patient could get the answer of their
them to give the antipyretic drug, drink a lot complaints from their own place...
of water, or just simply come to the
puskesmas”. ... nurses could observe the sign and
symptoms from patient’s home...
such as for the patient with heart disease,
5) The expectation toward telehealth their blood pressure can be
The sub theme of expectation toward observe in distant”
telehealth was identified from the sub theme
of beneficiary, identified from the category of
whether there was a good preparation and the
expectation to improve the health service. Discussion
The category of good preparation was The result of this study informed some
including: socialization, facilities support, and categories of cardiovascular disease, which
training. numbers were prone to increase both in
puskesmas and hospital. The tendency of the
“... if there’s new system, the socialization has growth in cardiography case was in sync with
to be done according to the protocol... the statement that in 2020 it was approximated
that the cardiovascular disease would become
... for the implementation, we need training for cause of death of 25 people each year.1
the individual who will use it
The characteristic of the patients who came to
... the knowledge from the human resource the puskesmaas were different than those who
had to get training... came to the hospital. Generally, patients came
to the puskesmas with complaint of the
increase in blood pressure and the other light the wide range of patterns seen in the
general symptoms; meanwhile the patients electrocardiograms of normal subjects and an
who came to the hospital usually had varied understanding of the effects of non-cardiac
complaint. One of the most common illnesses disorders on the trace are prerequisites to
found was acute coronary syndrome. Acute accurate interpretation.16 In this study, not all
coronary syndrome (ACS) is one of the most the health provider were able to interpret the
common life-threatening types of ECG result, generally the result was being
cardiovascular disease worldwide as well as in consulted to the doctor using fax, scan or
Indonesia. In the United States, more than phone calls.
50% of the 1.2 million people suffered an
acute coronary syndrome died each year The most common nursing diagnosis in the
before reaching a hospital, while in the United cardiovascular case were comfort status: pain,
Kingdom, the mortality rate was mobilization, fluid imbalance, and breathing
14
approximately 33%. Delays of treatment pattern disturbance. From the diagnosis
played a great contribution to the coronary emerged, the intervention that was carried out
death and heart dysfunction since the survival independently by the nurses were positioning,
outcomes significantly depend on the time rest and activity, and health education in order
elapsed between the onset of symptoms and to prepare the patients before they were
the initiation of thrombolysis therapy as the discharged. Health education is needed for
definitive treatment of acute coronary patients. Last studies have shown that patients
syndrome.15 are not uniformly committed to receiving
advice and the need therefore of targeted
The nursing care implemented by the nurses interventions. These trained professionals
started from the assessment, both could ensure need based and individualized
independently and collaboratively. The advice in a streamlined manner to bring about
assessment started with the complaint and the desired behavioral change.17
clinical history and family clinical history.
The general complaints stated by the patients The hindrance in continuity of care from
usually were breathing difficulty symptoms hospital to home and to puskesmas was found
and chest pain. The physical assessment in this research. Usually, the patients preferred
carried out were the measurement of blood to seek medical service in the hospital,
pressure, heart rate, respiration rate, and therefore the hospital became ‘Giant
assessment from head to toe. The supporting puskesmas’. The lack of trust toward the
assessment which usually carried out in the human resources and facilities were also the
cardiology case were ECG and complete cause of the preference in medical service
blood count laboratory, CK, CKMB, chosen, and these problems could have been
Troponin, and D-Dimer. This protocol was solved using the telehealth/telenursing system.
appropriate with the theory that there were There should be an information system which
four major diagnostic tools used in the managed the report process and the flow of
diagnosis of UA and STEMI in the clinical information so that it could guarantee the
history, the electrocardiography (ECG), continuity of care. Continuity of care was
cardiac markers, and stress testing.16 defined as the relationship and continuity of
the patient with the health service as service
The ECG itself was one of the expertise and information provider for the patient.18 The
needed in assessing, diagnosing, and post-hospitalized patients should get the
monitoring clinical outcome of the acute information of the further care and the
coronary syndrome patients. Familiarity with simplicity to get the immediate service in
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